Surgical strategies for prevention of amputation of the diabetic foot.

Prevention of amputation has become a key objective of clinicians providing care to patients with high-risk diabetic foot problems. In this regard, the multidisciplinary diabetic foot team (MDFT) has been embraced as the most effective way to manage patients with foot ulcers, infections, and Charcot feet. Importantly, such specialized teams have also integrated various surgical specialties to enable more expedient management of these often complex conditions. Experienced diabetic foot surgeons over the last three or four decades have contributed much to this discipline, whereby foot-sparing reconstructive procedures or minor amputations have become fundamental strategies for limb preservation teams. Central to limb salvage, of course, is the recognition of underlying vascular insufficiency and the importance of prompt (endo)vascular intervention. Restoration of adequate perfusion is essential to allow the podiatric, orthopaedic, or plastic surgeon to perform indicated functional reconstructive or minor amputation procedures. This evidence-based overview discusses the various indications and surgical principles inherent in modern concepts aimed at preventing amputation in the high-risk diabetic foot.

Effect of painless diabetic neuropathy on pressure pain hypersensitivity (hyperalgesia) after acute foot trauma.

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.

Internal pedal amputations.

Internal pedal amputation consists of resection of the metatarsals, midtarsal bones, or talus with preservation of the toes and soft-tissue envelope. Although used in the past for the treatment of tuberculosis within the pedal skeleton, internal pedal amputations have become almost forgotten, historical procedures. However, following internal pedal amputations of a diabetic patient, the foot undergoes significant contracture that results in a stable, functional, foreshortened residual foot capable of being protected in custom-molded shoe gear with external or in-shoe orthoses. The author presents the surgical approach and postoperative treatment regime for each form of internal pedal amputation, as well as "pearls" for success.

Orthotic management of Charcot feet after external fixation surgery.

The authors use a total contact cast (TCC), Charcot restraint orthotic walker (CROW), or prefabricated diabetic walker (DW) for the treatment of neuroarthropathy, depending on the medical, social, and economic circumstances. There is not one single orthosis for the treatment of Charcot feet, but there are several models with advantages and disadvantages the physician should be aware of. In a retrospective study of 200 Charcot feet, the ankle foot orthosis (AFO) built in the authors' workshop turned out to be an efficient and comfortable appliance for orthotic treatment after reconstructive surgery. They prefer this type of orthosis because of its versatility and its safe application in a compliant patient.

Optimized flow cytometric analysis of endothelial progenitor cells in peripheral blood.

Although flow cytometry is a rapid and convenient way to measure the number of circulating endothelial progenitor cells (EPC), there is no standard technique for preparation and measurement. The aim of this study was to present an optimized preparation method for EPC measurement which should serve as a standard to facilitate the comparison of the results in stem cell investigations by different research groups. We have looked for the preparation method which delivered the best immunostaining with the directly conjugated antibodies against VEGF R2, CD133, CD34, and CD45. In order to test the sensitivity of the method, we determined the number of EPC in the peripheral blood of volunteers by flow cytometry and by cell culture assay. Furthermore, we have evaluated the influence of different durations of conservation on the EPC cell count. The pre-treatment of blood samples with 0.2% formaldehyde for 30 minutes delivers the best immunostaining, and blood samples can be stored overnight at 4 degrees C without loss of counting rate for EPC. We found an excellent correlation (r = 0.98) between the flow cytometric measurement and the cell count of the cell culture method. The presented protocol for the flow cytometric measurement of EPC in the peripheral blood can be used as a diagnostic or prognostic tool; we propose this protocol as the standard for EPC quantification.