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1.  Use of collagenase ointment in conjunction with negative pressure wound therapy in the care of diabetic wounds: a case series of six patients 
Diabetic Foot & Ankle  2015;6:10.3402/dfa.v6.24999.
Background
Diabetic wounds with additional comorbidities are costly, time intensive, and difficult to heal. Often, multiple modalities may be necessary to achieve wound resolution, relying on the synergistic advantage of each therapy to affect wound healing. The selectivity of Clostridium collagenase is physiologically effective at degrading non-viable collagen fibers while preserving living collagen tissue. Additionally, negative pressure wound therapy (NPWT) has long been used to aid wound healing while concurrently depreciating biological wound burden time.
Methods
Six patients were selected from those appearing to our university based limb salvage service. Inclusion criteria included patients with a recurrent mixed fibrotic and granular wound base, in which NPWT was indicated, without exclusion criteria. Patients enrolled were administered clostridial collagenase ointment at each regularly scheduled NPWT dressing change. Patients were followed until healing, with visual representations of wound progression and time to full healing recorded.
Results
Tandem application of these therapies appeared to expedite wound healing by clearing degenerative fibrous tissue and expediting wound granulation without additional complication. Unfortunately, not all patients were able to reach full healing; with two patients experiencing ulcer recurrence, likely a result of their significant comorbid nature.
Conclusion
In our experience, we have noticed a specific subgroup of patients who benefit greatly when collagenase enzymatic debridement therapy is combined with NPWT. It is our belief that this combination therapy combines the molecular clearing of non-viable collagen with the wound granulation necessary to advance complex wounds to the next step in healing despite the current paucity in literature discussing this specific pairing.
doi:10.3402/dfa.v6.24999
PMCID: PMC4309834  PMID: 25630362
diabetes; ulcers; wound healing; negative pressure wound therapy; collagenase
2.  Reduction of pain via platelet-rich plasma in split-thickness skin graft donor sites: a series of matched pairs 
Diabetic Foot & Ankle  2015;6:10.3402/dfa.v6.24972.
In the past decade, autologous platelet-rich plasma (PRP) therapy has seen increasingly widespread integration into medical specialties. PRP application is known to accelerate wound epithelialization rates, and may also reduce postoperative wound site pain. Recently, we observed an increase in patient satisfaction following PRP gel (Angel, Cytomedix, Rockville, MD) application to split-thickness skin graft (STSG) donor sites. We assessed all patients known to our university-based hospital service who underwent multiple STSGs up to the year 2014, with at least one treated with topical PRP. Based on these criteria, five patients aged 48.4±17.6 (80% male) were identified who could serve as their own control, with mean time of 4.4±5.1 years between operations. In both therapies, initial dressing changes occurred on postoperative day (POD) 7, with donor site pain measured by Likert visual pain scale. Paired t-tests compared the size and thickness of harvested skin graft and patient pain level, and STSG thickness and surface area were comparable between control and PRP interventions (p>0.05 for all). Donor site pain was reduced from an average of 7.2 (±2.6) to 3 (±3.7), an average reduction in pain of 4.2 (standard error 1.1, p=0.0098) following PRP use. Based on these results, the authors suggest PRP as a beneficial adjunct for reducing donor site pain following STSG harvest.
doi:10.3402/dfa.v6.24972
PMCID: PMC4306752  PMID: 25623477
skin grafts; platelet-rich plasma; diabetic foot; pain reduction
3.  The lateral lesser toe fillet flap for diabetic foot soft tissue closure: surgical technique and case report 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.25732.
Wound closure for the diabetic foot can be challenging and often involves amputation or reconstruction. The authors describe a surgical technique and a case report of lateral lesser toe fillet flap in the management of a diabetic foot wound. The lateral lesser toe fillet flap reconstruction is a reproducible technique that incurs comparatively minimal technical complexity and provides a favorable option in the management of diabetic foot wounds where soft tissue coverage is required.
doi:10.3402/dfa.v5.25732
PMCID: PMC4272413  PMID: 25527137
diabetes mellitus; diabetic foot; toe fillet flap; amputation
4.  The role of Renasys-GO™ in the treatment of diabetic lower limb ulcers: a case series 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.24718.
