Surgical management of the diabetic foot:The current evidence

The prevalence of diabetes mellitus and its associated complications,particularly diabetic foot pathologies,poses significant healthcare challenges and economic burdens globally.This review synthesises current evidence on the surgical management of the diabetic foot,focusing on the interplay between neuropathy,ischemia,and infection that commonly culminates in ulcers,infections,and,in severe cases,amputations.The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies,as diabetic foot complications are a leading cause of hospital admissions among diabetic patients,significantly impacting morbidity and mortality rates.This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers,infections,and skeletal pathologies such as Charcot arthropathy,emphasising the critical role of early diagnosis,comprehensive management strategies,and interdisciplinary care in mitigating adverse outcomes.In addressing surgical interventions,this review evaluates conservative surgeries,amputations,and reconstructive procedures,highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies.The integration of advanced diagnostic tools,novel surgical techniques,and postoperative care,including offloading and infection control,are discussed in the context of optimising healing and preserving limb function.

Role of bisphosphonates in the management of acute Charcot foot

Diabetes mellitus is the most common cause of Charcot neuropathy affecting foot and ankle. Acute Charcot foot(CF) presents with a red and swollen foot in co-ntrast to the painless deformed one of chronic CF. En-hanced osteoclastogenesis plays a central role in the pathogenesis of acute CF. Many studies have shown elevated levels of bone turnover markers in patients with acute CF confirming it. These findings have led cl-inicians to use anti-resorptive agents [bisphosphonates(BP), calcitonin, and denosumab] along with immobi-lization and offloading in acute CF patients. The ma-ximum evidence among all anti-resorptive agents is available for BPs, although its quality is low. Pamidronate has been shown to reduce the markers of activity of CF like raised skin temperature, pain, edema, and bone turnover markers in the majority of studies. Intravenous BPs are known to cause acute phase reactions leading to flu-like illness following their first infusion, which can be ameliorated by oral acetaminophen. Alendronate is the only oral BP used in these patients. It needs to be taken on an empty stomach with a full glass of water to avoid esophagitis. The side-effects and contraindications to BPs should be kept in mind while treating acute CF patients with them.

Acute worsening of microvascular complications of diabetes mellitus during rapid glycemic control:The pathobiology and therapeutic implications

While chronic hyperglycaemia resulting from poorly controlled diabetes mellitus(DM)is a well-known precursor to complications such as diabetic retinopathy,neuropathy(including autonomic neuropathy),and nephropathy,a paradoxical intensification of these complications can rarely occur with aggressive glycemic management resulting in a rapid reduction of glycated haemoglobin.Although,acute onset or worsening of retinopathy and treatment induced neuropathy of diabetes are more common among these complications,rarely other problems such as albuminuria,diabetic kidney disease,Charcot’s neuroarthropathy,gastroparesis,and urinary bladder dysfunction are also encountered.The World Journal of Diabetes recently published a rare case of all these complications,occurring in a young type 1 diabetic female intensely managed during pregnancy,as a case report by Huret et al.It is essential to have a comprehensive understanding of the pathobiology,prevalence,predisposing factors,and management strategies for acute onset,or worsening of microvascular complications when rapid glycemic control is achieved,which serves to alleviate patient morbidity,enhance disease management compliance,and possibly to avoid medico-legal issues around this rare clinical problem.This editorial delves into the dynamics surrounding the acute exacerbation of microvascular complications in poorly controlled DM during rapid glycaemic control.

