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To evaluate the feasibility and early outcomes of below the ankle orbital atherectomy in chronic limb-threatening ischemia in patients with calcified foot arteries.12 patients (mean age 69.4 ± 14.7; range 57 to 85 years) who were affected by diabetes underwent orbital atherectomy below the knee and ankle arterial segments. Technical success was defined as orbital atherectomy passage and debulked the calcified lesion, delivery of adjunctive therapy, and30% residual stenosis at final angiogram. The procedural outcome included complications, amputation-free survival, and freedom from clinically-driven target lesion revascularization at 30-days and 6-months of follow-up.Orbital atherectomy was performed in 3 cases in Anterior tibial (AT) and dorsalis pedis (Ped) arteries + Posterior tibial (PT) and Lateral Plantar (Lat Plan), 5 cases in PT and Lat Plan arteries, 1 case of PT and Medial Plantar, 1 case of Peroneal and Plan Lat, and 2 cases of AT and Ped. After atherectomy, we used a drug-coated balloon (DCB) angioplasty. Technical success was achieved in 11 (91.6%) cases. No deaths were registered during the follow-up. The limb salvage rate was 100%, and no major amputations were registered. Amputation-free survival was 50%. Freedom from CD-TLR was 100% at 30 days and 91.7% at 6-months. One patient underwent a TLR at three months. No major cardiovascular events, limb events, or significant procedure-related complications were registered.CSI orbital atherectomy and DCB angioplasty appear a feasible and promissor treatment options in diabetic CLTI patients.

Several factors, such as ischemia, infection and skin injury impair the wound healing process. One common pathway in all these processes is related to the reactive oxygen species (ROS), whose production plays a vital role in wound healing. In this view, several strategies have been developed to stimulate the activation of the antioxidative system, thereby reducing the damage related to oxidative stress and improving wound healing. For this purpose, complex magnetic fields (CMFs) are used in this work on fibroblast and monocyte cultures derived from diabetic patients in order to evaluate their influence on the ROS production and related wound healing properties. Biocompatibility, cytotoxicity, mitochondrial ROS production and gene expression have been evaluated. The results confirm the complete biocompatibility of the treatment and the lack of side effects on cell physiology following the ISO standard indication. Moreover, the results confirm that the CMF treatment induced a reduction in the ROS production, an increase in the macrophage M2 anti-inflammatory phenotype through the activation of miRNA 5591, a reduction in inflammatory cytokines, such as interleukin-1 (IL-1) and IL-6, an increase in anti-inflammatory ones, such as IL-10 and IL-12 and an increase in the markers related to improved wound healing such as collagen type I and integrins. In conclusion, our findings encourage the use of CMFs for the treatment of diabetic foot.

Objectives Chronic wound infections may delay the healing process and are responsible for a significant burden on healthcare systems. Since inappropriate management may commonly occur in the care of these patients, this review aims to provide a practical guide underlining actions to avoid in the management of chronic wound infections. Methods We performed a systematic review of the literature available in PubMed in the last 10 years, identifying studies regarding the management of patients with chronic wound infections. A panel of experts discussed the potential malpractices in this area. A list of ‘Don'ts’, including the main actions to be avoided, was drawn up using the ‘Choosing Wisely’ methodology. Results In this review, we proposed a list of actions to avoid for optimal management of patients with chronic wound infections. Adequate wound bed preparation and wound antisepsis should be combined, as the absence of one of them leads to delayed healing and a higher risk of wound complications. Moreover, avoiding inappropriate use of systemic antibiotics is an important point because of the risk of selection of multidrug-resistant organisms as well as antibiotic-related adverse events. Conclusion A multidisciplinary team of experts in different fields (surgeon, infectious disease expert, microbiologist, pharmacologist, geriatrician) is required for the optimal management of chronic wound infections. Implementation of this approach may be useful to improve the management of patients with chronic wound infections.