Introduction
This case series aims to study the effectiveness of Renasys-GO™ negative pressure wound therapy system in the healing of diabetic lower limb ulcers.
Materials and methods
An electronic vacuum pump (Renasys-GO™, Smith & Nephew GmbH) was used to apply negative pressure wound therapy on wounds, with pressure settings determined according to clinical indication. Changes in wound dimension, infection status and duration of treatment were recorded over the course of Renasys-GO™ therapy in 10 patients with diabetic lower limb ulcers.
Results
Healing was achieved in all wounds, three by secondary closure and seven by split-thickness skin grafting. Eight wounds showed a reduction in wound size. The average duration of treatment with Renasys-GO™ therapy was 15.9 days, and all wounds showed sufficient granulation and were cleared of bacterial infection at the end of therapy.
Conclusions
Renasys-GO™ therapy may be beneficial in the treatment of diabetic lower limb ulcers and wounds. In this study, which included wounds presenting as post-surgery ray amputation, metatarsal excision wounds, post-debridement abscesses and ulcers, the Renasys-GO™ therapy prepared all wounds for closure via split-thickness skin grafting or secondary healing by promoting granulation tissue and reducing bacterial infection in approximately 2 weeks.
doi:10.3402/dfa.v5.24718
PMCID: PMC4236639  PMID: 25406680
diabetic lower limb wounds; negative pressure wound therapy; wound healing
5.  Effect of painless diabetic neuropathy on pressure pain hypersensitivity (hyperalgesia) after acute foot trauma 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.24926.
Introduction and objective
Acute injury transiently lowers local mechanical pain thresholds at a limb. To elucidate the impact of painless (diabetic) neuropathy on this post-traumatic hyperalgesia, pressure pain perception thresholds after a skeletal foot trauma were studied in consecutive persons without and with neuropathy (i.e. history of foot ulcer or Charcot arthropathy).
Design and methods
A case–control study was done on 25 unselected clinical routine patients with acute unilateral foot trauma (cases: elective bone surgery; controls: sprain, toe fracture). Cases were 12 patients (11 diabetic subjects) with severe painless neuropathy and chronic foot pathology. Controls were 13 non-neuropathic persons. Over 1 week after the trauma, cutaneous pressure pain perception threshold (CPPPT) and deep pressure pain perception threshold (DPPPT) were measured repeatedly, adjacent to the injury and at the opposite foot (pinprick stimulators, Algometer II®).
Results
In the control group, post-traumatic DPPPT (but not CPPPT) at the injured foot was reduced by about 15–25%. In the case group, pre- and post-operative CPPPT and DPPPT were supranormal. Although DPPPT fell post-operatively by about 15–20%, it remained always higher than the post-traumatic DPPPT in the control group: over musculus abductor hallucis 615 kPa (kilopascal) versus 422 kPa, and over metatarsophalangeal joint 518 kPa versus 375 kPa (medians; case vs. control group); CPPPT did not decrease post-operatively.
Conclusion
Physiological nociception and post-traumatic hyperalgesia to pressure are diminished at the foot with severe painless (diabetic) neuropathy. A degree of post-traumatic hypersensitivity required to ‘pull away’ from any one, even innocuous, mechanical impact in order to avoid additional damage is, therefore, lacking.
doi:10.3402/dfa.v5.24926
PMCID: PMC4224703  PMID: 25397867
quantitative sensory testing; allodynia; neuropathy; neuropathic ulcer; neuropathic arthropathy; nociception
6.  An overview of factors maximizing successful split-thickness skin grafting in diabetic wounds 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.24769.