Evaluation of Charcot Neuroarthropathy in Diabetic Foot Disease Patients at Tertiary Hospital

Purpose: To evaluate Charcot neuroarthropathy in diabetic foot patients at tertiary hospital. Methods and Material: It is a retrospective study from 2005 to 2015 of Charcot foot patients in diabetic patients admitted in King Abdulaziz University Hospital, Jeddah, Saudi Arabia. Sixty-four patients were admitted as diabetic foot disease and were studied by reviewing patients records of demography, pain, discharge, duration of disease, duration and types of diabetes IDDM [Insulin Dependant Diabetes Mellitus] NIDDM [Non Insulin Dependent Diabetes Mellitus], history of trauma, peripheral vascular disease, obesity, hypertension, co-morbid conditions, previous surgery, involvement of fore foot/midfoot/hindfoot, deformity, ulcer and treatment like casts, offloading devices, pharmacological like biphosphonates, debridement, osteotomy, arthrodesis, exostectomy, and amputation. Results: Majority of patients were males (81.2%). Mean age was 61.75 years. Pain was reported in 25% of patients, numbness in 12.5%, foot deformity in 23.4%, pus discharge in 73.4%, difficulty in walking in 12.5%, and 10.9% had history of trauma. Majority of patients were NIDDM 68.8%, IDDM 31.3%, (62.5% had DM more than 10 years and 36.9% had DM less than 10 years), controlled DM in 21.9% and uncontrolled DM in 73.4%, nephropathy in 46.3%, neuropathy in 59.4%, retinopathy in 40.6%, cardiomyopathy in 48.4% and vasculopathy in 56.3%. Charcot arthropathy was in 28.1% of cases and forefoot was involved in 65.5%, midfoot in 4.7% and hindfoot/ankle in 21.9%. It was forefoot which was mainly involved in Charcot joint disease. It was demonstrated by X-rays which showed subluxation in 40.6%, dislocation in 54.7%, disorganized foot joints in 42.2%, bone resorption in 23.4%, osteomyelitis in 14.1%, fractures in 50%, joint collapse in 39.1% and destruction of articular surfaces in 37.5%. Debridement was done in 25% of cases while 75% of patients underwent some sort of amputation. 14.1% of patients underwent above knee amputation, 10.9% below knee amputation, 10.9% transmetatarsal and 39.1% toe amputation. Debridement and amputation were the main treatment offered. Conclusions: Diabetic patients with Charcot joint disease pose great challenge in management. Emphasis should be given for early detection, investigations and prompt treatment. Treatment should be tailored according to stage of disease and patient occupation.

Charcot osteoarthropathy in diabetes: A brief review with an emphasis on clinical practice

Charcot osteoarthropathy (COA) is a potentially limbthreatening condition that mainly affects diabetic patients with neuropathy. In everyday practice, it presents as a red, hot, swollen foot, usually painless, and is frequently trig gered by trivial injury. Its etiology is traditionally attributed to impairment of either the autonomic nervous system, leading to increased blood flow and bone resorption, or of the peripheral nervous system, whereby loss of pain and protective sensation render the foot susceptible to repeated injury. More recently, excessive local inflammation is thought to play a decisive role. Diagnosis is based on clinical manifestation and imaging studies (plain X-rays, bone scan, Magnetic Resonance Imaging). The mainstay of management is immediate off-loading, while surgery is usually reserved for chronic cases with irreversible deformities and/or joint instability. The aim of this review is to provide an overview of COA in terms of pathogenesis, classification and clinical presentation, diagnosis and treatment, with an emphasis on the high suspicion required by clinicians for timely recognition to avoid further complications.

Does Greek Foot Predispose to Morton’s Neuroma?

Background: Morton’s neuroma is the enlargement of an interdigital nerve most commonly located between the third and fourth metatarsals. Greek foot is a normal variant where the first metatarsal is shorter than the second metatarsal. To our knowledge, there is currently no reported association between Greek foot and Morton’s neuroma in the literature. Methods: Retrospective study of 184 patients. Two separate cohorts were recruited. Cohort A comprised of 100 randomly selected asymptomatic patients. Cohort B comprised of 84 patients with a history of foot pain and histologically confirmed Morton’s neuroma. Foot shape was determined by using a self-assessment tool and plain radiographs. Statistical analyses were performed using the Chi-square test on the association between Greek foot and Morton’s neuroma. A p-value of ﹣9). Conclusions: This study has shown a possible association between the presence of a Greek foot and the presence of Morton’s neuroma. Although our study design has limitations and does not allow full statistical analysis, we do believe that the shown association between Greek foot and Morton’s neuroma can help clinicians and other health care providers in establishing the diagnosis of Morton’s neuroma in patients with a painful foot.

