2024 TSOC/TSPS Joint Consensus: Strategies for Advanced Vascular Wound Management in Arterial and Venous Diseases.

The Taiwan Society of Cardiology (TSOC) and Taiwan Society of Plastic Surgery (TSPS) have collaborated to develop a joint consensus for the management of patients with advanced vascular wounds. The taskforce comprises experts including preventive cardiologists, interventionists, and cardiovascular and plastic surgeons. The consensus focuses on addressing the challenges in diagnosing, treating, and managing complex wounds; incorporates the perfusion evaluation and the advanced vascular wound care team; and highlights the importance of cross-disciplinary teamwork. The aim of this joint consensus is to manage patients with advanced vascular wounds and encourage the adoption of these guidelines by healthcare professionals to improve patient care and outcomes. The guidelines encompass a range of topics, including the definition of advanced vascular wounds, increased awareness, team structure, epidemiology, clinical presentation, medical treatment, endovascular intervention, vascular surgery, infection control, advanced wound management, and evaluation of treatment results. It also outlines a detailed protocol for assessing patients with lower leg wounds, provides guidance on consultation and referral processes, and offers recommendations for various wound care devices, dressings, and products. The 2024 TSOC/TSPS consensus for the management of patients with advanced vascular wounds serves as a catalyst for international collaboration, promoting knowledge exchange and facilitating advancements in the field of advanced vascular wound management. By providing a comprehensive and evidence-based approach, this consensus aims to contribute to improved patient care and outcomes globally.

Are current wound classifications valid for predicting prognosis in people treated for limb-threatening diabetic foot ulcers?

This study aims to investigate whether the current wound classifications were valid for the treatment prognosis of subjects treated for limb-threatening diabetic foot ulcers (LTDFU). A total of 1548 patients with LTDFU and infection were studied, with wounds recorded using the Wagner, Texas, PEDIS and WIfI classifications while major lower extremity amputations (LEAs) or in-hospital mortality incidences were defined as poor outcomes. Among them, 153 (9.9%) patients received major LEAs and 38 (2.5%) patients died. After adjustments, the Wagner classification and Texas stage as well as clinical factors such as comorbidity with major adverse cardiac events (MACE), being under dialysis and having serum levels of C-reactive protein (CRP) and albumin were independent factors for prognosis. For patients without dialysis, Wagner and Texas stage stood out independently for prognosis. For patients on dialysis, only levels of CRP (odds ratio [OR] = 2.2 in Wagner, OR = 2.0 in WIfI, OR = 2.2 in Texas, OR = 2.3 in PEDIS) and albumin (OR = 0.4 in four classifications) were valid predictors. The Wagner system and Texas stage were valid for predicting prognosis in treatment for LTDFUs, suggesting a role of vascular perfusion. MACE history, levels of CRP and albumin level should assist in prediction; more significantly, only levels of CRP and albumin appeared valid for those subjects undergoing dialysis.

ENERGI-F703 gel, as a new topical treatment for diabetic foot and leg ulcers: A multicenter, randomized, double-blind, phase II trial.

