Four-stage surgical regime limits amputation in diabetic foot
MedWire News: A four-stage operative regime achieves a low rate of major amputation and ulcer recurrence in patients with diabetic foot ulcer and deformity, study data show.
The regime resulted in a 1% amputation rate and a 15% ulcer recurrence rate. But, while this is superior to rates reported in the existing literature, the researchers acknowledge that the regimen, which includes debridement, closure, unloading, and correction, is complex and costly.
Worldwide around 6 million diabetic patients suffer from a diabetic foot, of whom 5-15% have a foot ulcer and 3% an additional foot and/or ankle deformity.
The main principles of therapy of the diabetic foot are optimization of metabolism, infection control, revascularization, corrective surgical procedures, and optimal shoe/insole supply.
"It has been estimated that amputations could be reduced 75% (or to less than 500,000) worldwide if everyone followed optimal treatment protocols," comment Martinus Richter and Stefan Zech from Location Hospital Rummelsberg in Germany.
For the current study the researchers devised a four-stage regimen for operative treatment of diabetic foot ulcer with deformity.
Debridement (stage 1) aimed to remove all nonvital tissue with the goal to achieve a sterile situation with vacuum-assisted sealing. Intraoperative microbiologic specimens were obtained to determine the necessary antibiotic therapy. If the microbiologic specimens were positive, debridement was repeated up to a maximum of five times after which amputation was performed if the wound was still infected.
After achieving a sterile situation, closure (stage 2) was performed during the same hospital stay with sutures followed by local shifted skin graft, combined with meshgraft. If these options were not successful, functional amputation was considered.
The closed ulcer was then completely unloaded (stage 3) for 6 weeks using different orthoses, such as crutches or wheelchairs.
Last, deformities such as flatfoot and cavus foot that were considered to increase the risk for repetitive ulcer were corrected with arthrodesis including partial weight bearing then customized insoles and/or special diabetic shoes (stage 4).
In all, 335 patients with diabetic foot ulcer and deformity entered stage 1 between January 2006 and August 2010.
Of these, 300 (90%) patients completed treatment with an average follow-up period of 26 months. Recurrent ulcer was registered in 46 (15%) patients.
The overall amputation rate was 14%, the majority at digital or midfoot level: four (1%) cases required a below-knee amputation, three (3%) midfoot/transmetatarsal, five (2%) transmetatarsal, and 26 (9%) amputation of toes.
"The introduced operative four-stage regimen is doubtless a very complex and expensive management," Richter and Zech comment in Foot and Ankle Surgery.
Nevertheless they note: "Above all a low rate of major amputation is decisive. It is medical knowledge that major amputations are responsible for highest cost by far during the clinical course."
By Andrew Czyzewski