CT Scan of the Foot in Patients with Chronic Non-Healing Diabetic Foot Ulcer

Background: Diabetes mellitus is a chronic disease where there is an increased blood sugar level in the body which is either caused due to inability of the pancreas to secrete insulin or the body’s inability to utilize it. The prevalence of diabetes mellitus is growing rapidly worldwide. Statistics show that in the year 2014, there were a total of 422 million cases of DM. Diabetes mellitus is a major cause of heart attacks, kidney failure, blindness and leg amputations. Diabetic foot ulcers are quite common and are estimated to affect nearly 15% of all diabetic patients during their lifetime. In long standing diabetic patients with chronic non-healing ulcers, bony changes or deformities are not uncommon. These bony changes can be identified using CT scans. Materials and Methods: An observational study was conducted on a total of 40 patients with chronic non-healing ulcer attending the surgery outpatient department of Saveetha Medical College, Chennai, Tamilnadu. The CT-scans of their foot were observed for deformities or bony changes. Results: Out of 40 patients, 67.5% were males and 32.5% were females. A maximum number of subjects fell under the age group of 51 - 60 years. The most common site of the ulcer was found to be in the plantar surface of big toe (53%). Among the 40 patients, 33 of them were found to have bony abnormalities on the CT scan of foot and no apparent changes were seen in the rest. Bone erosions (35%), osteopenic changes (22.5%), Charcot’s joint (2.5%), osteophyte formation (12.5) and reduced joint space (10%) were the predominant changes observed on the CT scans of the study population.

Sever’s Disease: An Underdiagnosed Foot Injury in the Pediatric Emergency Department

Sever’s disease—also known as calcaneal apophysitis—is a common cause of heel pain in pediatric patients typically aged 7 - 14 years old. Sever’s disease can be painful and limit a child’s function as well as participation in physical activity. Herein, we described a case of delayed presentation of chronic Sever’s disease in a child who had been experiencing heel pain for over one year which worsened substantially when the child began to participate in sports. This is important for the emergency medicine physician because Sever’s disease represents an underdiagnosed cause of foot and heel pain in the pediatric patient and may be often missed. We describe the diagnosis and treatment options of Sever’s disease as well as associated controversies, e.g., whether activity is indeed the cause of Sever’s disease and whether imaging is needed for a diagnosis.

Effect of Lion’s Foot (<i>Alchemilla vulgaris</i>) on Liver and Renal Functions in Rats Induced by CCl₄

The present work aims to study the influence of antioxidants activity of lion’s foot (Alchemilla vulgaris) leaves at different concentrations to give more protection against chronic liver disease. Results indicated that dried lion’s foot leaves had rich in total polyphenolic and flavonoids content (395.65 and 183.10 mg/100g, respectively). These results were reflected to the antioxidant activity (DPPH);it’s noticed that the antioxidant activity of dried lion’s foot leaves was high (131.74%). The major polyphenolic components were benzoic acid (1084.63 ppm) followed by ellagic acid, catechol, and catechin (614.16, 580.54, and 566.53 ppm, respectively) then salicylic acid and protocatechuic acid (479.71 and 444.43 ppm, respectively). On the same trend, flavonoids fractions indicated the highest content in luteo-6-arabinase 8-glucose, apig. 6-rhamnase 8-glucose, acatein, narengin and luteolin (40.01;15.04;8.07;6.64 and 6.42 ppm, respectively). Fifty-six male albino rats were used in biological experiments. Rats fed on basal diet for two weeks before the performance of the experiment. At the beginning, rats divided into eight main group were fed on diets for 45 days as follows: Negative control group (first group) was fed on basal diet. Forty nine rats were fed on basal diet and induced by CCl4, in paraffin oil (50% v/v, 2 ml/Kg) twice weeks subcutaneous injection to induce chronic damage in the liver, then divided into 7 groups numbered from group 2 to group 8. Positive control group rats fed on basal diet till final experiment (second group). Group 3 and 4 rats treated with 50 and 100 ppm ethanolic leaves extracts, respectively. Also, group 5 and 6 treated with 50 and 100 ppm aqueous leaves extracts, respectively. All extracts were fed on orally every day. While, rats in group 7 treated with 1% and 2% dried lion’s foot leaves. At the end of the experimental period, serums were collected to determine liver and renal functions. The liver was removed surgically for histopathological observation. The results revealed that CCl4 intoxication impaired liver function. Serum AST, ALT, ALP and total bilirubin levels were elevated by CCl4 administration, while significant decreasing was noticed in serum albumin in CCl4 group. Histopathologically, CCl4 caused congestion of central vain, fatty change of hepatocytes, and focal inflammatory cells in filtration. Treatment with lion’s foot with different forms and concentration attenuated these adverse effects and markedly ameliorated histopathological and biochemical alterations caused by CCl4 especially with 2% powder and 100 ppm ethanol extract administration. Therefore, the results of this study concluded that lion’s foot can be proposed to protect hepatotoxicity induced by CCl4 in rats. The results also revealed that the hepatoprotection effect of lion’s foot may be attributed to its antioxidant contents and free radical scavenger effect.

