Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes.

OBJECTIVE: The two most common sites for diabetic neuropathic foot ulcers are the forefoot and the heel. Each site has special characteristics that determines its course. The aim of this study is to compare clinical presentation, management and outcome of diabetic neuropathic forefoot ulcers to diabetic neuropathic heel ulcers. METHOD: This was a prospective cross-sectional comparative study carried in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A hundred patients with neuropathic diabetic ulcer were included, half were forefoot ulcers and the other half were hindfoot ulcers, two patients were lost on follow-up from each group. Neuropathy was graded using 10g monofilament nylon. Patients with vascular ischaemia, ankle brachial index pressure (ABPI) <0.9 and >1.1 were excluded. Other patient's data included demographic, foot and ulcer characteristics, comorbidities and outcomes. Foot ulcers were categorised according to Wagner classification, site and size of ulcer and presence of infection. Comorbidities evaluated included hypertension, ischaemic heart disease and renal impairment. All patients received standard wound care and regular follow-up. RESULTS: The age of the studied patients was 54.3 ± 11 years (mean ± standard deviation (SD 11)) and 52.9 ± 11 years for forefoot and heel ulcer respectively. The mean duration of diabetes was 12.4 ± 6 years for forefoot ulcers and 13.3 ± 7 years for heel ulcer. The mean duration of foot ulcer was 21 and 26 days for forefoot and heel respectively. Forefoot ulcers healed within 12 week in 45% of patients and by 20 weeks in 63%, while 35% of heel ulcers healed by 12 weeks and 54% healed by 20 weeks (p=0.058). Based on Wagner classification, healing was best in class 1 among both forefoot and heel ulcers, 22.4% and 12.2% respectively (p=0.003 for forefoot and 0.002 for heel). First and second metatarsal heads were the common site of forefoot ulcer. Heel ulcers >3cm dimension had longer duration of healing compared to forefoot ulcers at both 12 and 20 weeks (p<0.02). CONCLUSION: Healing in diabetic neuropathic forefoot ulcer was better than heel ulcer, though not reaching statistically significant value. Wagner class 1 had the best healing among both ulcers and a heel ulcer >3cm had a significantly longer healing time. DECLARATION OF INTEREST: The authors have no conflict of interest to declare.

Extended leg infection of diabetic foot ulcers: risk factors and outcome.

OBJECTIVE: To identify the risk factors for extension of infection to the leg in diabetic foot ulcers (DFU) and to evaluate its role as a prognostic measure regarding limb salvage and healing time. METHOD: This retrospective case-control study took place in Jabir Abu Eliz Diabetic (JADC) during 2006-2008. Forty-eight patients diagnosed with a diabetic foot ulcer (DFU) with the infection extending to the leg (case group) were compared with an equal number of patients with a DFU without extension (control group). Risk factors for extension were identified by univariate analysis and both groups were compared with regard to limb salvage and healing time. RESULTS: Previous history of toe amputation was more frequent in the case group (p=0.004). The case group patients were significantly more likely to present with fever (p=0.01), pallor (p=0.02), confusion (p=0.04), and necrosis (p=0.004). Ulcers located in the heel were more frequent in the case group when compared with controls (p=0.0001) while more toes ulcers were found in the control group (p=0.001). A significant number of patients in the case group had an ulcer of more than 5cm diameter compared with those in the control group (p=0.001). The total number of patients presented with severe disease (Wagner grade 3-5) was significantly more in the case group compared with controls (p=0.004). Patients with severe infection (grade 4) were more in the case group compared with the controls (p=0.04). There were no significant differences between the two groups with regard to major and minor amputation rate. The case group had a longer duration of healing when compared with the controls. Seventy-five per cent of the controls healed by 6 months (n=31) compared with 22% in the case group (n=8 ; p=0.001). CONCLUSION: Toe amputation, wound located in the heel, wound size more than 5cm and advanced Wagner grade (3-5) and severe sepsis, grade 4, may be considered as risk factors for extension of infection to the leg in DFU. However, this extension did not carry a poor prognostic value to the final outcome if adequate therapeutic measures were followed.

External strangulated hernia in Khartoum, Sudan.

OBJECTIVES: To determine the pattern of presentation and outcome of strangulated external hernia, to predict the risk factors of strangulation, and to draw the attention towards the incidence of strangulation and its sequelae which are preventable by early repair. DESIGN: A prospective study over a two year period. SETTING: Khartoum Teaching Hospital, Casualty Department during the period May 2002 to May 2004. SUBJECTS: Sixty four patients with strangulated external hernias. RESULTS: The mean age was 42 years and the age range was between 0.5-72 years. The male: female ratio was 5:1 and males dominated all types of hernia except in incisional hernia where more females were noted. Strangulated inguinal hernia was the most common type in 35 patients, being more common on hernias of a relatively short history (<1 year). Pre-strangulation symptoms like change in size, irreducibility and pain were reported by 57 (90%) patients few days to few weeks prior to strangulation. More than half of the patients presented to the hospital 24 hours after developing the symptoms. All patients were surgically explored, 52 through an inguinal incision and 12 via formal laparotomy. The total number of bowel resection was 24 (37.5%), mainly in those presenting after 48 hours and 12 of them were between the age of 51-60 years. There were four (6.25%) deaths. CONCLUSION: Early diagnosis of patients with hernia and elective surgical treatment may offer the best way to minimise the relatively high morbidity and mortality associated with emergency operations.