Background: Diabetic foot and leg ulcers are a major cause of disability among patients with diabetes mellitus. A topical gel called ENERGI-F703, applied twice daily and with adenine as its active pharmaceutical ingredient, accelerated wound healing in diabetic mice. The current study evaluated the safety and efficacy of ENERGI-F703 for patients with diabetic foot and leg ulcers. Methods: This randomized, double-blind, multicenter, phase II trial recruited patients from eight medical centers in Taiwan. Patients with intractable diabetic foot and leg ulcers (Wagner Grade 1-3 without active osteomyelitis) were randomly assigned (2:1) to receive topical ENERGI-F703 gel or vehicle gel twice daily for 12 weeks or until complete ulcer closure. The investigator, enrolled patients and site personnel were masked to treatment allocation. Intention to treat (ITT) population and safety population were patient to primary analyses and safety analyses, respectively. Primary outcome was complete ulcer closure rate at the end of treatment. This trial is registered with ClinicalTrials.gov, number NCT02672436. Findings: Starting from March 15th, 2017 to December 26th, 2019, 141 patients were enrolled as safety population and randomized into ENERGI-F703 gel (n = 95) group or vehicle gel (n = 46) group. In ITT population, ENERGI-F703 (n = 90) and vehicle group showed ulcer closure rates of 36.7% (95% CI = 26.75% - 47.49%) and 26.2% (95% CI = 13.86% - 42.04%) with difference of 9.74 % (95 % CI = -6.74% - 26.23%) and 25% quartiles of the time to complete ulcer closure of 69 days and 84 days, respectively. There were 25 (26.3%) patients in ENERGI-F703 group and 11 (23.9%) patients in vehicle group experiencing serious adverse events and five deaths occurred during the study period, none of them related to the treatment. Interpretation: Our study suggests that ENERGI-F703 gel is a safe and well-tolerated treatment for chronic diabetic foot and leg ulcers. Further studies are needed to corroborate our findings in light of limitations. Funding: Energenesis Biomedical Co., Ltd.

Impact of wound microbiology on limb preservation in patients with diabetic foot infection.

AIMS/INTRODUCTION: To investigate the association between specific bacterial pathogens and treatment outcome in patients with limb-threatening diabetic foot infection (LT-DFI). MATERIALS AND METHODS: Consecutive patients treated for LT-DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 and 2017. Patients with positive wound culture results at first aid were enrolled. Clinical factors, laboratory data, and wound culture results were compared. Lower-extremity amputations and in-hospital mortality were defined as a poor outcome. RESULTS: Among the 558 patients, 272 (48.7%) patients had lower extremity amputation and 22 (3.9%) patients had in-hospital mortality. Gram-negative bacterial (GNB) infection was the independent factor following factors adjustment. When all the 31 microorganisms were analyzed, only E. coli (adjusted odds ratio [aOR], 3.01; 95% CI, 1.60-5.65), Proteus spp. (aOR, 2.99; 95% CI, 1.69-5.29), and Pseudomonas aeruginosa (aOR, 2.00; 95% CI 1.20-3.32) were associated with poor outcome. The analysis of specific GNB species in association with major- or minor- amputation have been reported. No specific pathogen was associated with cause of death in patients with mortality within 30 days. The antimicrobial-resistant strains were not associated with a poor treatment outcome. CONCLUSIONS: The presence of GNB was associated with limb amputations. This study provides insight into more timely and appropriate management of the diabetic foot infection.

Diabetic Foot Infection Presenting Systemic Inflammatory Response Syndrome: A Unique Disorder of Systemic Reaction from Infection of the Most Distal Body.

Diabetic foot infection (DFI) is a major complication of diabetic foot that lead to nontraumatic lower-extremity amputation (LEA). Such distal infection of the body having systemic inflammatory response syndrome (SIRS) is rarely reported. Consecutive patients treated for limb-threatening DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 to 2017. Clinical factors, laboratory data, perfusion, extent, depth, infection and sensation (PEDIS) wound score in 519 subjects with grade 3 DFI and 203 presenting SIRS (28.1%) were compared. Major LEA and in-hospital mortality were defined as poor prognosis. Patients presenting SIRS had poor prognosis compared with those with grade 3 DFI (14.3% versus 6.6% for major LEA and 6.4% versus 3.5% for in-hospital mortality). Age, wound size, and HbA1c were independent risk factors favoring SIRS presentation. Perfusion grade 3 (odds ratio 3.37, p = 0.044) and history of major adverse cardiac events (OR 2.41, p = 0.036) were the independent factors for poor prognosis in treating patients with DFI presenting SIRS. SIRS when presented in patients with DFI is not only limb- but life-threatening as well. Clinicians should be aware of the clinical factors that are prone to develop and those affecting the prognosis in treating patients with limb-threatening foot infections.