Open wounds, from ulcerations or slow healing, are one of the comorbidities in diabetic patients that can lead to amputation. Therefore, an optimal way to close and heal wounds quickly in diabetic patients is required. Split-thickness skin grafts (STSG) offer a quick method of wound closure for diabetic patients. This article review will look at causes of failure in STSG, and ways to optimize success.
doi:10.3402/dfa.v5.24769
PMCID: PMC4216388
biofilm; chronic; bioengineered alternative tissue; debridement; closure
7.  Osteomyelitis in the diabetic foot 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.24445.
Osteomyelitis (OM) is a common complication of diabetic foot ulcers and/or diabetic foot infections. This review article discusses the clinical presentation, diagnosis, and treatment of OM in the diabetic foot. Clinical features that point to the possibility of OM include the presence of exposed bone in the depth of a diabetic foot ulcer. Medical imaging studies include plain radiographs, magnetic resonance imaging, and bone scintigraphy. A high index of suspicion is also required to make the diagnosis of OM in the diabetic foot combined with clinical and radiological studies.
doi:10.3402/dfa.v5.24445
PMCID: PMC4119293  PMID: 25147627
osteomyelitis; diabetic foot; ulcer; infection; antibiotics; amputation
8.  Complication rates in diabetics with first metatarsophalangeal joint arthrodesis 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.24649.
Background
First metatarsophalangeal joint (MTPJ) arthrodesis has been an effective surgical entity when indicated, but a range of severe to mild complications can occur from this procedure. Patients with diabetes mellitus have an increased risk in surgical complications, most commonly associated with soft tissue and bone healing, when compared to non-diabetic patients. The purpose of this study was to evaluate the complication rates of first MTPJ arthrodesis in diabetic patients and compare them to the existing complication rates for the procedure.
Methods
A retrospective chart review was done on 76 diabetic patients, from June 2002 to August 2012. Thirty-two males and 44 females were included in the study. The authors evaluated many variables that could impact postoperative complications, including age, gender, bone graft incorporation, hemoglobin A1c, tobacco use, body mass index, peripheral neuropathy, hallux extensus, hallux interphalangeal arthritis, and rheumatoid arthritis, and compared them with the complication findings. Patient follow-up was no less than 24 months.
Results
Overall, approximately two-thirds of the patients had no complications and 35.5% of patients had at least one mild or moderate complication. Of the non-union and mal-union complications, 80 and 70% had peripheral neuropathy, respectively. One hundred percent of the patients that had mal-positions or hardware failure also had peripheral neuropathy. No severe complications were seen during follow-up. Only two of the moderate complications needed revisions, and the rest of those with moderate complications were asymptomatic.
Conclusion
In conclusion, first MTPJ arthrodesis is overall an effective and beneficial procedure in patients with diabetes mellitus. Diabetic patients with peripheral neuropathy have an increased risk for mild and moderate complications.
doi:10.3402/dfa.v5.24649
PMCID: PMC4074606  PMID: 24987496
diabetes mellitus; complications; peripheral neuropathy; first metatarsophalangeal arthrodesis
9.  Risk factors for methicillin-resistant Staphylococcus aureus in diabetic foot infections 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.23575.
Objective
The purpose of this study was to evaluate risk factors for methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized for diabetic foot infections.
Methods
We reviewed hospital admissions for foot infections in patients with diabetes which had nasal swabs, and anaerobic and aerobic tissue cultures at the time of admission. Data collected included patient characteristics and medical history to determine risk factors for developing an MRSA infection in the foot.
Results
The prevalence of MRSA in these infections was 29.8%. Risk factors for MRSA diabetic foot infections were history of MRSA foot infection, MRSA nasal colonization, and multidrug-resistant organisms (p<0.05). Positive predictive value (PPV) and negative predictive value (NPV) of nasal colonization with MRSA to identify MRSA diabetic foot infections were 66.7% and 80.0% (sensitivity 41%, specificity 90%). Admission from a nursing home was not a significant risk factor.
Conclusion
Positive nasal swabs are not predictive of the infecting agent; however, a negative nasal swab rules out MRSA as the infecting agent in foot wounds with 90% accuracy.
doi:10.3402/dfa.v5.23575
PMCID: PMC3984406  PMID: 24765246
MRSA; infection; diabetic foot; ulcer
10.  Vacuum-assisted closure versus conventional dressings in the management of diabetic foot ulcers: a prospective case–control study 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.23345.