Diabetic foot ulcer treatment is a challenge for the healthcare world. Widespread infection and the presence of critical ischemia (especially with end-stage renal disease) can lead to major amputation rather than amenable to conservative treatment. Surgical strategies of the diabetic foot have been changing over the past 10 years and are now focused on reconstructive treatment and limb salvage. These goals were achieved, thanks to an evolution of distal revascularization techniques and a distinct approach, which integrates various methods focused on limb salvage. Podoplastic techniques of the diabetic foot are focused on infection clearance, the surgical treatment of corrective deformities, soft tissue coverage and limb ischemia correction along with the management of diabetes and the comorbidities that compromise tissue repair processes. The reconstructive techniques used in diabetic foot treatment owe their effectiveness in part to the results of technological improvements such as the circular external fixator as a tool for stabilization and surgical site protection. In the last decade, many studies have shown that circular external fixation should be considered as the most useful method to protect the reconstructive surgical site in limb salvage of the diabetic foot. The objective of this review is to highlight the role of surgical offloading using circular external fixation as an adjunct to the podoplastic diabetic foot reconstruction procedures.

We have analyzed in a retrospective study of consecutive diabetic patients affected by no-option critical limb ischemia (CLI) the efficacy of the dermal substitute Integra Dermal Regeneration Template for treatment of complicated foot lesions. The primary end point was limb salvage and 1-year amputation-free survival. The secondary end point was healing time of surgical site. Between October 2014 and October 2017, 1024 patients with diabetic foot ulcer (DFU) and CLI were admitted. In 84 patients (8.2%), there was a failure in distal revascularization with a persistent CLI after the procedure. Despite the persistent CLI, a group of 26 patients of this cohort obtained complete wound healing. Among them, 13 patients were treated with surgical debridement or open amputations and application of dermal substitute Integra Dermal Regeneration Template and the other 13 patients were treated without any dermal substitute. The Integra group healed within a mean time of 83.5 days, and the control group healed within a mean of 139 days ( P = .028). No major amputation was carried out at 1-year follow-up in the Integra group versus 15% in the control group. A conservative foot surgery or an approach with minor amputation in diabetic patients with no-option CLI may achieve limb salvage. The use of Integra Dermal Regeneration Template in patients with DFU and no-option CLI may be a useful option in a limb salvage program.

Critical limb ischemia (CLI) is a severe manifestation of peripheral artery disease characterized by ischemic pain, which is frequently associated with diabetes and non-healing lesions to inferior limbs. The clinical management of diabetic patients with CLI typically includes percutaneous transluminal angioplasty (PTA) to restore limb circulation and surgical treatment of diabetic foot ulcers (DFU). However, even after successful treatment, CLI patients are prone to post-procedure complications, which may lead to unplanned revascularization or foot surgery. Unfortunately, the factors predicting adverse events in treated CLI patients are only partially known. This study aimed to identify potential biomarkers that predict the disease course in diabetic patients with CLI. For this purpose, we measured the circulating levels of a panel of 23 molecules related to inflammation, endothelial dysfunction, platelet activation, and thrombophilia in 92 patients with CLI and DFU requiring PTA and foot surgery. We investigated whether these putative biomarkers were associated with the following clinical endpoints: (1) healing of the treated DFUs; (2) need for new revascularization of the limb; (3) appearance of new lesions or relapses after successful healing. We found that sICAM-1 and endothelin-1 are inversely associated with DFU healing and that PAI-1 and endothelin-1 are associated with the need for new revascularization. Moreover, we found that the levels of thrombomodulin and sCD40L are associated with new lesions or recurrence, and we show that the levels of these biomarkers could be used in a decision tree to assign patients to clusters with different risks of developing new lesions or recurrences.

Surgery for acute and chronic diabetic foot problems has long been an integral component of care. While partial foot amputations remain as important diabetic limb-salvaging operations, foot-sparing reconstructive procedures have become equally important strategies to preserve the functional anatomy of the foot while addressing infection, chronic deformities, and ulcerations. A classification of types of diabetic foot surgery is discussed in accordance with the soft tissue status and acuity of the presenting foot problem. This brief overview from the Association for Diabetic Foot Surgeons describes common conditions best treated by surgical interventions, as well as specific indications. While techniques and indications continue to evolve, effective surgical management of the diabetic foot remains an integral component of care as well as for the prevention of recurrent ulceration.

