Combined primary subintimal and endoluminal angioplasty for ischaemic inferior-limb ulcers in diabetic patients: 5-year practice in a multidisciplinary 'diabetic-foot' service.

INTRODUCTION: This study aims to assess the patency, the clinical success and the limb-salvage rates of combined subintimal (SA) coupled to endoluminal angioplasty (EA) as the initial treatment of ischaemic inferior-limb ulcers in diabetic patients and to study the influence of other concurrent factors in the tissue-healing process. MATERIALS AND METHOD: Since September 2002 until December 2007, a consecutive series of 176 limbs with manifold ischaemic wounds in 161 diabetic patients were treated by associated multilevel angioplasties in a multidisciplinary 'diabetic-foot team' (a third-line diabetic-care institution integrating two departmental hospitals). There were 98 associated SA with EA procedures, 26 re-vascularisations by single SA technique and 52 others including selective multilevel EAs that were retrospectively reviewed. The mean follow-up period was 22.1 months (in the range of 1-50 months) by clinical and duplex evaluation (every 6 months). RESULTS: The initial technical success was noted in 149 limbs (84%). For the single or associated SA procedures, 102 of 124 procedures were successful (82%) and 145 of 150 of the miscellaneous EAs (96%) evinced an equally favourable outcome. The 27 initially failed endovascular procedures (22 SA and five EA) required 16 surgical re-vascularisation, eight adjuvant endovascular procedures besides three amputations. A total of 21 secondary and five tertiary angioplasties were equally necessary during the entire follow-up period of these patients. The 30-day survival rate was 99% (one patient died from myocardial infarction). In a intention-to-treat analysis, the cumulative primary and secondary patencies at 12, 24, 36 and 48 months were 62%, 45%, 41% and 38%, together with 80%, 69%, 66% and 66%, respectively. The aggregate clinical success rates at the same intervals were 86%, 77%, 70% and 69%, while the corresponding limb-salvage proportions showed 89%, 83%, 80% and 80%, respectively. The primary patency was negatively affected at 1 and 4 years by the length of the occluded segment (>10 cm) and the end-stage renal disease (ESRD) (p<0.0001). The limb-salvage rates were unfavourably influenced at the same periods by the extent of tissue defects (>3 cm), the ESRD and the presence of osteomyelitis. In addition, at 4 years, the age (>70 years), the accompanying peripheral neuropathy, the bedridden status and the presence of cardiac failure (left ventricular ejection fraction (LVEF)<30%) appeared equally as negative predictors (p<0.0001) for wound healing and limb rescue. CONCLUSION: Primary angioplasty represents a low aggressive and efficacious method to improve the healing process in diabetic ischaemic ulcers. However, beyond appropriate re-vascularisation, even repetitive if necessary, achieving satisfactory limb-salvage rates probably implies a multidisciplinary control of the presenting risk factors for wound healing as well.

Why a multidisciplinary team may represent a key factor for lowering the inferior limb loss rate in diabetic neuro-ischaemic wounds: application in a departmental institution.

UNLABELLED: INTRODUCTION/AIM OF THE STUDY: To assess the influence of a multidisciplinary approach on the limb salvage rates in the treatment of patients suffering from diabetic ischaemic inferior limb ulcers. MATERIALS & METHOD: From September 2001 until March 2008, a consecutive series of 183 limbs with diabetic ischaemic wounds in 163 patients were treated by combined multi-level angioplasties as the primary revascularization approach in an institutional diabetic programme (two departmental hospitals). The avoidance of limb loss was retrospectively analyzed before and after the year 2005, as a landmark for implementing a "multidisciplinary diabetic foot clinic" in the routine daily care. RESULTS: Initial technical success for endovascular revascularization was noted in 152 limbs (83%). The aggregate limb salvage proportions at 12, 24, 32, 60 and 66 months (+/- SEM) were: 87% (+/- 2.8), 80% (+/- 3.9), 77% (+/- 4.4) and thereafter 77% (+/- 4.4), respectively. A comparison between the limb salvage rates before and after initiating the multidisciplinary group showed a significant difference (p = 0.040, CI: 1.040-5.311, HR: 2.35, Chi square = 4.22) with better results in the latest interval, employing effective team activity. No statistical deviation was found regarding the technique itself for revascularization at the same intervals (p = 0.381). CONCLUSION: Our experience suggests that limb salvage for diabetic ischaemic wounds may be favourably influenced by a co-ordinated multidisciplinary group. Although appropriate revascularization is crucial for limb rescue, a pluralist control of the attending risk factors influencing wound healing might be of matchless importance as well.

[Osteochondroma of the clavicle and pain syndrome of the shoulder. Apropos of a case. Review of the literature]. / Ostéochondrome de la clavicule et syndrome douloureux de l'épaule. A propos d'un cas. Revue de la littérature.

INTRODUCTION: Osteochondroma, a frequent benign tumor of the bone, is in most cases asymptomatic. Localization in the clavicle is extremely rare. The authors report an isolated case occurring in the coraco-clavicular area responsible for a painful shoulder syndrome evoking rotator cuff tendinitis. METHODS: A 47 years female patient consulted for painful shoulder syndrome. Pain occurred following an effort and at night. On clinical examination, the area around the coracoid process was tender as was the supraspinatus fossa. Passive anterior elevation of the shoulder was limited to 150 degrees. She had a positive Job's sign as well as a painful << Gross armtest >>. Initial Radiological assessment showed no anomalies. Arthrographic CT scan revealed an expansive process compatible with osteochondroma. The lesion was in contact with the supraspinatus muscles and the coracoid process. Extraperiosteal resection was performed through a delto-pectoral approach. Recovery of a painless mobile joint was rapid. DISCUSSION: Clavicular embryology is not yet well understood. The appearance of an exostosis at this localization seems to confirm that the clavicular cartilage behaves as an epiphyseal bone plate. The exostosis, which has a congenital origin, can appear, when it reaches a certain size or when it mechanically interferes with surrounding muscles and tendons. In our observation, the lesion led to irritation of the supraspinatus muscle leading to tendinitis. Diagnosis is usually made on standard roentgenographic evaluation. CT scan and MRI show a cartilaginous coating which should not exceed 10 mm in the case of a benign tumor. There exists a possibility of sarcomatous degeneration, but this is rare on the peripheral skeleton. Treatment should be performed by complete extraperiosteal resection of the exostosis along with its perichondral cover. CONCLUSION: Clavicular localization of an osteochondroma is very rare. This case report illustrates the possibility of a painful shoulder syndrome associated with this lesion. This report also seems to suggest the hypothesis that the cartilage at this level behaves as an epiphyseal bone plate.

Mucormycosis in an apparently normal host. Case study and literature review.

Mucormycosis refers to an opportunistic fungal infection most often related to predisposing conditions, especially uncontrolled diabetes. It can occur as a rapidly extending rhinocerebral infection presenting a high mortality rate. The same micro-organism has, however, been identified in benign paranasal infections in the absence of a general debilitating condition, suggesting that host factors are of the utmost importance in the outcome of paranasal mucormycosis.