Changing the natural history of diabetic neuropathy: incidence of ulcer/amputation in the contralateral limb of patients with a unilateral nerve decompression procedure

The natural history of diabetes neuropathy is progressive and irreversible loss of sensibility in the feet, leading to ulceration and/or amputation in 15% of patients. The prevalence of neuropathy is more than 50% in those who have been diabetic for 20 years. Decompression of the tibial and peroneal nerves in those with diabetic neuropathy improves sensation in 70% of patients. The impact of this surgery on the development of ulcers and amputations in both the operated and the contralateral, nonoperated limb was evaluated in a retrospective analysis of 50 patients with diabetes a mean of 4.5 years (range, 2-7 years) from the date of surgery. No ulcers or amputations occurred in the index limb of these patients. In contrast, there were 12 ulcers and 3 amputations in 15 different patients in contralateral limbs. This difference was significant at P < 0.001. It is concluded that decompression of lower extremity nerves in diabetic neuropathy changes the natural history of this disease, representing a paradigm shift in health care costs.     

Transcutaneous oxygen tension measurements on limbs of diabetic and nondiabetic patients with peripheral vascular disease

We measured transcutaneous oxygen tension (TcPo2) at a skin temperature of 44 degrees C on 319 limbs in an approximately equal number of nondiabetic and diabetic patients with peripheral vascular disease. Measurements were made above the knee, below the knee (BK), and on the dorsum of the foot. Nondiabetic limbs with leg/foot (the lesser of BK or foot) TcPo2 values below 20 mm Hg were significantly more likely to have ulcers, to have rest pain, or to require an amputation on the limb as compared with limbs with leg/foot TcPo2 values above 20 mm Hg. Patients with more severe symptoms had significantly reduced limb TcPo2 values, and these values were lower at more distal measurement sites. Generally, these results were similar in diabetic and nondiabetic patients without limb ulceration; however, the diabetic patients were more likely to have ulcers in the presence of high limb TcPo2. This observation suggests that ulceration in a substantial proportion of the diabetic patients may have resulted from factors other than insufficient cutaneous tissue oxygen delivery.     

Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization

OBJECTIVES: The natural history of limbs affected by ischemic ulceration is poorly understood. In this report, we describe the outcome of limbs with stable chronic leg ulcers and arterial insufficiency that were treated with wound-healing techniques in patients who were not candidates for revascularization. METHODS: A prospectively maintained database of limb ulcers treated at a comprehensive wound center was used to identify patients with arterial insufficiency, defined as an ankle-brachial index (ABI) <0.7 or a toe pressure <50 mm Hg. Patients were treated without revascularization when medical comorbidity or anatomic considerations did not allow revascularization with acceptable risk. Ulcers were treated with a protocol emphasizing pressure relief, débridement, infection control, and moist wound healing. Risk factors analyzed for their affect on healing and amputation risk included age, gender, diabetes mellitus, chronic renal insufficiency (serum creatinine > 2.5 mg/dL), severity of ischemia measured by ABI or toe pressure, wound grade, wound size, and wound location. RESULTS: Between January 1999 and March 2005, 142 patients with 169 limbs having arterial insufficiency and full-thickness ulceration were treated without revascularization. Mean patient age was 70.8 +/- 4.5. Diabetes mellitus was present in 70.4% of limbs and chronic renal insufficiency in 27.8%. Toe amputations or other foot-sparing procedures were performed in 28% of limbs. Overall, limb loss occurred in 37 patients. By life-table analysis, 19% of limbs required amputation < or =6 months of initial treatment and 23% at 12 months. Complete wound closure was achieved in 25% by 6 months and in 52% by 12 months. Statistical analysis showed a correlation between ABI and the risk of limb loss. In patients with an ABI <0.5, 28% and 34% of limbs experienced limb loss at 6 and 12 months, respectively, compared with 10% and 15% of limbs in patients with an ABI >0.5 (P = .01). The only risk factor associated with wound closure was initial wound size (P < .005). CONCLUSIONS: Limb salvage can be achieved in most patients with arterial insufficiency and uncomplicated chronic nonhealing limb ulcers using a program of wound management without revascularization. Healing proceeds slowly, however, requiring more than a year in many cases. Patients with an ABI <0.5 are more likely to require amputation. Interventions designed to improve outcomes in critical limb ischemia should stratify outcomes based on hemodynamic data and should include a comparative control group given the natural history of ischemic ulcers treated in a dedicated wound program.     

Assessing Decreased Sensation and Increased Sensory Phenomena in Diabetic Polyneuropathies