Aims Charcot neuropathic osteoarthropathy (CN) represents a complication for diabetic patients which involves a progressive alteration of the osteoarticular apparatus with high risk of amputation. The aim of the study was to assess whether the localization of CN and the extent or grading of the osteomyelitis have an influence on the rate of limb salvage and the time to recovery. Methods We treated a diabetic population affected by CN complicated by ulceration and widespread osteomyelitic involvement. All patients were treated surgically to eliminate infected tissues, stabilize and correct the bone deformities. Histopathological and microbiological analyses were carried out on the bone specimens. Results Thirty-three patients affected by CN complicated by large osteomyelitic involvement of midfoot and/or ankle were treated between January 2010 and May 2014. The mean follow-up was 409,35 ± 154,06 days. Thirty patients had complete recovery (90.91%) at the end of follow-up. No difference in limb salvage rate and time to recovery was observed when stratifying the population according to CN localization, extent and grading of osteomyelitis. Conclusions In this cohort prospective study we observed a high percentage of limb salvage in patients affected by CN complicated by diffuse midfoot/hindfoot osteomyelitis. The localization of Charcot deformity and the extent/stage of osteomyelitis did not change the rate of limb salvage.

Objective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center. Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with diagnosis of DF and CLI. All patients were followed-up for at least one year and/or total recovery. The primary endpoint was one-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival. Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At one year, AFS, limb salvage, and survival rates were 34%, 34% and 83%, respectively. Lesions located proximal to Lisfranc joint were associated with major amputation (HR 2.1 [1.2-3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log rank p=0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02-59.89]). Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival. Funding Statement: The authors declare: "None." Declaration of Interests: The authors report no relationships that could be construed as a conflict of interest. Ethics Approval Statement: Clinical and procedural data from all patients admitted to Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) are recorded in a dedicated clinical database and accurately verified for completeness and accuracy against the patients’ clinical charts. Patients are prospectively followed up for at least 12 months. The analysis was based on current clinical practice, therefore the regulatory authorities required an ordinary written informed consent to procedures and data collection, which was obtained from all patients. The protocol of the study was in accordance with the Declaration of Helsinki.

Ulceration of the plantar aspect of the first metatarsophalangeal joint is a common localization in the diabetic foot. Conservative treatment of this lesion is a challenging problem, performed through the soft tissues and osseous debridement. The present study included a cohort of 28 patients affected by diabetes mellitus and a first ray lesion penetrating the bone. After surgical debridement with removal of the infected bone, we positioned antibiotic-loaded bone cement and stabilized the treated area with an external fixator. All patients with critical limb ischemia had their vascular disease treated before the procedure. The mean follow-up was 12.2 ± 6.9 months. Four patients developed a relapse of the ulceration after the procedure. In the postoperative period, 1 patient (3.57%) developed dehiscence of the surgical site and underwent a second procedure. In the follow-up period, 2 patients (7.14%) experienced bone cement dislocation. In 1 of these patients, a new ulceration was observed dorsally to the surgical site. The approach was surgical revision with bone cement replacement and stabilization with a new external fixator. In the other patient, given the absence of ulcerations, the cement was removed, and arthrodesis with internal stabilization using 2 cannulated screws was performed. One patient (3.57%), who had developed a relapse of ulceration after recurrent critical ischemia, underwent a percutaneous revascularization procedure and transmetatarsal amputation. During the follow-up period, no ulceration recurrences, transfer ulcerations, shoe fit problems, or gait abnormalities were detected in the other 24 patients. Our study presents the results of a technique requiring a 1-stage surgical approach to a relatively common problem, which is often difficult to solve.

Charcot osteoarthropathy is a serious complication of diabetic neuropathy. Its prevalence in the diabetic population varies in the literature in relation to certain variables, such as the method of assessment, clinical or instrumental; the population studied; and the scope of the selection. This article is intended as a review of the recent literature concerning Charcot osteoarthropathy in its evolution and complications characterized by the development of ulceration and subsequent bone infection. Diagnosis and treatment strategies—either medical or surgical—are discussed both for Charcot arthropathy and osteomyelitis.

