Differences between national and international guidelines for the management of diabetic foot disease.

AIM: No studies have investigated if national guidelines to manage diabetic foot disease differ from international guidelines. This study aimed to compare guidelines of Western Pacific nations with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. METHODS: The 77 recommendations in five chapters of the 2015 IWGDF guidance documents were used as the international gold standard reference. The IWGDF national representative(s) from 12 Western Pacific nations were invited to submit their nation's diabetic foot guideline(s). Four investigators rated information in the national guidelines as "similar," "partially similar," "not similar," or "different" when compared with IWGDF recommendations. National representative(s) reviewed findings. Disagreements in ratings were discussed until consensus agreement achieved. RESULTS: Eight of 12 nations (67%) responded: Australia, China, New Zealand, Taiwan, and Thailand provided national guidelines; Singapore provided the Association of Southeast Asian Nations guidelines; and Hong Kong and the Philippines advised no formal national diabetic foot guidelines existed. The six national guidelines included were 39% similar/partially similar, 58% not similar, and 2% different compared with the IWGDF recommendations. Within individual IWGDF chapters, the six national guidelines were similar/partially similar with 53% of recommendations for the IWGDF prevention chapter, 42% for wound healing, 40% for infection, 40% for peripheral artery disease, and 20% for offloading. CONCLUSIONS: National diabetic foot disease guidelines from a large and diverse region of the world showed limited similarity to recommendations made by international guidelines. Differences between recommendations may contribute to differences in national diabetic foot disease outcomes and burdens.

Prevention of diabetic foot complications.

This paper discussed the importance of prevention of diabetic foot ulcers and our institution's protocol for prevention, reviewing the existing evidence in the literature regarding the effectiveness of the preventive approach. Diabetes mellitus is the second most significant cause of disease in Singapore after ischaemic heart disease. National University Hospital, Singapore, adopts a two-pronged strategy for the management of diabetic foot ulcers. The most important strategy is prevention, and education is key. Education should mainly be directed at patients and caregivers, but also professionals (general practitioners, allied health professionals and nurses) so that they can effectively educate patients and caregivers. Patient education includes care of diabetes mellitus, care of the foot and use of appropriate footwear. Patients also tend to have poor foot hygiene. Annual foot screening for diagnosed diabetics plays an important role. However, prolonged and sustained government intervention is necessary to provide education and screening on a national scale.

Tissue banking in Asia Pacific region: past, present and future.

Tissue banking in the Asia Pacific regions is driven by two main forces-firstly the International Atomic Energy Agency (IAEA) via Regional Co-operative Agreement projects and secondly by the Asia Pacific Association of Surgical Tissue Banking (APASTB). This overview is written in three sections: (1) History of tissue banking in individual country in the region. (2) History of APASTB. (3) History of IAEA programme in Asia Pacific region. The current status and future of the tissue banking programme in the region will be discussed.

Early clinical manifestations of vibrio necrotising fasciitis.

We present five patients with vibrio necrotising fasciitis, a lethal and disabling disease. Two of these patients had a history of exposure to either warm seawater or raw/live seafood, three had underlying chronic liver disease, and four presented with hypotension and fever. There were three deaths and four patients required intensive care unit stays. Among the two survivors, one had high morbidity. Only one patient met the criteria of Laboratory Risk Indicator for Necrotising Fasciitis score > 6. A clinician should suspect possible vibrio necrotising fasciitis if the following are present: contact with fresh seafood/warm seawater, a known history of chronic liver disease and pain that is out of proportion to cutaneous signs. All patients must be managed via intensive care in high dependency units. We recommend a two-step surgical protocol for patient management involving an initial local debridement, followed by a second-stage radical debridement and skin grafting.

Negative-pressure wound therapy for management of diabetic foot wounds: a review of the mechanism of action, clinical applications, and recent developments.

Negative-pressure wound therapy (NPWT) plays an important role in the treatment of complex wounds. Its effect on limb salvage in the management of the diabetic foot is well described in the literature. However, a successful outcome in this subgroup of diabetic patients requires a multidisciplinary approach with careful patient selection, appropriate surgical debridement, targeted antibiotic therapy, and optimization of healing markers. Evolving NPWT technology including instillation therapy, nanocrystalline adjuncts, and portable systems can further improve results if used with correct indications. This review article summarizes current knowledge about the role of NPWT in the management of the diabetic foot and its mode of action, clinical applications, and recent developments.