China's Wearable Device Manufacturers Set Foot in the Global Market

According to Q2 Report on China’s Wearable Device Market,China’s wearable devices in Q2 2016 saw an output of 9.54 million units,up 13.2%month-on-month and 81.4%yearon-year.The basic wearable devices representing by wristband,children watch and smart shoes increased by92.1%year-on-year and the smart wearable devices represented by smart watch increased by 3.4%year-on-year.'Unlike the overseas

The Role of Orthotic Service in Modern Rehabilitation of Patients with Charcot-Marie-Tooth Disease

Charcot-Marie-Tooth (CMT) disease, which encompasses several hereditary motor and sensory neuropathies, is one of the most common neuro-muscular disorders. 80% of patients having CMT disease are diagnosed with per cavus deformity. Orthosis is widespread and varies widely in forms. The paper arises the necessity of habilitation at the earliest possible stage as only a few patients use it. The meta-analysis of 412 scientific papers concerning this problem demonstrates the getting better gate, balance and the stopping CMT progression which is scientifically proven. It is also shown that patients with CMT use low prevalence of orthotics, and demonstrate low compliance of patients (for various reasons), high expectations from this habilitation technique.

糖尿病Charcot足患者临床特点及预后

目的 总结20例糖尿病Charcot足患者临床表现及预后,以提高临床医师对该病的认识.方法 回顾性分析空军总医院2008年6月至2013年6月诊断的20例糖尿病Charcot足患者临床特点及预后情况.结果 20例糖尿病Charcot足均为单足病变,患者平均年龄（55±8）岁,男性占75.0％（15/20）;糖尿病病史（12±6）年,患足血供可,足畸形前存在对称性麻木中位时间6年,血糖控制不佳,血脂基本正常.糖尿病慢性并发症中以微血管病变为主,以并发糖尿病肾病、糖尿病自主神经病变为多,分别占65.0％ （13/20）、75.0％ （15/20）.4例行小腿中上1/3截肢术、7例行截趾术、1例行患足第1跖跗单关节内置固定螺丝整形手术;6例换药,创面愈合;1例踝部创面好转出院;1例患足无溃疡,予以配置矫正鞋.随访1～5年,1例死于心肌梗死;1例因心房颤动引发脑梗死卧床;2例因尿毒症开始透析;1例患足原创面再次破溃;1例失访;余患者拄拐或轮椅助行,无糖尿病足溃疡.结论 男性为糖尿病Charcot足相对高发人群;多存在血糖控制不佳;早期患足减压、制动,均利于保护患足和促进足部创面愈合.