Chronic wounds such as diabetic foot wounds are a tremendous burden to the health care system and often require a multidisciplinary approach to prevent amputations. Advanced technologies such as negative pressure wound therapy (NPWT) and bioengineered tissues have been successfully used in the treatment of these types of complex wounds. However, the introduction of NPWT with instillation (NPWTi) has provided an alternative treatment for treating complex and difficult-to-heal wounds. This article provides an overview of NPWT and the new NPWTi system and describes preliminary experience using NPWTi on patients with complicated infected diabetic foot wounds after surgical debridement and in a multidisciplinary setting.

Diabetic hindfoot ulcers, complicated by osteomyelitis, are associated with a high risk of major amputation. Partial calcanectomy, preceded by an effective management of the infection and of the eventual peripheral artery disease, can be considered as valid therapeutic option. We have evaluated a therapeutic protocol for diabetic hindfoot ulcers complicated by osteomyelitis, which, besides an adequate surgical debridement, considers a reconstructive pathway assisted by the positioning of a circular external fixator. We made a prospective study of a cohort of diabetic patients affected by heel ulcer complicated by osteomyelitis. All patients underwent open partial calcanectomy associated with the positioning of a circular external frame specifically designed for hindfoot stabilization and offloading. A reconstructive procedure was implemented starting with the application of negative pressure wound therapy and coverage with dermal substitute and split thickness skin grafting. From November 2014 to November 2015, 18 consecutive patients were enrolled. Mean follow-up period was 212.3 ± 64.0 days. Healing was achieved in 18 (100%) patients. The mean healing time was 69.0 ± 64.0 days. No major amputation had to be performed during the follow-up. Open partial calcanectomy associated with external fixation and skin reconstruction was as efficient as limb salvage in patients with infected lesions of the hindfoot complicated by calcaneal osteomyelitis.

Diabetic foot disease is a major health problem, which concerns 15% of the 200 million patients with diabetes worldwide. Major amputation, above or below the knee, is a feared complication of diabetes. More than 60% of non-traumatic amputations in the western world are performed in the diabetic population. Many patients who undergo an amputation, have a history of ulceration. Major amputations increase morbility and mortality and reduce the patient's quality of life. Treatment of foot complications is one of the main items in the absorption of economic and health resources addressed to the diabetic population. It is clear that effective treatment can bring about a reduction in the number of major amputations. Over recent years, we have seen a significant increase in knowledge about the physiopathological pathways of this complication, together with improvements in diagnostic techniques, but above all a standardized conservative therapeutic approach, which allows limb salvage in a high percentage of cases. This target has been achieved in specialized centers. An important prelude to diabetic foot treatment is the differing diagnosis of neuropathic and neuroischemic foot. This differentiation is essential for effective treatment. Ulceration in neuropathic foot is due to biomechanical stress and high pressure, which involves the plantar surface of toes and metatarsal heads. Treatment of a neuropathic plantar ulcer must correct pathological plantar pressures through weight bearing relief. Surgical treatment of deformities, with or without ulcerations, is effective therapy. A neuropathic ulcer that is not adequately treated can become a chronic ulcer that does not heal. An ulcer that does not heal for many months has a high probability of leading to osteomyelitis, for which treatment with antibiotics is not useful and which usually requires a surgical procedure. Charcot neuroarthropathy is a particular complication of neuropathy which may lead to fragmentation or destruction of joints and bones. A well-timed diagnosis of Charcot neuroartropathy is essential to avoid deformities of chronic evolution. In the diabetic population peripheral vascular disease (PVD) is the main risk factor for amputation. If peripheral vascular disease is ignored, surgical treatment of the lesion cannot be successful. In diabetic patients, PVD is especially distal, but often fully involves the femoral, popliteal and tibial vessels. It can be successfully treated with either open surgical or endovascular procedures. Infection is a serious complication of diabetic foot, especially when neuroischemic: phlegmon or necrotizing fascitis are not only limb-threatening problems, but also life-threatening ones. In this case, emergency surgery is needed. Primary and secondary prevention of foot ulceration is the main target. Prevention programs must be carried out to highlight risk factors, lowering amputation incidence.

