[Diabetic foot syndrome-Part 2 : Revascularization, treatment alternatives, care structures, recurrency prophylaxis]. / Diabetisches Fußsyndrom ­ Teil 2 : Revaskularisation, Behandlungsalternativen, Versorgungsstrukturen, Rezidivprophylaxe.

Diabetic foot syndrome (DFS) is the most frequent reason for major amputations in Germany. The majority of foot lesions are triggered by repetitive pressure in diabetic polyneuropathy. Peripheral arterial occlusive disease (PAOD) impairs wound healing and is the main risk factor for amputations. The treatment of wounds and infections as well as timely revascularization are decisive. The use of endovascular and vascular surgical methods depends on the distribution pattern and length of the occlusion processes. Both procedures are complementary. Bypass surgery is of great importance for neuroischemic DFS. Multidisciplinary centers that provide revascularization in DFS can achieve an improvement of arterial blood flow in 90% of the cases and reduce the amputation rate by up to 80%. Due to the high recurrence rate of diabetic foot lesions, measures for secondary prophylaxis are of exceptional importance (podological and orthopedic technical care, foot surgery).

[Diabetic foot syndrome-Part 1 : Definition, pathophysiology, diagnostics and classification]. / Diabetisches Fußsyndrom ­ Teil 1 : Definition, Pathophysiologie, Diagnostik und Klassifikation.

There are ca. 8 million persons with diabetes mellitus living in Germany. A late sequelae of diabetes is the diabetic foot syndrome (DFS), the prevalence of which is greatly increasing. It comprises all alterations of the foot as a result of diabetic polyneuropathy as well as microvascular and macrovascular (peripheral arterial occlusive disease, PAOD) alterations. Many of the ca. 250,000 newly diagnosed diabetic foot ulcers per year become chronic wounds. Despite intensive efforts for prevention, early diagnosis and adequate wound care, ca. 13,000 persons with diabetes undergo major limb amputation in Germany every year. With consistent treatment in interdisciplinary centers and by exhausting all possible methods of wound treatment, pressure relief as well as arterial revascularization, the major amputation rate in patients with diabetic foot problems can be reduced by 80%. With a suitable strategy of prevention, the recurrence rate of foot ulcers would be reduced.

[Concept of plantarization for toe correction in diabetic foot syndrome]. / Konzept der Plantarisierung zur Zehenkorrektur beim diabetischen Fußsyndrom.

OBJECTIVE: Elimination of plantarization of the tip of the toe and torsion of digit 1 (D1) or D5 using percutaneous tenotomy of the flexor hallucis longus (FHL) - or the flexor digitorum longus (FDL) muscle. INDICATIONS: Flexible, in some cases also fixated hyperflexion misalignment and torsion misalignment of the distal phalanx of the toe with plantarization of physiologically non-loaded bearing parts of the toes in patients with diabetic foot syndrome (neuropathy). CONTRAINDICATIONS: Critical limb ischemia. SURGICAL TECHNIQUE: Percutaneous tenotomy of the FHL or FDL tendons using the minimally invasive lancet technique without the use of a tourniquet while the tendon is flexed by causing hyperextension of the distal phalanx and simultaneous extension of the distal interphalangeal (DIP) or interphalangeal (IP) joints. POSTOPERATIVE MANAGEMENT: Immediate full weight-bearing mobilization in sufficiently wide protective footwear with customized cushioning or a diabetes-adapted foot bed, follow-up in initially frequent intervals (2-4 per week) in order to track the development of the transfer lesions. In the case of existing wounds, more frequent visits and relief of the wounds using a post-operative shoe are required. No thrombosis prevention with full weight-bearing is necessary. RESULTS: In 138 patients with diabetic foot syndrome with polyneuropathy, of which 90 were men (65.2 %) and 48 were women (34.8 %) with a median age of 65.1 years, a total of 291 toe operations with tenotomy of the FHL- or FDL-tendon were performed. Patients were either acutely affected by apical toe lesions (92.1 %) or showed an increased risk of ulcer formation (7.9 %). The median time to closing of the wound was 13 days. It was longer with higher Wagner stages. Of the surgically treated toes 3.1 % were affected by nosocomial infections. At the 1­year follow-up 92.4 % of the patients did not show pathological results of the operated toe. Recurrence of the DFS occurred mostly during the first 6 months postoperatively. In the first year postoperatively 68.1 % of the patients remained in remission. Of the toes with Wagner grade 0, 93.7 % were free of local recurrence during the entire monitoring period and 72.2 % of the operated toes with Wagner grade 3. Within the first 1.5-8.5 months 13 % of the patients were affected by transfer lesions.

Trends in amputations in people with hospital admissions for peripheral arterial disease in Germany.

BACKGROUND: Using the information of the federal statistics, a detailed description of the hospitalisation rate for amputation in Germany was possible for the first time, and trends since 2005 can be reported. PATIENTS AND METHODS: Detailed lists of all amputations coded as minor amputations (OPS 5 - 864) and major amputations (OPS 5 - 865) performed in 2005 and 2008, divided into the 4th and 5th number of the OPS-code, were provided by the Federal Statistical Office. RESULTS: Despite an increase in total number of hospitalized patients suffering from peripheral arterial disease and neurovascular disease there is a relevant decrease in age adjusted major amputation rates per 100.000 population in Germany from 27.0 in 2005 to 25.1 in 2008 in males and from 19.7 in 2005 to 17.1 in 2008 in females. Overall minor amputation rates do not show such a decrease but increased in males (from 47.4 in 2005 to 53.7 in 2008) und remained unchanged in females (23.1 in 2005 and 23.1 in 2008). In the 6th and 7th decade of life males have approximately four times higher major and minor amputation rates than females. CONCLUSIONS: Hospitalisation rate for major amputation in Germany decreased in the recent years whereas hospitalisation rate for minor amputation did not.

[Results of a structured hypertension teaching and treatment programme]. / Wege zur Verbesserung der Qualität der antihypertensiven Therapie bei Diabetes mellitus - Ergebnisse des strukturierten Hypertonie Behandlungs- und Schulungsprogrammes.

The benefit of good blood pressure control in patients with arterial hypertension has been repeatedly demonstrated. In high risk patients, a good blood pressure control is one of the main prerequisites for the reduction in morbidity and mortality. However, as shown in population-based studies, the quality of blood pressure control both in patients with essential hypertension and in hypertensive diabetic patients is still unsatisfactory. Only a minority of patients achieve target blood pressure values below 140/90 mm Hg. This situation has not changed within the recent years, although the prescriptions of antihypertensive drugs have continuously increased. This paper describes a structured hypertension treatment and teaching programme (HTTP) which was developed and evaluated during the last 16 years and which aims at intensification of antihypertensive therapy by active involvement of the patient in his own treatment. This programme primarily focuses on the improvement of the patients' long-term treatment compliance by means of information about non-pharmacological and pharmacological therapies and instructions to regular blood pressure self measurements. The efficacy and feasibility of the HTTP has been evaluated in several studies which unanimously show considerable benefits not only concerning blood pressure control but, most importantly, regarding reduction in the incidence and progression of hypertension associated diseases as cerebro- and cardiovascular events and diabetic nephropathy. Therefore, it seems essential to implement the HTTP in the German health care system in order to finally achieve the desired quality of care for patients with arterial hypertension.