Objective
To compare the effectiveness of vacuum-assisted closure (VAC) versus conventional dressings in the healing of diabetic foot ulcerations (DFUs) in terms of healing rate (time to prepare the wound for closure either spontaneously or by surgery), safety, and patient satisfaction.
Methods
Randomized case–control study enrolling 56 patients, divided into two groups. Group A (patients treated with VAC) and Group B (patients treated with conventional dressings), with an equal number of patients in each group. DFUs were treated until wound closure, either spontaneously, surgically, or until completion of the 8-week period.
Results
Granulation tissue appeared in 26 (92.85%) patients by the end of Week 2 in Group A, while it appeared in 15 (53.57%) patients by that time in Group B. 100% granulation was achieved in 21 (77.78%) patients by the end of Week 5 in Group A as compared to only 10 (40%) patients by that time in Group B. Patients in Group A had fewer number of positive blood cultures, secondary amputations and were satisfied with treatment as compared to Group B.
Conclusion
VAC appears to be more effective, safe, and patient satisfactory compared to conventional dressings for the treatment of DFUs.
doi:10.3402/dfa.v5.23345
PMCID: PMC3982118  PMID: 24765245
diabetic foot ulcer; infections; conventional dressings; vacuum-assisted closure; wound closure
11.  The modified Pirogoff's amputation in treating diabetic foot infections: surgical technique and case series 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.23354.
Background
This paper describes the surgical technique of a modified Pirogoff's amputation performed by the senior author and reports the results of this operation in a single surgeon case series for patients with diabetic foot infections.
Methods
Six patients with diabetic foot infections were operated on by the National University Hospital (NUH) diabetic foot team in Singapore between November 2011 and January 2012. All patients underwent a modified Pirogoff's amputation for diabetic foot infections. Inclusion criteria included the presence of a palpable posterior tibial pulse, ankle brachial index (ABI) of more than 0.7, and distal infections not extending proximally beyond the midfoot level. Clinical parameters such as presence of pulses and ABI were recorded. Preoperative blood tests performed included a glycated hemoglobin level, hemoglobin, total white blood cell count, C-reactive protein, erythrocyte sedimentation rate, albumin, and creatinine levels. All patients were subjected to 14 sessions of hyperbaric oxygen therapy postoperatively and were followed up for a minimum of 10 months.
Results
All six patients had good wound healing. Tibio-calcaneal arthrodesis of the stump was achieved in all cases by 6 months postoperatively. All patients were able to walk with the prosthesis.
Conclusions
The modified Pirogoff's amputation has been found to show good results in carefully selected patients with diabetic foot infections. The selection criteria included a palpable posterior tibial pulse, distal infections not extending proximally beyond the midfoot level, ABI of more than 0.7, hemoglobin level of more than 10 g/dL, and serum albumin level of more than 30 g/L.
doi:10.3402/dfa.v5.23354
PMCID: PMC3976534  PMID: 24711887
Pirogoff amputation; diabetes; diabetic foot complications; clinical outcome; prosthesis
12.  A study of prognostic factors in Chinese patients with diabetic foot ulcers 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.22936.
Objective
Few studies have identified factors as predictors of clinical prognosis of patients with diabetic foot ulcers (DFUs), especially of Chinese patients. In this study, we assessed the prognostic factors of Chinese patients with DFUs.
Methods and materials
This was a retrospective study (January 2009–January 2011) of 194 DFUs conducted in an inpatient population at PLA 454 Hospital in Nanjing, China, to determine the prognostic influential factors of DFUs in Chinese patients. All of the studied patients were grouped into an amputation group, a non-healing group, and a cured group, according to the clinical prognosis. Patient parameters, including gender, age, smoking habits, education level, family history of diabetes mellitus, medical history, duration of foot lesions and complications, ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), urinary albumin/creatinine ratio (Alb/Cr), fundus oculi, electrocardiogram, DFU characteristics, bacterial nature, and neuropathy, were cross-studied among the three groups.