OBJECTIVE—To evaluate the clinical efficacy and safety of HYAFF 11-based autologous dermal and epidermal grafts in the management of diabetic foot ulcers. RESEARCH DESIGN AND METHODS—A total of 79 patients with diabetic dorsal (n = 37) or plantar (n = 42) ulcers were randomized to either the control group with nonadherent paraffin gauze (n = 36) or the treatment group with autologous tissue-engineered grafts (n = 43). Weekly assessment, aggressive debridement, wound infection control, and adequate pressure relief (fiberglass off-loading cast for plantar ulcers) were provided in both groups. Complete wound healing was assessed within 11 weeks. Safety was monitored by adverse events. RESULTS—Complete ulcer healing was achieved in 65.3% of the treatment group and 49.6% of the control group (P = 0.191). The Kaplan-Meier mean time to closure was 57 and 77 days, respectively, for the treatment versus control groups. Plantar foot ulcer healing was 55% and 50% in the treatment and control groups, respectively. Dorsal foot ulcer healing was significantly different, with 67% in the treatment group and 31% in the control group (P = 0.049). The mean healing time in the dorsal treatment group was 63 days, and the odds ratio for dorsal ulcer healing compared with the control group was 4.44 (P = 0.037). Adverse events were equally distributed between the two groups, and none were related to the treatments. CONCLUSIONS—The autologous tissue-engineered treatment exhibited improved healing in dorsal ulcers when compared with the current standard dressing. For plantar ulcers, the off-loading cast was presumably paramount and masked or nullified the effects of the autologous wound treatment. This treatment, however, may be useful in patients for whom the total off-loading cast is not recommended and only a less effective off-loading device can be applied.

OBJECTIVE—to evaluate the reulceration and reamputation rates in a cohort of diabetic patients following first ray amputation. RESEARCH DESIGN AND METHODS—We evaluated a cohort of 89 diabetic patients, 63 men and 26 women, who underwent first ray amputation in the period from January 2000 to December 2001. The first ray lesions were Wagner grade 2 in 3 patients, Wagner grade 3 in 47 patients, and Wagner grade 4 in 39 patients. Following surgical wound healing, all patients wore special footwear with rocker bottom soles and custom molded insoles and were put on an intensive secondary prevention program. RESULTS—The mean follow-up duration was 16.35 ± 6.76 months (range 7–28). Fifteen patients developed new ulcerations, with 11 lesions occurring ipsilaterally and 4 contralaterally to the first ray amputation. In seven patients, the new lesion was treated and healed with dressing. Eight patients underwent a new surgical procedure: panmetatarsal head resection in four patients, toe amputation in two patients, a transmetatarsal amputation in one patient, and Lisfranc’s amputation in one patient. CONCLUSIONS—In the population studied, the first ray amputation presented a lower reulceration and reamputation rate with respect to that reported in the literature. This finding should therefore be attributed to the follow-up program, which uses shoes with a rocker bottom sole and custom molded insoles and intensive ambulatory check-ups.

Diabetic foot disease is a major health problem that concerns 15% of the 200 million patients with diabetes worldwide. More than 60% of non-traumatic amputations in the western world are performed in the diabetic population. Many patients who undergo an amputation have a history of ulceration. Treatment of foot complications is one of the main items of consumption of economic and health resources in diabetic patients. Over recent years, knowledge about the physiopathological pathways of this complication has increased significantly, together with improvements in diagnostic techniques and, above all, the establishment of a standardized conservative therapeutic approach, which allows limb salvage in a high percentage of cases. An important prelude to diabetic foot treatment is the differential diagnosis between neuropathic and neuroischaemic foot, which is essential for effective treatment. Ulceration in neuropathic foot is due to biomechanical stress and high pressure, which involves the plantar surface of the toes and metatarsal heads. In the diabetic population, peripheral vascular disease (PVD) is the main risk factor for amputation. In diabetic patients, PVD is mostly distal, but often fully involves the femoral, popliteal, and tibial vessels. It can be successfully treated with either open surgical or endovascular procedures. If PVD is ignored, surgical treatment of the lesion cannot be successful. Infection is a serious complication of diabetic foot, especially when neuroischaemic: phlegmon and necrotizing fascitis are not only limb-threatening problems, but also life-threatening. In this case, emergency surgery is needed. The aim of this review is to describe the therapeutic strategies for the various types of diabetic foot syndrome.

