Results of the modified Pirogoff amputation with cannulated screws for diabetic foot infection.

INTRODUCTION: Syme amputation has been shown to have value in patients with diabetic foot infections, but it has inherent drawbacks. A potential alternative is the modified Pirogoff amputation. Our objective was to evaluate the outcome of modified Pirogoff amputation using internal fixation with 6.5-mm cannulated screws in the management of diabetic foot. METHODS: This is a prospective study of 13 patients admitted from January 2012 to June 2015. Inclusion criteria were infection limited to the forefoot, presence of a palpable posterior tibial pulse and an ankle-brachial index of more than 0.7. Internal fixation of the calcaneum to the tibial was performed using two 6.5-mm cannulated screws under image intensifier control. RESULTS: In ten cases, the wounds were healed at three weeks. Osseous union was observed in ten cases; the time taken for its occurrence was 2-5 months. Removal of screws was performed in five cases. Five cases developed technical complications of screw tract infection, with two cases having distal screw migration. Good results, defined as cases not requiring a below-knee amputation for two years postoperatively, were obtained in 10 (77%) cases. At the three-year follow-up, three additional cases required proximal amputation, leaving 7 (54%) cases with good outcomes. CONCLUSION: Our prospective study showed that with careful selection of patients, good postoperative results can be obtained. There is a definite role for modified Pirogoff amputation in the management of diabetic foot problems.

Foot screening for diabetics.

INTRODUCTION: This study aims to evaluate the results of foot screening performed in a study population of 2137 diabetics (3926 feet) screened from 2006 to 2008 by the National University Hospital (NUH) multi-disciplinary team for diabetic foot problems. MATERIALS AND METHODS: A standardised protocol was designed. Foot screening consisted of detailed history taking and clinical examination including assessment for sensory neuropathy by Semmes Weinstein monofilament (SWMF) and neurothesiometer and assessment of vasculopathy by ankle-brachial index (ABI) and total body irradiation (TBI). The foot screening was performed by a trained staff nurse. All patients were classified according to King's College Classification. RESULTS: Majority of the patients were in the fifth (27.9%) and sixth (30.0%) decades of life. Two thousand sixty-four had type II diabetes, and only 73 had type I diabetes. Neuropathy was found in 1307 (33.3%) feet based on 5.07 SWMF. Vasculopathy was recorded in 510 (13.0%) and 546 (13.9%) feet based on ABI <0.8 and TBI <0.7. According to King's Classification, 1069 (50.0%) were Stage 1: Normal and 615 (28.8%) were Stage 2: At-Risk. CONCLUSION: Foot screening should be performed as early as possible to detect "At-Risk" feet and prevent the development of diabetic foot complications, thereby further reducing the risk of major amputations.

Effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers.

INTRODUCTION: This is the fi rst prospective study done locally to determine the effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers. MATERIALS AND METHODS: An electronic vacuum pump was used to apply controlled negative pressure evenly across the wound surface. Changes in wound dimension, presence of wound granulation and infection status of diabetic foot ulcers in 11 consecutive patients with diabetes were followed over the course of VAC therapy. RESULTS: Healing was achieved in all wounds. Nine wounds were closed by split-skin grafting and 2 by secondary closure. The average length of treatment with VAC therapy was 23.3 days. Ten wounds showed reduction in wound size. All wounds were satisfactorily granulated and cleared of bacterial infection at the end of VAC therapy. CONCLUSIONS: VAC therapy was useful in the treatment of diabetic foot infection and ulcers, which after debridement, may present with exposed tendon, fascia and/or bone. These included ray amputation wounds, wounds post-debridement for necrotising fasciitis, wounds post-drainage for abscess, a heel ulcer and a sole ulcer. It was able to prepare ulcers well for closure via split-skin grafting or secondary closure in good time. This reduced cost of VAC therapy, as therapy was not prolonged to attain greater reduction in wound area. VAC therapy also provides a sterile, more controlled resting environment to large, exudating wound surfaces. Large diabetic foot ulcers were thus made more manageable.

Value of team approach combined with clinical pathway for diabetic foot problems: a clinical evaluation.

AIMS: To evaluate the effectiveness of management of diabetic foot problems (DFP) by the National University Hospital (NUH) Multidisciplinary Diabetic Foot Team combined with a clinical pathway in terms of average length of stay (ALOS), readmission rates, hospitalisation cost per patient, major reamputation rate, and complication rate. METHODS: 939 patients admitted to the Department of Orthopaedic Surgery, NUH, for DFP from 2002 (before team formation) to 2007 (after team formation). It consisted of six cohorts of patients - 61 for 2002, 70 for 2003, 148 for 2004, 180 for 2005, 262 for 2006, and 218 for 2007. All patients were managed by the NUH Multidisciplinary Diabetic Foot Team combined with a clinical pathway. Statistical analyses were carried out for five parameters (ALOS, hospitalisation cost per patient, major amputation rate, readmission rate, and complication rate). RESULTS: From 2002 to 2007, the ALOS was significantly reduced from 20.36 days to 12.20 days (p=0.0005). Major amputation rate was significantly reduced from 31.15 to 11.01% (p<0.0005). There was also a significant reduction in complication rate from 19.67 to 7.34% (p=0.005). There were reductions in the hospitalisation cost per patient and readmission rate after formation of the multidisciplinary team but they were not statistically significant. CONCLUSION: Our evaluation showed that a multidisciplinary team approach combined with the implementation of a clinical pathway in NUH was effective in reducing the ALOS, major amputation rate, and complication rate of DFP.

Socioeconomic profile of diabetic patients with and without foot problems.

INTRODUCTION: To identify the differences in a socioeconomic profile between two cohorts of diabetic patients - one with diabetic foot problems and another without diabetic foot problems. MATERIALS AND METHODS: The cohort with diabetic foot problems (including cellulitis, abscess, osteomyelitis, septic arthritis, gangrene, ulcers, or Charcot joint disease) consisted of 122 diabetic patients, while the other cohort without foot problems consisted of 112 diabetic patients. Both were seen at the National University Hospital from January to April 2007. A detailed protocol was designed and the factors studied included patient profile, average monthly household income, education, compliance to diabetic medication, attendance at clinics for diabetic treatment, exercise, smoking, alcohol consumption, gender, and glycosylated haemoglobin (HbA1(C)) level. These were studied for significant differences using univariate and stepwise multivariate logistic regression analysis. RESULTS: With multivariate analysis, Malay ethnicity (p<0.001), education of up to secondary school only (p=0.021), low average monthly household income of less than SGD $2,000 (p=0.030), lack of exercise (at least once a week, p=0.04), and elevated HbA1(C) level (>7.0%; p=0.015) were found to be significantly higher in the cohort with diabetic foot problems than the cohort without. CONCLUSIONS: There are significant differences in the socioeconomic factors between diabetic patients with diabetic foot problems and those without.