Amino acids and wound healing in people with limb-threatening diabetic foot ulcers.

BACKGROUND: Amino acids are associated with wound healing in traumatic wounds and burns, although their effects on healing in patients with diabetic foot ulcers (DFUs) are limited. This study aimed to evaluate and identify specific amino acids associated with healing outcomes of patients with DFUs. METHODS: Sixty-two out of 85 patients who completed the in-hospital treatment for limb-threatening DFUs were enrolled. All ulcers had epithelialization without clinical evidence of infection at discharge. The patients and their families were instructed on foot-care techniques and committed to regular follow-up for 1 year. Baseline characteristics, PEDIS wound classification, laboratory data and serum amino acid levels were used to analyze their predictive power. RESULTS: Fifty-seven patients completed the study in which 38 had healed and 19 had unhealed ulcers. The unhealed group had higher incidence of coronary artery disease and larger wound size. Most patients received endovascular therapy (81.6% healed group; 78.9% unhealed group) before enrollment. Following adjustments for clinical factors, the serum levels of arginine (326.4 µmol/L vs. 245.0 µmol/L, P = 0.045), isoleucine (166.7 µmol/L vs. 130.1 µmol/L, P = 0.019), leucine (325.8 µmol/L vs. 248.9 µmol/L, P = 0.039), and threonine (186.7 µmol/L vs. 152.0 µmol/L, P = 0.019) were significantly higher in the healed group. CONCLUSIONS: The amino acids associated with wound healing in DFUs differ from those reported for traditional traumatic wounds. These findings affirm the necessity for future large-scaled studies for the application of these amino acids in DFU healing, either as prognostic predictors or supplemented regimens.

1H Nuclear Magnetic Resonance (NMR)-Based Cerebrospinal Fluid and Plasma Metabolomic Analysis in Type 2 Diabetic Patients and Risk Prediction for Diabetic Microangiopathy.

Insulin resistance and metabolic derangement are present in patients with type 2 diabetes mellitus (T2DM). However, the metabolomic signature of T2DM in cerebrospinal fluid (CSF) has not been investigated thus far. In this prospective metabolomic study, fasting CSF and plasma samples from 40 T2DM patients to 36 control subjects undergoing elective surgery with spinal anesthesia were analyzed by 1H nuclear magnetic resonance (NMR) spectroscopy. NMR spectra of CSF and plasma metabolites were analyzed and correlated with the presence of T2DM and diabetic microangiopathy (retinopathy, nephropathy, and neuropathy) using an area under the curve (AUC) estimation. CSF metabolomic profiles in T2DM patients vs. controls revealed significantly increased levels of alanine, leucine, valine, tyrosine, lactate, pyruvate, and decreased levels of histidine. In addition, a combination of alanine, histidine, leucine, pyruvate, tyrosine, and valine in CSF showed a superior correlation with the presence of T2DM (AUC:0.951), diabetic retinopathy (AUC:0.858), nephropathy (AUC:0.811), and neuropathy (AUC:0.691). Similar correlations also appeared in plasma profiling. These metabolic alterations in CSF suggest decreasing aerobic metabolism and increasing anaerobic glycolysis in cerebral circulation of patients with T2DM. In conclusion, our results provide clues for the metabolic derangements in diabetic central neuropathy among T2DM patients; however, their clinical significance requires further exploration.

Knowledge of the Warning Signs of Foot Ulcer Deterioration Among Patients With Diabetes.