Chlorhexidine Anaphylaxis Masquerading as Septic Shock.

Chlorhexidine is a commonly used antiseptic and disinfectant in the health-care setting. Its usage has increased in recent years with intensive campaigns and infection control guidelines to combat hospital-acquired infections. As a result, patients and health-care workers (HCW) are exposed to increasing chlorhexidine usage. In recent years, adverse reactions to chlorhexidine ranging from allergic contact dermatitis, photosensitivity, fixed drug eruptions, urticaria and anaphylactic shock have been reported. Most have been isolated case reports on adverse reactions occurring in healthy individuals or HCW. We report a case of anaphylactic shock caused by applying chlorhexidine cleansing solution and masquerading as septic shock from left-leg necrotising fasciitis.

Use of a definitive cement spacer for simultaneous bony and soft tissue reconstruction of mid- and hindfoot diabetic neuroarthropathy:a case report.

The prevalence of diabetes mellitus has been increasing, and ≤25.8 million people, or 8.3% of the US population, have diabetes. Diabetic Charcot arthropathy and foot ulcers are serious complications of diabetes mellitus. They have been associated with greater risks of lower extremity amputation and mortality. Studies have shown that the amputation risk relative to patients with Charcot arthropathy alone is 7 times greater for patients with a foot ulcer, and 12 times greater for patients with Charcot arthropathy and a foot ulcer. Surgical reconstruction of Charcot arthropathy of the foot is often difficult, because of bone loss, deformities, vasculopathy, and the presence of active infection with or without soft tissue loss. It will be even more challenging if >1 region of the foot has been affected, such as the mid- and hindfoot. In such situations, an amputation would usually be the surgical option. We present a case of limb-threatening Charcot deformity with instability complicated by osteomyelitis, bone loss, and a large soft tissue defect. We used a limb salvage strategy with hindfoot fusion combined with an antibiotic-impregnated cement spacer for reconstruction of the midfoot, which was performed simultaneously with a local adipofascial flap for soft tissue coverage, resulting in a plantigrade, painless, and functional foot.

The role of Renasys-GO™ in the treatment of diabetic lower limb ulcers: a case series.

INTRODUCTION: This case series aims to study the effectiveness of Renasys-GO™ negative pressure wound therapy system in the healing of diabetic lower limb ulcers. MATERIALS AND METHODS: An electronic vacuum pump (Renasys-GO™, Smith & Nephew GmbH) was used to apply negative pressure wound therapy on wounds, with pressure settings determined according to clinical indication. Changes in wound dimension, infection status and duration of treatment were recorded over the course of Renasys-GO™ therapy in 10 patients with diabetic lower limb ulcers. RESULTS: Healing was achieved in all wounds, three by secondary closure and seven by split-thickness skin grafting. Eight wounds showed a reduction in wound size. The average duration of treatment with Renasys-GO™ therapy was 15.9 days, and all wounds showed sufficient granulation and were cleared of bacterial infection at the end of therapy. CONCLUSIONS: Renasys-GO™ therapy may be beneficial in the treatment of diabetic lower limb ulcers and wounds. In this study, which included wounds presenting as post-surgery ray amputation, metatarsal excision wounds, post-debridement abscesses and ulcers, the Renasys-GO™ therapy prepared all wounds for closure via split-thickness skin grafting or secondary healing by promoting granulation tissue and reducing bacterial infection in approximately 2 weeks.

Hydrosurgery is Effective for Debridement of Diabetic Foot Wounds.