Results
Compared with the other two groups, the amputation group showed a higher number of males, older in age, lower ABI and TcPO2 levels, higher Wagner wound grading and size, and significantly higher urinary Alb/Cr ratio, blood urea nitrogen, serum creatinine, white blood cell count, and erythrocyte sedimentation rate. Compared to the cured group (162 patients), more patients with an older age, smoking, family history of diabetes mellitus, medical history of foot ulcerations, lower ABI and TcPO2 levels, higher urine Alb/Cr ratio, and serum creatinine were found in the non-healing group. Regression analysis was used to study the correlation between various factors and clinical prognosis, and the results were as follows: age, Wagner wound classification, and heel ulcerations were negatively correlated to the DFU prognosis, whereas the female population, ABI, and TcPO2 were positively correlated with DFU prognosis.
Conclusion
In this retrospective study, we conclude that the DFU prognosis may be related to age, gender, wound location (heel), Wagner wound classification, ABI, and TcPO2 levels in the Chinese population.
doi:10.3402/dfa.v5.22936
PMCID: PMC3955769  PMID: 24765244
Chinese; diabetic foot ulcers; prognosis; ankle brachial index; Wagner wound classification
13.  Combined use of Ilizarov external fixation and Papineau technique for septic pseudoarthrosis of the distal tibia in a patient with diabetes mellitus 
Diabetic Foot & Ankle  2014;5:10.3402/dfa.v5.22841.
The surgical treatment of open pilon fractures has a high complication rate especially in diabetic patients. In this article, we present a case of an infected tibial non-union after an open reduction and internal fixation in a diabetic patient, treated with Ilizarov external fixation combined with Papineau technique. Combined use of external fixation and Papineau technique can provide an alternative option for the treatment of septic pseudoarthrosis of the distal tibia.
doi:10.3402/dfa.v5.22841
PMCID: PMC3926991  PMID: 24563728
tibia; infection; non-union; Ilizarov; external fixation; Papineau technique
14.  Early results from an angiosome-directed open surgical technique for venous arterialization in patients with critical lower limb ischemia 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.22713.
Background
Patients with critical lower limb ischemia without patent pedal arteries cannot be treated by the conventional arterial reconstruction. Venous arterialization has been suggested to improve limb salvage in this subgroup of patients but has not gained wide acceptance. We report our early experience after implementing deep and superficial venous arterialization of the lower limb.
Materials and methods
Ten patients with critical ischemia and without crural or pedal arteries available for conventional bypass surgery or angioplasty were treated with distal venous arterialization. Inflow was from the most distal unobstructed segment. Run-off was the dorsal pedal venous arch (n=5), the dorsal pedal venous arch and a concomitant vein of the posterior tibial artery (n=3), or the dorsal pedal venous arch and a concomitant vein of the common plantar artery (n=2) depending on the location of the ischemic lesion. Venous valves were destroyed using antegrade valvulotomes, guide wires, knob needles, or retrograde valvulotomes via an extra incision.
Results
Seven of the operated limbs were amputated after 23 (1–256) days (median [range]). The main reasons for amputation were lack of healing of either the original wound, of incisional wounds on the foot, or persisting pain at rest. In three cases, the bypass was open at the time of amputation. Two patients experienced complete wound healing after 231 and 342 days, respectively. By the end of follow-up, the last patient was ambulating with slow wound healing but without pain 309 days after surgery.