晚期夏科氏足的诊治进展

夏科氏关节病是一种罕见的周围性神经病变,通常与糖尿病、神经血管病等疾病有关,其发生率极低。糖尿病患者一生中夏科氏关节病的患病率为0.1%~10%,如果存在周围神经病变,则会增加至29%~35%,最常累及足部。晚期夏科氏足可造成感染、溃疡、畸形、脱位和骨折等症状,严重者需截肢,甚至危及生命,因此早期干预治疗至关重要。本文讨论晚期夏科氏足的诊断及治疗方式,以提高临床对夏科氏足的重视。

血清S-100B、神经烯醇化酶在重型手足口病患儿颅脑损伤中的检测意义

目的:探讨血清S-100B、神经烯醇化酶(NSE)在重型手足口病(HFMD)患儿颅脑损伤中检测的临床价值。方法:用酶联免疫测定法检测S-100B、NSE的水平含量。选取本院2012年6-12月住院部重型HFMD患儿58例(重型HFMD组),其中重型40例,危重型18例(含3例死亡病例);同期住院轻型HFMD患儿39例为轻型HFMD组,另取同期门诊健康体检儿童30例作为正常对照组。分析两者与重型HFMD患儿颅脑损伤严重程度及预后的关系。结果:(1)重型HFMD组患儿血清S-100B、NSE水平明显高于轻型HFMD组及正常对照组,差异均有统计学意义(P<0.01);(2)轻型HFMD组患儿与正常对照组血清S-100B、NSE水平比较差异无统计学意义(P>0.05);(3)危重型与重型HFMD患儿血清S-100B、NSE水平比较差异有统计学意义(P<0.05);(4)重型HFMD患儿治疗前后血清S-100B、NSE水平比较差异有统计学意义(P<0.05)。结论 :血清S-100B、NSE在重型HFMD中可反映颅脑损伤严重程度,可作为重型HFMD患儿颅脑损伤早期诊断及预后评估的重要指标。

糖尿病足截肢患者胫后神经中S-100蛋白、蛋白激酶C-β_2表达的病理学研究

目的观察不同糖尿病病程患者胫后神经中蛋白激酶C-β_2(protein kinaseβ_2,PKC-β_2)、S-100蛋白的表达情况,为糖尿病周围神经病变与PKC-β_2、S-100蛋白关系的研究提供依据。方法选取2012年5月至2017年6月在河北北方学院附属第一医院骨外科因糖尿病足行高位截肢患者截下的肢体共50例,均于大腿中下1/3截肢,手术时留取截肢肢体胫后神经,应用免疫组织化学方法观察不同糖尿病病程患者胫后神经PKC-β_2及S-100蛋白表达的差异。结果免疫组织化学染色结果显示,不同糖尿病病程患者的糖尿病足胫后神经均有PKC-β_2、S-100蛋白表达,且随糖尿病病程延长,糖尿病足胫后神经中PKC-β_2表达水平逐渐增高,S-100蛋白表达水平逐渐降低,差异均有显著性(P<0.05)。结论 PKC-β_2表达增多、S-100蛋白表达减少可能通过某种机制参与了糖尿病周围神经病变的发生发展。

丙种球蛋白治疗重症手足口病临床效果及其对血清S-100β蛋白、NSE的影响研究

目的:观察丙种球蛋白治疗重症手足口病的临床疗效及其对血清S-100β蛋白、神经元特异性烯醇化酶(NSE)的影响。方法:82例重型手足口病患儿按随机数字表法分为观察组和对照组,各41例。对照组采取常规治疗和对症处理;观察组在对照组治疗基础上给予静脉丙种球蛋白治疗。记录2组临床症状、神经系统表现、住院时间。检测2组血清S-100β蛋白、NSE水平。结果:观察组总有效率为97.56%,高于对照组的75.61%(P<0.05);观察组皮疹消退时间、热退时间和易惊、肢体震颤消失时间以及住院时间均短于对照组(P<0.05~P<0.01);观察组治疗后血清S-100β蛋白、NSE水平均较对照组明显下降(P<0.01)。结论:在常规治疗基础上,应用静脉丙种球蛋白治疗重症手足口病可缩短患儿临床症状、体征持续时间,减少住院时间,提高临床治疗效果,明显降低血清S-100β蛋白、NSE水平。