Background: Charcot neuroarthropathy is a serious complication associated with diabetic neuropathy. This complication probably is most serious when the ankle is involved because of the instability and progressive deformity, which often leads to ulceration, osteomyelitis, and amputation. Arthrodesis before the ulcerated lesion appears is considered a limb salvage treatment. One of the most effective techniques for an unstable ankle in Charcot neuroarthropathy is retrograde transcalcaneal nailing. Methods: Eighteen diabetic patients, without a history of ulceration, were treated from July, 2003, to November, 2005, with panarthrodesis of the ankle using intramedullary retrograde transcalcaneal nailing. The average follow up was 14 ± 10.1 months. All patients completed the unloaded postoperative period with a fiberglass cast (3 months nonweightbearing and 3 months partial weightbearing) and commenced walking in shoes with a stiff rocker sole and a molded insole. Results: During the followup period there were no major complications. In three patients, removal of one of the proximal screws used for anchoring the nail to the tibia was done because of protrusion causing skin breakdown. Fourteen patients had a stable fusion and four patients had fibrous union. The percentage of limb salvage was 100% in the followup period. Conclusions: Our study confirms that this operative technique is effective and safe.

To evaluate the clinical efficacy and safety of HYAFF 11-based autologous dermal and epidermal grafts in the management of diabetic foot ulcers.A total of 79 patients with diabetic dorsal (n = 37) or plantar (n = 42) ulcers were randomized to either the control group with nonadherent paraffin gauze (n = 36) or the treatment group with autologous tissue-engineered grafts (n = 43). Weekly assessment, aggressive debridement, wound infection control, and adequate pressure relief (fiberglass off-loading cast for plantar ulcers) were provided in both groups. Complete wound healing was assessed within 11 weeks. Safety was monitored by adverse events.Complete ulcer healing was achieved in 65.3% of the treatment group and 49.6% of the control group (P = 0.191). The Kaplan-Meier mean time to closure was 57 and 77 days, respectively, for the treatment versus control groups. Plantar foot ulcer healing was 55% and 50% in the treatment and control groups, respectively. Dorsal foot ulcer healing was significantly different, with 67% in the treatment group and 31% in the control group (P = 0.049). The mean healing time in the dorsal treatment group was 63 days, and the odds ratio for dorsal ulcer healing compared with the control group was 4.44 (P = 0.037). Adverse events were equally distributed between the two groups, and none were related to the treatments.The autologous tissue-engineered treatment exhibited improved healing in dorsal ulcers when compared with the current standard dressing. For plantar ulcers, the off-loading cast was presumably paramount and masked or nullified the effects of the autologous wound treatment. This treatment, however, may be useful in patients for whom the total off-loading cast is not recommended and only a less effective off-loading device can be applied.

Patients with diabetes have an impaired wound healing process that contributes to the pathophysiology that may lead to amputation. In this case study, an extensive (103.49 cm2) full-thickness cutaneous wound with exposure of a necrotic Achilles' tendon in a patient with diabetes, neuropathy, and infrapopliteal vascular disease of the lower limbs was healed using a two-stage autologous skin substitute technique. The scaffolds on which the autologous fibroblasts and keratinocytes were grown comprised an ester derivative of hyaluronic acid. Two applications of the cultured autologous fibroblasts and one of the cultured autologous keratinocytes were placed on the wound at 7-day intervals. The ulcer healed completely 60 days following the first fibroblast graft application. After 16 months of follow-up, no recurrence was noted and the patient can walk without ancillary support. This novel tissue engineering technique is a promising treatment for wound healing.