Conclusion
Venous arterialization may be used as a treatment of otherwise unsalveable limbs. The success rate is, however, limited. Technical optimization of the technique is warranted.
doi:10.3402/dfa.v4i0.22713
PMCID: PMC3867748  PMID: 24358432
critical limb ischemia; venous arterialization; revascularization; amputation prevention; wound healing
15.  Charcot foot in diabetes and an update on imaging 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21884.
Charcot neuroarthropathy (CN) is a serious complication of diabetes mellitus that can cause major morbidity including limb amputation. Since it was first described in 1883, and attributed to diabetes mellitus in 1936, the diagnosis of CN has been very challenging even for the experienced practitioners. Imaging plays a central role in the early and accurate diagnosis of CN, and in distinction of CN from osteomyelitis. Conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, and positron emission tomography are the imaging techniques currently in use for the evaluation of CN but modalities other than magnetic resonance imaging appeared to be complementary. This study focuses on imaging findings of acute and chronic neuropathic osteoarthropathy in diabetes and discrimination of infected vs. non-infected neuropathic osteoarthropathy.
doi:10.3402/dfa.v4i0.21884
PMCID: PMC3837304  PMID: 24273635
diabetes mellitus; complications; diabetic foot; Charcot foot; diagnostic imaging
16.  Osteomyelitis or Charcot neuro-osteoarthropathy? Differentiating these disorders in diabetic patients with a foot problem 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21855.
Both osteomyelitis and Charcot neuro-osteoarthropathy (CN) are potentially limb-threatening complications of diabetic neuropathy, but they require quite different treatments. Almost all bone infections in the diabetic foot originate from an infected foot ulcer while diabetic osteoarthropathy is a non-infectious process in which peripheral neuropathy plays the critical role. Differentiating between diabetic foot osteomyelitis and CN requires careful evaluation of the patient, including the medical history, physical examination, selected laboratory findings, and imaging studies. Based on available studies, we review the approaches to the diagnostic differentiation of osteomyelitis from CN of the foot in diabetic patients.
doi:10.3402/dfa.v4i0.21855
PMCID: PMC3819473  PMID: 24205433
diabetic foot; osteomyelitis; Charcot neuro-osteoarthropathy
17.  Radiographic and functional results in the treatment of early stages of Charcot neuroarthropathy with a walker boot and immediate weight bearing 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.22487.
Background
One of the most common gold standards for the treatment of Charcot neuroarthropathy (CN) in the early Eichenholtz stages I and II is immobilization with the total contact casting and lower limb offloading. However, the total amount of offloading is still debatable.
Objectives
This study evaluates the clinical and radiographic findings in the treatment of early stages of CN (Eichenholtz stages I and II) with a walker boot and immediate total weight-bearing status.
Methods
Twenty-two patients with type 2 diabetes mellitus (DM) and CN of Eichenholtz stages I and II were selected for non-operative treatment. All patients were educated about their condition, and full weight bearing was allowed as tolerated. Patients were monitored on a fortnightly basis in the earlier stages, with clinical examination, temperature measurement, and standardized weight-bearing radiographs. Their American Orthopedic Foot and Ankle Society (AOFAS) scores were determined before and after the treatment protocol.
Results
No cutaneous ulcerations or infections were observed in the evaluated cases. The mean measured angles at the beginning and end of the study, although showing relative increase, did not present a statistically significant difference (p > 0.05). Mean AOFAS scores showed a statistically significant improvement by the end of the study (p < 0.005).
Conclusion
The treatment of early stages of CN (Eichenholtz stages I and II) with emphasis on walker boot and immediate weight bearing has shown a good functional outcome, non-progressive deformity on radiographic assessment, and promising results as a safe treatment option.
doi:10.3402/dfa.v4i0.22487
PMCID: PMC3813827  PMID: 24179634
Charcot neuroarthropathy; classification; ulceration; diabetes; weight bearing
18.  A developing world experience with distal foot amputations for diabetic limb salvage 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.22477.
Objectives
To evaluate the functional outcome, morbidity, and viability of foot salvage in diabetic patients.
Materials and methods
This prospective case series was conducted from March 2007 to December 2012 at the department of surgery Pakistan Ordnance Factories Hospital, Wah Cantt, Pakistan. 123 males and 26 female patients were included in the study. All the patients were treated after getting admitted in the hospital and wounds were managed with daily dressings, nursing care and debridement of necrotic tissue with adequate antibiotic coverage.