INTRODUCTION: Diabetic foot wounds are serious complications of diabetes mellitus. Surgical debridement is a very important part of the management of diabetic wounds. Sharp debridement using the scalpel is normally performed. Versajet II hydrosurgery system is an alternative technique for debridement. To our knowledge, this is the fi rst study conducted to evaluate the use of hydrosurgery debridement for diabetic foot wounds. MATERIALS AND METHODS: This pilot study included 15 consecutive patients with diabetic foot wounds who were admitted to the National University Hospital (NUH) and were managed by the Diabetic Foot Team from June 2012 to December 2012. All wounds underwent hydrosurgery debridement. Patients' demographic details, clinical details on wound assessments, and outcome were recorded and analysed. RESULTS: The Versajet II hydrosurgery system was found to show some advantages over standard surgical scalpel debridement. It allowed adequate debridement whilst preserving more viable tissue to promote rapid healing. It could be manoeuvred over complex wound terrain. The time required for debridement was short--an average of 9.5 minutes. Good wound healing was achieved in all 15 cases. Only 1 Versajet debridement was required in 13 cases and 2 required an extra debridement. Twelve wounds were healed by split thickness skin grafting (STSG) and 3 wounds by secondary healing. Two of the STSG were infected but they were subsequently healed by dressings via secondary healing. CONCLUSION: Although good wound healing was achieved in all 15 cases, further study that uses a larger cohort and a randomised controlled trial is required to fully evaluate the effectiveness, or otherwise, of the Versajet II hydrosurgery system for the debridement of diabetic foot wounds.

Osteomyelitis in the diabetic foot.

Osteomyelitis (OM) is a common complication of diabetic foot ulcers and/or diabetic foot infections. This review article discusses the clinical presentation, diagnosis, and treatment of OM in the diabetic foot. Clinical features that point to the possibility of OM include the presence of exposed bone in the depth of a diabetic foot ulcer. Medical imaging studies include plain radiographs, magnetic resonance imaging, and bone scintigraphy. A high index of suspicion is also required to make the diagnosis of OM in the diabetic foot combined with clinical and radiological studies.

The modified Pirogoff's amputation in treating diabetic foot infections: surgical technique and case series.

BACKGROUND: This paper describes the surgical technique of a modified Pirogoff's amputation performed by the senior author and reports the results of this operation in a single surgeon case series for patients with diabetic foot infections. METHODS: Six patients with diabetic foot infections were operated on by the National University Hospital (NUH) diabetic foot team in Singapore between November 2011 and January 2012. All patients underwent a modified Pirogoff's amputation for diabetic foot infections. Inclusion criteria included the presence of a palpable posterior tibial pulse, ankle brachial index (ABI) of more than 0.7, and distal infections not extending proximally beyond the midfoot level. Clinical parameters such as presence of pulses and ABI were recorded. Preoperative blood tests performed included a glycated hemoglobin level, hemoglobin, total white blood cell count, C-reactive protein, erythrocyte sedimentation rate, albumin, and creatinine levels. All patients were subjected to 14 sessions of hyperbaric oxygen therapy postoperatively and were followed up for a minimum of 10 months. RESULTS: All six patients had good wound healing. Tibio-calcaneal arthrodesis of the stump was achieved in all cases by 6 months postoperatively. All patients were able to walk with the prosthesis. CONCLUSIONS: The modified Pirogoff's amputation has been found to show good results in carefully selected patients with diabetic foot infections. The selection criteria included a palpable posterior tibial pulse, distal infections not extending proximally beyond the midfoot level, ABI of more than 0.7, hemoglobin level of more than 10 g/dL, and serum albumin level of more than 30 g/L.

Clinical outcomes of below knee amputations in diabetic foot patients.