BACKGROUND: Seeking treatment in a timely manner may prevent lower limb amputation subsequent to diabetic foot ulcers. Knowledge regarding the warning signs is one importantfactor that is related to the timely treatment seeking of patients with diabetic foot ulcers. However, there is no previousresearch on which aspects of such knowledge that patients with diabetes are lacking. PURPOSE: The aims of this study were to test the psychometric properties of a questionnaire that was designed to assess the knowledge of the warning signs of diabetic foot ulcer deterioration and to determine the knowledge of these warning signs among patients with a history of diabetic foot ulcers. METHODS: A cross-sectional study design was used. Patients with a history of diabetic foot ulcers were recruited using convenience sampling (N = 385). Data were analyzed using Spearman's rank correlation and the Mann-Whitney U test. RESULTS: The questionnaire showed good known-group validity, satisfied internal consistency (Kuder-Richardson Formula 20 = .82), and exhibited acceptable 2-week test-retest reliability (Spearman's rho coefficient = .75). More than 30% of the participants were unaware of the warning signs of peripheral vascular insufficiency and severe infection. Of the participants, 75.8% felt that the time to seek medical treatment of diabetic foot ulcers was when they experienced wound deterioration. Those who held this opinion had significantly less knowledge regarding the warning signs of diabetic foot ulcer deterioration than did those who had not. Other factors that were significantly associated with less knowledge included being older, having less education, not having an existing foot ulcer, having no foot ulcer treatment history, and never having received education regarding foot ulcers. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The questionnaire showed adequate validity and reliability and thus may be used by healthcare practitioners and researchers to assess the knowledge of at-risk patients regarding the warning signs of diabetic foot ulcer deterioration. Patient education regarding the importance of timely treatment seeking and warning signs should be promoted.

Anatomical Basis and Clinical Application of Synovial Flaps in the Wrist and Distal Forearm.

BACKGROUND: Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed. METHODS: Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region. RESULTS: All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms. CONCLUSIONS: When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.

The impact of nutritional status on treatment outcomes of patients with limb-threatening diabetic foot ulcers.

AIM: This study aimed to investigate the nutritional status of patients with limb-threatening diabetic foot ulcers (DFUs) and its impact on treatment outcomes. METHODS: A total of 478 consecutive patients (mean age, 65.4years) treated for limb-threatening DFUs were enrolled. Nutritional status assessment using the Mini Nutritional Assessment (MNA) and Geriatric Nutritional Risk Index (GNRI) was performed by three qualified dieticians within 48hours of admission. Limb-preservation outcomes were stratified into major lower extremity amputation (LEA) (above the ankle, n=33), minor LEA (distal to ankle, n=117) and no amputation (non-LEA, n=328). RESULTS: Most patients were identified as being at risk of malnutrition (70.5%) or malnourished (14.6%) (mean MNA score, 20.6±3.4). MNA scores decreased with increasing severity of LEA (mean, 21.1, 20.0, and 17.9, respectively; P for linear trend <0.001), associated inversely with the tendency to require LEA (P for linear trend was 0.001), and associated independently with both major and minor LEA outcomes (adjusted odds ratio [aOR]=0.80, 95% confidence interval [CI], 0.65-0.99, P=0.042 and aOR=0.89, 95% CI, 0.80-0.99, P=0.032, respectively). The predictive value was sustained in patients younger than age 65years. Though GNRI results had similar associations with outcomes, its predictive value was limited in minor LEA and younger population. CONCLUSIONS: Patients' nutritional status was shown to have significant influence on limb-preservation outcomes for limb-threatening DFUs. Nutritional assessment of this patient population using the MNA is recommended.

Clinical Characteristics and Risk Factor Analysis for Lower-Extremity Amputations in Diabetic Patients With Foot Ulcer Complicated by Necrotizing Fasciitis.