Results
In total, 149 patients (mean age: 56±7.52 years) with 171 amputations were included in the study. The mean duration of diabetes mellitus (DM) was 9±4.43 years. Ninety-seven percent of the patients were diagnosed with type 2 DM. Wound debridement was performed under general anesthesia in 48 (33.2%) patients, whereas local anesthesia was used for the rest of the patients after having good glycemic control and improvement in general health. The most common pathogen isolated from the infected wounds was Staphylococcus aureus in approximately 46% cases. Regarding the types of amputation, partial toe amputation was performed in 21 (12.2%) cases, second-toe amputation in 60 (35%) cases, hallux amputation in 41 (24%) cases, multiple toe amputations in 29 (17%) cases, bilateral feet involvement was observed in 16 (9.3%) cases, and transmetatarsal amputation was performed in 4 (2.3%) cases. The wounds healed well except in 19 cases where amputation had to be revised to a more proximal level. Thirty-nine patients died during the study period: 3 died of wound-related complications and 36 died of systemic complications.
Conclusion
With the ever-increasing epidemic of DM, the number of patients with diabetic foot ulcers has also significantly risen. Early surgical management with good glycemic control and foot care with close monitoring can decrease amputations and thus foot salvage can be successfully achieved.
doi:10.3402/dfa.v4i0.22477
PMCID: PMC3805841  PMID: 24155996
diabetic foot; limb salvage; glycemic control; amputations; infections
19.  The system of care for the diabetic foot: objectives, outcomes, and opportunities 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21847.
Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.
doi:10.3402/dfa.v4i0.21847
PMCID: PMC3796020  PMID: 24130936
foot ulcer; diabetes; peripheral vascular disease; diabetic neuropathy; delivery of healthcare; physician's practice patterns
20.  Charcot foot and ankle with osteomyelitis 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21361.
This paper presents a review of the current literature discussing topics of Charcot osteoarthropathy, osteomyelitis, diagnosing osteomyelitis, antibiotic management of osteomyelitis, and treatment strategies for management of Charcot osteoarthropathy with concurrent osteomyelitis.
doi:10.3402/dfa.v4i0.21361
PMCID: PMC3789286  PMID: 24098835
Charcot foot; osteomyelitis; diabetes mellitus; infection; neuropathy
21.  Negative-pressure wound therapy in the management of diabetic Charcot foot and ankle wounds 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.20878.
As the prevalence of diabetes mellitus continues to rise, innovative medical and surgical treatment options have increased dramatically to address diabetic-related foot and ankle complications. Among the most challenging clinical case scenarios is Charcot neuroarthropathy associated with soft tissue loss and/or osteomyelitis. In this review article, the authors present a review of the most common utilizations of negative-pressure wound therapy as an adjunctive therapy or combined with plastic surgery as it relates to the surgical management of diabetic Charcot foot and ankle wounds.
doi:10.3402/dfa.v4i0.20878
PMCID: PMC3782614  PMID: 24069526
negative-pressure wound therapy; Charcot foot; diabetes mellitus; neuropathy; plastic surgery; external fixation
22.  Electrical stimulation to accelerate wound healing 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.22081.
Background
There are several applications of electrical stimulation described in medical literature to accelerate wound healing and improve cutaneous perfusion. This is a simple technique that could be incorporated as an adjunctive therapy in plastic surgery. The objective of this review was to evaluate the results of randomized clinical trials that use electrical stimulation for wound healing.
Method
We identified 21 randomized clinical trials that used electrical stimulation for wound healing. We did not include five studies with treatment groups with less than eight subjects.
Results
Electrical stimulation was associated with faster wound area reduction or a higher proportion of wounds that healed in 14 out of 16 wound randomized clinical trials. The type of electrical stimulation, waveform, and duration of therapy vary in the literature.
Conclusion
Electrical stimulation has been shown to accelerate wound healing and increase cutaneous perfusion in human studies. Electrical stimulation is an adjunctive therapy that is underutilized in plastic surgery and could improve flap and graft survival, accelerate postoperative recovery, and decrease necrosis following foot reconstruction.
doi:10.3402/dfa.v4i0.22081
PMCID: PMC3776323  PMID: 24049559
diabetic foot ulcer; electric stimulation therapy; treatment outcome; perfusion; infection
23.  Relative sensory sparing in the diabetic foot implied through vibration testing 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21278.