INTRODUCTION: This study aims to evaluate the predictive factors affecting the clinical outcome of Below Knee Amputations (BKA) performed in diabetic foot patients admitted to National University Hospital (NUH) Multi-Disciplinary Diabetic Foot Team. MATERIALS AND METHODS: This is a prospective cohort study of 151 patients admitted to the Department of Orthopaedic Surgery, NUH, for Diabetic Foot Problems (DFP) from January 2006 to January 2010. All had undergone BKA performed by NUH Multi-Disciplinary Diabetic Foot Team. Statistical analyses (univariate and multivariate analysis with logistic regression) were carried out using SPSS version 18.0, for factors such as demographic data, diabetic duration and control, clinical findings and investigations, indications for surgery, preoperative investigations and evaluation, microbiological cultures, and these were compared to the clinical outcome of the patient. A good clinical outcome is defined as one not requiring proximal re-amputation and whose stump healed well within 6 months. The ability to ambulate with successful use of a prosthesis after 1 year was documented. Statistical significance was set at P <0.050. RESULTS: Mean age of study population was 55.2 years with a male to female ratio of about 3:2. Mean follow up duration was 36 months. Of BKAs, 73.5% gave a good outcome. Univariate analysis showed that smoking, previous limb surgery secondary to diabetes, high Total White Count (TW), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Urea, Creatinine (Cr), Neutrophils, absence of posterior tibial and popliteal pulses, low Ankle Brachial Index (ABI) and Toe Brachial Index (TBI) were associated with poor clinical outcome. Multivariate analysis showed that high CRP, ESR, Neutrophils, absence of popliteal pulse and low ABI were associated with poor clinical outcome. Of patients, 50.3% attained mobility with prosthesis after 1 year. Mortality rate was 21.2% within 6 months of operation, with sepsis being the most significant cause of death. CONCLUSION: Success rate of BKA was 73.5%, with mortality rate being 21.2% within 6 months. In this cohort, 50.3% were able to attain eventual mobility with prosthesis after 1 year. Sepsis was the most significant cause of death. Markers of infection such as high CRP, ESR, neutrophils; and indicators of poor vascularity such as absence of popliteal pulse and low ABI were significantly associated with poor clinical outcome.

Distal amputations for the diabetic foot.

Minor amputations in diabetic patients with foot complications have been well studied in the literature but controversy still remains as to what constitutes successful or non-successful limb salvage. In addition, there is a lack of consensus on the definition of a minor or distal amputation and a major or proximal amputation for the diabetic population. In this article, the authors review the existing literature to evaluate the efficacy of minor amputations in this selected group of patients in terms of diabetic limb salvage and also propose several definitions regarding diabetic foot amputations.

Allografts with autogenous platelet-rich plasma for tibial defect reconstruction: a rabbit study.

PURPOSE: To evaluate the effect of autogenous platelet-rich plasma (PRP) for fresh-frozen allografts in tibial defect reconstruction in rabbits. METHODS: 40 adult New Zealand white rabbits underwent tibial defect reconstruction with autografts (n=12), allografts without PRP (n=12), or allografts with PRP (n=12) and were observed for 12, 16, and 24 weeks (4 for each period). Tibias of the remaining 4 rabbits were used as donor allografts, and the remaining allografts were procured from recipient rabbits. A 1.5- cm cortical segment of the tibia was osteotomised, and then fixed with a 9-hole mini-compression plate and 2 cerclage wires. Allografts were stripped off the periosteum and soft tissues and medullary contents, and then stored in a freezer at -80 ºC. All allografts were deep frozen for at least 4 weeks before transplantation. 7 ml of whole blood was drawn to prepare 1 ml of PRP. The PRP was then mixed with 1.0 ml of human thrombin to form a platelet gel. The PRP gel was then packed into the medullary canal of the allograft and applied on the cortical surface before tibial defect reconstruction. Rabbits were sacrificed at 12, 16, and 24 weeks. The specimens were assessed for bone union at host-graft junctions and for bone resorption, new bone formation, callus encasement, and viable osteocyte counts. RESULTS: There were 4 specimens in each group at each observation period. Osteoid bridging the gap at host-graft junctions was noted in all specimens in the autograft and allograft-with-PRP groups at week 12 and in the allograft-without-PRP group at week 24. Bone union in allografts without PRP was delayed. All indices for biological incorporation (resorption index, new bone formation index, callus encasement index, and viable osteocyte count) were significantly greater in the autograft than allograft-without-PRP groups, except for the resorption index at week 24, whereas the differences were not significant between the autograft and allograft-with-PRP groups. The differences between the 2 allograft groups were usually not significant, except for the resorption index. CONCLUSION: PRP-augmented allografts behaved similarly to autografts for tibial defect reconstruction in rabbits. PRP increased bone union and bone resorption.

Assessment of sensory neuropathy in patients with diabetic foot problems.