Patients with diabetes are at a higher risk of having diabetic foot ulcers (DFUs) or necrotizing fasciitis (NF). The present study aims to examine the clinical characteristics and associated risk factors for lower-extremity amputation (LEA) in patients with DFU complicated by NF.We retrospectively reviewed patients treated at a major diabetic foot center in Taiwan between 2009 and 2014. Of the 2265 cases 110 had lower-extremity NF. Limb preservation outcomes were classified as major LEA, minor LEA, or limb-preserved. Clinical characteristics, laboratory data, and bacterial culture results were collected for analysis.Of the 110 patients with NF, 100 had concomitant DFUs (NF with DFU) and the remaining 10 had no DFU (NF without DFU). None of the NF patients without DFU died nor had their leg amputated. Two NF patients with DFU died of complications. The amputation rate in the surviving 98 NF patients with DFU was 72.4% (46.9% minor LEA and 25.5% major LEA). Seventy percent of the NF patients without DFU had monomicrobial infections (60% with Streptococcus species), and 81.4% NF patients with DFU had polymicrobial infections. Anaerobic organisms were identified in 66% of the NF patients with DFU. Multinomial logistic regression analysis revealed an association between high-grade Wagner wound classification (Wagner 4 and Wagner 5) and LEA (adjusted odds ratio [aOR] = 21.856, 95% confidence interval [95% CI] = 1.625-203.947, P = 0.02 and aOR = 20.094, 95% CI = 1.968-205.216, P = 0.01 for major and minor LEA, respectively) for NF patients with DFU. In addition, a lower serum albumin level was associated with major LEA (OR = 0.066, P = 0.002).In summary, once DFUs were complicated by NF, the risk of amputation increased. Empirical treatment for NF patients with DFU should cover polymicrobial infections, including anaerobic organisms. The high-grade wound classification and low serum albumin level were associated with LEA.

Functional and aesthetic outcomes of the fingertips after nail lengthening using the eponychial flap.

INTRODUCTION: Eponychial flap technique is able to lengthen the visible nail and allow the preservation of the nail complex following fingertip amputations with nail bed involvement. The study assessed the functional and aesthetic outcomes of the reconstructed fingertips using the eponychial flap. METHODS: Eponychial flaps were performed in 11 fingertip amputations. Two-point discrimination, light touch, Purdue dexterity test, and pinch power of the reconstructed digits were examined. Patient-reported outcomes including subjective pain, Michigan Hand Outcome Questionnaire, and visual analog scale for appearance were documented. For comparison, nine patients with similar fingertip amputations treated by stump revision and nail bed ablation were included. RESULTS: The average length of the visible nail beds of the injured digits was 33.3% compared with the contralateral normal nail beds. The eponychial flap could lengthen the nail beds by an average of 32.4% of the length of the contralateral side. The mean follow-up was 26 months. Patients treated using the eponychial flap had greater pinch power of the reconstructed digits, higher satisfaction, and better aesthetic results when compared with patients receiving stump revision and nail bed ablation. There were no significant differences between two groups in sensation and Purdue dexterity test. Patient satisfaction was correlated with the reconstructed nail length. CONCLUSION: The eponychial flap is a simple and safe technique that can restore the functional and aesthetic fingertip in selected distal phalanx amputations. The aesthetics, pinch power, and patient satisfaction are significantly better with fingernail preservation and elongation using the eponychial flap.

Prognostic factors for Taiwanese patients with cutaneous melanoma undergoing sentinel lymph node biopsy.