EV71手足口病患儿血清NSE、CK-BB及S-100B检测的临床意义

目的探讨EV71手足口病患儿检测神经元特异性烯醇化酶(NSE)、肌酸激酶脑型同工酶(CK-BB)、S-100B蛋白的临床意义。方法选择本院收治的50例重症手足口病患儿为重症组,50例普通型手足口病患儿为普通组,选择30例健康儿童为对照组,采用酶联免疫吸附法测定三组研究对象血清NSE和S-100B蛋白表达水平。采用电泳法检测CK-BB表达水平,比较三组研究对象血清NSE、S-100B及CK-BB表达水平的差异。结果重症组、普通组、对照组血清NSE、CK-BB、S-100B表达水平存在显著差异(P<0.01),重症组患儿血清NSE、CK-BB、S-100B表达水平高于普通组,重症组及普通组患儿血清NSE、CK-BB、S-100B表达水平均高于对照组。结论手足口病患儿血清NSE、CK-BB和S-100B表达水平升高,其血清浓度与病情相关,检测血清NSE、CK-BB和S-100B表达水平对手足口病患儿的早期诊断及预后评估具有参考意义。

联合检测脑钠肽、血糖、神经元特异性烯醇化酶及S-100β蛋白在重症手足口病中的诊断效能

目的探究脑钠肽(BNP)、血糖(Glu)、神经元特异性烯醇化酶(NSE)、S-100β蛋白(S-100β)联合检测在重症手足口病诊断中的价值。方法回顾性分析2017年5月至2020年5月河北医科大学附属河北省儿童医院儿科病房住院且诊断符合手足口病的100例患儿及同期健康体检的100名儿童的临床资料。依据病情严重程度将手足口病患儿分为轻症组(41例)与重症组(59例),将健康体检儿童作为对照组。比较三组BNP、Glu、NSE、S-100β水平,logistic回归分析重症手足口病的影响因素,ROC曲线分析BNP、Glu、NSE、S-100β及四项指标联合诊断重症手足口病的价值。结果重症组BNP、Glu、NSE、S-100β水平高于轻症组及对照组(P<0.05);轻症组Glu、NSE水平高于对照组(P<0.05)。BNP、Glu、NSE、S-100β为重症手足口病的独立影响因素(OR>1,P<0.05)。BNP、Glu、NSE、S-100β及四项指标联合预测重症手足口病的曲线下面积为0.815、0.880、0.639、0.910、0.914,敏感度为88.1%、83.1%、37.3%、88.1%、89.8%,特异度为61.0%、87.8%、95.1%、90.2%、90.2%。结论重症手足口病患儿BNP、Glu、NSE、S-100β水平显著高于轻症患儿及健康儿童,四项指标联合检查有利于重症手足口病患儿的早期诊断。

糖尿病足患者血浆活化蛋白C抵抗、蛋白C和蛋白S活性的测定

目的探讨PC、PS活性的变化在糖尿病足形成中的作用和临床意义,以及APCR与糖尿病足形成的关系。方法采用Dahlback法对50例健康成年人(对照组)及60例糖尿病足患者(DF1、DF2组)进行APCR阳性率测定,同时测定受检者蛋白C(PC,)和蛋白S(PS)。结果糖尿病足(DF)患者血浆PC/PS活性下降与对照组有显著性差异。结论血浆PC/PS活性检测对糖尿病足患者的诊断、估计预后和疗效观察有参考价值,且APCR阳性者有动脉血栓发生的倾向。

糖尿病Charcot足早期手术治疗临床疗效分析

目的探讨外科手术治疗糖尿病Charcot足的临床疗效。方法对2009—02—2013—02间在我院应用外科手术方法治疗的9例糖尿病charcot足患者的临床资料进行分析。结果随访3～44个月，平均24．4个月，均为EichenholtzI期，手术治疗后9例患者均取得满意疗效，避免了足部难治性溃疡及截肢等并发症出现，所有患者的行走能力均恢复到先前水平。结论采用手术治疗EichenhohzI期糖尿病Charcot足，可避免足部难治性溃疡出现及截肢发生，是一种理想的治疗方法。