Our aim of this study was to compare the accuracy of three different modalities for testing sensory neuropathy in diabetic patients with and without diabetic foot problems. The three devices used included the pin-prick testing using the Neurotip® (PPT), the Semmes-Weinstein 5.07/10 g monofilament testing (SWMT), and the rapid-current perception threshold (R-CPT) measurements using the Neurometer® testing. Our study population consisted of 54 patients (108 feet) with diabetic foot problems treated at the National University Hospital in Singapore by our multi-disciplinary diabetic foot care team. Our results showed no difference in sensory neuropathy detected by PPT and 5.07/10 g SWMT in both the pathological and normal foot. In the pathological foot, there was significant increase in sensory neuropathy detected by the Neurometer® device at both the big toe and ankle sites as compared to PPT and 5.07/10 g SWMT. In the normal foot, there was a significant increase in sensory neuropathy detected by the Neurometer® device at the big toe site only as compared to PPT and 5.07/10 g SWMT. Finally, the Neurometer® measurements detected a statistically higher proportion of feet with sensory neuropathy as compared to detection by the PPT or 5.07/10 g SWMT.

Predictive factors for lower extremity amputations in diabetic foot infections.

The objective of this study was to evaluate the epidemiology of diabetic foot infections (DFIs) and its predictive factors for lower extremity amputations. A prospective study of 100 patients with DFIs treated at the National University Hospital of Singapore were recruited in the study during the period of January 2005-June 2005. A protocol was designed to document patient's demographics, type of DFI, presence of neuropathy and/or vasculopathy and its final outcome. Predictive factors for limb loss were determined using univariate and stepwise logistic regression analysis. The mean age of the study population was 59.8 years with a male to female ratio of about 1:1 and with a mean follow-up duration of about 24 months. All patients had type 2 diabetes mellitus. Common DFIs included abscess (32%), wet gangrene (29%), infected ulcers (19%), osteomyelitis (13%), necrotizing fasciitis (4%) and cellulitis (3%). Thirteen patients were treated conservatively, while surgical debridement or distal amputation was performed in 59 patients. Twenty-eight patients had major amputations (below or above knee) performed. Forty-eight percent had monomicrobial infections compared with 52% with polymicrobial infections. The most common pathogens found in all infections (both monomicrobial and polymicrobial) were Staphylococcus aureus (39.7%), Bacteroides fragilis (30.3%), Pseudomonas aeruginosa (26.0%) and Streptococcus agalactiae (21.0%). Significant univariate predictive factors for limb loss included age above 60 years, gangrene, ankle-brachial index (ABI) <0.8, monomicrobial infections, white blood cell (WBC) count ≥ 15.0×10(9)/L, erythrocyte sedimentation rate ≥100 mm/hr, C-reactive protein ≥15.0 mg/dL, hemoglobin (Hb) ≤10.0g/dL and creatinine ≥150 µmol/L. Upon stepwise logistic regression, only gangrene, ABI <0.8, WBC ≥ 15.0×10(9)/L and Hb ≤10.0g/dL were significant.

Effectiveness of bridge V.A.C. dressings in the treatment of diabetic foot ulcers.

OBJECTIVES: This is a prospective study of the clinical efficacy of the V.A.C. Granufoam Bridge Dressing for the treatment of diabetic foot ulcers. MATERIALS AND METHODS: Five consecutive patients with diabetic foot ulcers were treated with V.A.C. Granufoam Bridge Dressings and studied over a period of 22-48 days. The indications for treatment included diabetic patients with open ray amputation wounds and wounds post-drainage for abscess with exposed deep structures. Clinical outcome was measured in terms of reduction in wound dimensions, presence of wound granulation, microbial clearance, and development of wound complications. RESULTS: Our results showed that with V.A.C. therapy, wound healing occurred in all patients. The number of dressings required ranged from 8 to 10. The baseline average wound size was 23.1 cm(2). Wound areas shrunk by 18.4-41.7%. All subjects achieved 100% wound bed granulation with an average length of treatment of 33 days. Microbial clearance was achieved in all cases. All wounds healed by secondary intention in one case and four cases required split-thickness skin grafting. CONCLUSION: The V.A.C. Granufoam Bridge Dressing is effective in the treatment of diabetic foot ulcers. It promotes reduction of wound area, wound bed granulation, and microbial clearance. By allowing placement of the suction pad outside the foot, it allowed patients to wear protective shoes and to walk non-weight bearing with crutches during V.A.C. therapy.