BACKGROUND/PURPOSE: Sentinel lymph node biopsy (SLNB) is a standard procedure in the management of clinically node-negative melanoma. However, few studies have been performed on SLNB in Asia, which is an acral melanoma-prevalent area. This study evaluated the clinicopathologic prognostic factors of disease-free survival (DFS) and overall survival (OS) in Taiwanese patients with cutaneous melanoma who received wide excision and SLNB. The prognosis of patients with false-negative (FN) SLNB was also evaluated. METHODS: Malignant melanoma cases were reviewed for 518 patients who were treated between January 2000 and December 2011. Of these patients, 127 patients with node-negative cutaneous melanoma who received successful SLNB were eligible for inclusion in the study. RESULTS: The SLNB-positive rate was 34.6%. The median DFS was 51.5 months, and the median OS was 90.9 months at the median follow-up of 36.6 months. Multivariate analysis revealed that patients whose melanoma had a Breslow thickness greater than 2 mm had a significantly shorter DFS than patients whose melanoma had a Breslow thickness of 2 mm or less [hazard ratio (HR), 3.421; p = 0.005]. Independent prognostic factors of OS were a Breslow thickness greater than 2 mm (HR, 4.435; p = 0.002); nonacral melanoma (HR, 3.048; p = 0.001); and an age older than 65 years (HR, 2.819; p = 0.036). During the follow-up period, 13 of 83 SLN-negative patients developed a regional nodal recurrence. The SLNB failure rate was 15.7% and the FN rate was 22.8%. Compared to patients with a true-positive SLNB, patients with FN SLNB had a significantly shorter DFS (p = 0.001) but no significant difference in OS (p = 0.262). CONCLUSION: Except for the pathologic subtypes, prognostic factors in Taiwan are similar to those used in other melanoma-prevalent countries. Identifying and closely monitoring patients at risk of nodal recurrence after a negative SLNB is important.

Achilles tendon lengthening: friend or foe in the diabetic foot?

BACKGROUND: Literature in the past decade has shown that Achilles tendon-lengthening surgery in addition to total contact casting decreases the rate of plantar ulcer recurrence in the forefoot and midfoot; however, the risk of heel ulceration or recurrent equinus deformity with new forefoot or midfoot wounds is not insignificant. The purpose of this study was to compare the rate of recurrent ulceration between the patient groups who have undergone soft-tissue repair of diabetic forefoot or midfoot wounds either with or without concomitant Achilles tendon-lengthening surgery. METHODS: All diabetic patients with plantar forefoot or midfoot ulceration who underwent soft-tissue reconstruction during two different time periods-from 1983 to 1991 or from 1996 to 2004-were reviewed. Multiple patient-related factors were compared. The "early group" consisted of 179 wounds in 149 patients who underwent wound closure surgery alone. The "later group" included 145 wounds in 138 patients who underwent similar wound closure procedures with the addition of Achilles tendon-lengthening surgery. RESULTS: Twenty-five percent in the early group and 2 percent of patients in the later group developed recurrent ulceration requiring reoperation, which resulted in 94 percent relative risk reduction (p < 0.001), whereas the risk factors and demographic data were similar in each group. In addition, 12 percent in the early group and 4 percent of the later group developed transfer lesions (p < 0.001). CONCLUSION: If one avoids excessive Achilles lengthening, the addition of an Achilles tendon-lengthening procedure can significantly reduce the risk of recurrent diabetic foot ulcerations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Primary free functioning muscle transfer for fingers with accompanying tendon transfer for thumb provide one-stage upper extremity composite reconstruction in acute open wound.

BACKGROUND: Upper limb trauma may present as both soft tissue and muscle defects necessitating a free skin flap to effect a repair. The limb's core (basic) functionality can be returned with a secondary tendon transfer or a functioning muscle transfer. A functioning muscle flap can provide for soft tissue repair and functional restoration in a single procedure, but the success of such procedures requires further clarification. MATERIAL: From 1997 to 2006, nine patients underwent free functioning muscle transfer performed for upper extremity composite structure and functional defects, including four flexor digitorum profundus muscle and three extensor digitorum comminis muscle defects. Seven thumb tendon defects were managed with simultaneous tendon and free functioning muscle transfer. In addition, two opponensplasties and one thumb basal joint arthrodesis were performed for thumb function revision. RESULT: In all nine patients, procedures were completed without complications, the flaps surviving, enabling the patients to achieve opposable hand function. The muscle strength accomplished M4.2 (M3-5). The grip power was 41.7, and pinch power 55.3%, when compared with the other hand. CONCLUSION: Primary functioning muscle transfer can provide a one-stage composite functional restoration in an open wound. The thumb can be reconstructed with tendon transfer followed by opponensplasty to achieve a satisfactory range of opposable function.