Background
The dorsal aspect of the hallux is often cited as the anatomic location of choice for vibration testing in the feet of diabetic patients. To validate this preference, vibration tests were performed and compared at the hallux and 5th metatarsal head in diabetic patients with established neuropathy.
Methods
Twenty-eight neuropathic, diabetic patients and 17 non-neuropathic, non-diabetic patients underwent timed vibration testing (TVT) with a novel 128 Hz electronic tuning fork (ETF) at the hallux and 5th metatarsal head.
Results
TVT values in the feet of diabetic patients were found to be reduced at both locations compared to controls. Unexpectedly, these values were significantly lower at the hallux (P<0.001) compared to the 5th metatarsal head.
Conclusion
This study confirms the hallux as the most appropriate location for vibration testing and implies relative sensory sparing at the 5th metatarsal head, a finding not previously reported in diabetic patients.
doi:10.3402/dfa.v4i0.21278
PMCID: PMC3776325  PMID: 24049560
diabetic foot; diabetes mellitus; diabetic polyneuropathy; diabetes-related complications; neurological examination; sural nerve
24.  An analysis of clinical activity, admission rates, length of hospital stay, and economic impact after a temporary loss of 50% of the non-operative podiatrists from a tertiary specialist foot clinic in the United Kingdom 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21757.
Introduction
Podiatrists form an integral part of the multidisciplinary foot team in the treatment of diabetic foot–related complications. A set of unforeseen circumstances within our specialist diabetes foot service in the United Kingdom caused a loss of 50% of our non-operative podiatry team for almost 7 months during 2010. Some of this time was filled by non-specialist community non-operative podiatrists.
Methods
We assessed the economic impact of this loss by examining data for the 5 years prior to this 7-month interruption, and for the 2 years after ‘normal service’ was resumed.
Results
Our data show that the loss of the non-operative podiatrists led to a significant rise in the numbers of admissions into hospital, and hospital length of stay also increased. At our institution a single bed day cost is £275. During the time that the numbers of specialist non-operative podiatry staff were depleted, and for up to 6 months after they returned to normal activities, the extra costs increased by just less than £90,000. The number of people admitted directly from specialist vascular and orthopaedic clinics is likely to have increased due to the lack of capacity to manage them in the diabetic foot clinic. Our data were unable to assess these individuals and did not look at the costs saved from avoiding surgery. Thus the actual costs incurred are likely to be higher.
Conclusions
Our data suggest that specialist non-operative podiatrists involved in the treatment of the diabetic foot may prevent unwarranted hospital admission and increased hospitalisation rates by providing skilled assessment and care in the outpatient clinical settings.
doi:10.3402/dfa.v4i0.21757
PMCID: PMC3772317  PMID: 24040488
diabetes; foot clinic; podiatrist; economic value; multidisciplinary team
25.  Charcot neuroarthropathy in simultaneous kidney–pancreas transplantation: report of two cases 
Diabetic Foot & Ankle  2013;4:10.3402/dfa.v4i0.21819.
Charcot neuroarthropathy (CN) is considered a major complication in diabetes mellitus (DM), and it is estimated that 1% of diabetic patients may develop this complication. Simultaneous kidney–pancreas transplantation (SKPT) is one of the most effective therapies for patients with type 1 DM and end-stage diabetic nephropathy. Some cases with a Charcot-modified clinical presentation during the postoperative convalescence period after SKPT have been described. The clinical presentation may condition severe destructive lesions, and good practices include systematic follow-up. Based on the cases described, SKPT is one more entity that might lead to CN ‘foot-at-risk’. The aim of this article is to describe two cases of neuropathic arthropathy with rapid progression in the short term after SKPT.
doi:10.3402/dfa.v4i0.21819
PMCID: PMC3758518  PMID: 24003361
arthropathy; neurogenic; Charcot foot; transplant; kidney; pancreas

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