Skin grafting as a salvage procedure in diabetic foot reconstruction to avoid major limb amputation.

BACKGROUND: Bone and tendons exposure in diabetic patients requires flap reconstruction to avoid major limb amputation. However, for critical and unstable diabetic patients, revascularization and flap reconstruction may not be feasible. Skin grafts can be used in such a situation, and the purpose of this study is to evaluate this procedure in terms of treatment outcome. METHODS: From October 2003 to October 2006, there were 73 critical diabetic cases with bone and tendon exposure at the lower extremities. Repeated debridements were performed to remove the exposed tendon and burr the bare bone until bleeding. Some cases needed adjuvant therapy to promote granulation for skin grafting. RESULTS: Before skin grafting, thirty cases need toe amputation. The mean presurgical preparation period for a suitable granulation bed was 38.4 days. After skin grafting, wound healing was achieved within 4 weeks in 54 cases, and it took over 4 weeks in 9 cases. In 2 cases, a second skin graft was required.Forefoot stump revision was performed in 3 cases. Total wound healing could not be achieved within 3 months in 5 cases. The complete wound healing rate was 74% in 1 month and 86.3% in 2 months. CONCLUSION: In order to preserve the feet, the skin grafting rather than major amputation is suitable for critical and unstable diabetic patients. The drawback is the relatively prolonged treatment course.

C-reactive protein as an outcome predictor for percutaneous transluminal angioplasty in diabetic patients with peripheral arterial disease and infected foot ulcers.

AIM: Although percutaneous transluminal angioplasty (PTA) is an effective therapeutic procedure for critical limb ischemia, several clinical factors can influence the outcome of PTA for peripheral arterial disease (PAD). The aim of this study is to identify the outcome predictors of PTA in infected diabetic foot patients with PAD. METHODS: Eighty-five diabetic patients with a total of 90 infected limbs treated by PTA participated in this study. Patients were initially admitted for infected foot ulcers and were later diagnosed with PAD. Even though all patients underwent successful PTA within 15 days of admission, limb salvage was successful in 66 cases while 24 underwent subsequent amputation. The clinical characteristics and laboratory variables of both groups before PTA were compared and analyzed. RESULTS: Significantly higher level of C-reactive protein (CRP) was observed in the major amputation group before PTA. The cutoff value via receiver operating characteristic curve was 50mg/L (81.8% specificity, 70.7% sensitivity). Multivariate logistic regression analysis revealed that CRP levels may serve as valuable marker in determining a successful outcome. CONCLUSION: Reduced CRP levels (<50mg/L), which indicates a low infection severity, may serve as a major predictor of successful PTA outcome in diabetic patients with infected foot ulcers.

Hand and finger replantation after protracted ischemia (more than 24 hours).

Ischemia tolerance has been a major concern during hand and finger replantation. Because of multiple referrals and damage control resuscitation, ischemia is occasionally prolonged for more than 24 hours. Amputation impairs functional efficiency in amputees; therefore, if there is a favorable indication for replantation, microsurgical replantation can be performed to salvage the function of the affected part to an acceptable extent.Between 1998 and 2006, 14 patients underwent 25 replantations after prolonged ischemia of more than 24 hours. Of the 14 patients, 12 were referred to our hospital after unsuccessful replantations and admitted to the emergency room. Two of these patients underwent thumb amputations, and 10 patients underwent multiple digit amputations. Two patients underwent wrist amputation with associated polytrauma and profound shock, both hand replantations were performed on the following day after ICU management with damage control resuscitation was performed to control excessive bleeding and stabilize vital signs.In this study, 16 replantations were successful and 9 failed; thus, the success rate was 64.0%. Several secondary procedures were required for restoring the functional ability of the reconstructed parts.Ischemia time is critical for limb salvage. Hands and fingers have very little muscle tissue. Hence, replantation of these parts can be performed even in the case of prolonged ischemia to restore the hand function.