Loss of sensation and increased sensory phenomena are major expressions of varieties of diabetic polyneuropathies needing improved assessments for clinical and research purposes. We provide a neurobiological explanation for the apparent paradox between decreased sensation and increased sensory phenomena. Strongly endorsed is the use of the 10-g monofilaments for screening of feet to detect sensation loss, with the goal of improving diabetic management and prevention of foot ulcers and neurogenic arthropathy. We describe improved methods to assess for the kind, severity, and distribution of both large- and small-fiber sensory loss and which approaches and techniques may be useful for conducting therapeutic trials. The abnormality of attributes of nerve conduction may be used to validate the dysfunction of large sensory fibers. The abnormality of epidermal nerve fibers/1 mm may be used as a surrogate measure of small-fiber sensory loss but appear not to correlate closely with severity of pain. Increased sensory phenomena are recognized by the characteristic words patients use to describe them and by the severity and persistence of these symptoms. Tests of tactile and thermal hyperalgesia are additional markers of neural hyperactivity that are useful for diagnosis and disease management.Altered sensation (loss or increased sensory phenomena) may be early and prominent manifestations of varieties of polyneuropathy associated with diabetes. These neuropathies may be classified into four major varieties: distal symmetric sensorimotor polyneuropathies (typical and atypical diabetic sensorimotor polyneuropathy [DSPN]); compression and entrapment varieties (median neuropathy at the wrist [carpal tunnel syndrome]); radiculoplexus neuropathies (lumbosacral [Bruns Garland syndrome], thoracic, and cervical); and cranial neuropathies (1–3). Although none of these varieties are uniquely associated with DM, all varieties are more prevalent in diabetes. Underlying mechanisms are different among these varieties (1–3).Decreased sensation and increased sensory phenomena are not being adequately evaluated in clinical medicine. Possible reasons include the following: 1) methodologies of such assessments are not sufficiently emphasized in training of health care professionals; 2) insufficient time is taken in their evaluation (i.e., to assess kind, severity, and distribution of sensation loss, let alone to assess increased sensory phenomena); 3) reference values are often not available or used; 4) standard techniques of assessment are typically not used, for example, to assess clinical sensation with cotton wool, disposable stick pins, tuning forks, or other; 5) validated quantitative sensation tests (QSTs) are generally not used; and 6) compensation for such testing is unavailable.Here we review the neurobiology underlying decreased and increased sensory phenomena occurring in diabetic polyneuropathies (DPNs) and methodologies of their assessment. Especially emphasized in this review are improved methods to screen for sensation loss of feet, with the goal of preventing ulcers and neurogenic arthropathy; use of composite scores of neuropathic signs; computer-assisted (smart) QSTs; nerve conduction (NC) measurements; and counts of intraepidermal nerve fibers as neuropathy end points for therapeutic trials of DPN severity. Also described are measures of increased sensory phenomena.     

Does severe venous insufficiency have a different etiology in the morbidly obese? Is it venous?

OBJECTIVE: Chronic venous insufficiency (CVI) is the most common cause of leg ulcers. Patients with morbid obesity are remarkable for particularly recalcitrant ulcers. Because obesity is not specifically incorporated in CEAP or other venous scoring systems, we sought to characterize this group of patients more completely. METHODS: Patients with severe CVI (CEAP clinical class, 4, 5, and 6), and class III obesity (body mass index [BMI], >40) were reviewed. Findings from clinical and duplex ultrasound scan (DU) examinations were compared with the CEAP classification, its adjunctive venous clinical severity score, and sensory thresholds. RESULTS: A review of clinic records identified 20 ambulatory patients with a mean age of 62 years, a mean BMI of 52, and a mean weight of 164 kg (361 lbs); all but one had bilateral symptoms. No evidence of venous insufficiency was detected with DU in 24 of the 39 limbs. Although some valvular incompetence was detected with DU in 15 of 39 limbs, these abnormalities were widely dispersed between 28 sites; eight limbs had findings at only one site. Ulceration (mean area, 29 cm(2)) was present in 25 limbs and necessitated 7 months for healing; 13 (52%) recurred at least once during a mean observation period of 36 months. The mean sensory threshold of 5.21 exceeded current risk thresholds used in diabetic screening programs. The distribution of CEAP clinical class was C4 (n = 14), C5 (n = 14), and C6 (n = 11). Increasing CEAP class correlated with an increased mean BMI of 47, 52, and 56, respectively (P <.01). CEAP also correlated with a rising mean venous clinical severity score of 10, 11, and 15, respectively (P <.05). CONCLUSION: Patients with class III obesity had severe limb symptoms, typical of CVI, but approximately two thirds of the limbs had no anatomic evidence of venous disease. The association of increasing limb symptoms with increasing obesity suggested that the obesity itself contributes to the morbidity.     

The influence of renal function on diabetic foot ulceration

We examined the effect of renal function on the formation, severity, and outcome of diabetic foot lesions. Information was collected from a retrospective hospital chart survey and analyzed by univariate and multivariate linear regression analysis. Creatinine clearance, peripheral neuropathy, and peripheral vascular disease were all found to be independently associated with formation of foot lesions, indicating that each of these acts by distinct biologic mechanisms. Renal function had no bearing on the severity of lesions or on their eventual healing. We conclude that foot ulcers are more likely to develop in diabetic patients who also suffer from renal impairment, but they are no less likely to heal than are those in patients with normal renal function. We further conclude that attempts to preserve functional limbs in these patients are justified.     

Diabetic Neuropathy: Is Pain God's Greatest Gift to Mankind?

Diabetic neuropathy is common and it has been estimated that around 40% of older type 2 diabetic patients have risk factors for foot ulceration. It is the loss of the "gift of pain" that results in the development of what should be preventable foot lesions in many patients. As neuropathy is silent in up to 50% of patients, all diabetic patients should receive an annual screening by careful examination of the lower limbs for evidence of any sensory loss or peripheral vascular disease. Similarly, it must be remembered when treating neuropathic foot lesions that patients will willingly weight-bear on plantar ulcers: suitable offloading is therefore the first-line treatment for such lesions.     

Impact of the bacteriology of diabetic foot ulcers in limb loss

Infections in feet of patients with diabetes mellitus is common, complex and costly. The aim of this study to investigate the isolated microorganisms in infected diabetic foot ulcers, and the impact of these infectious agents in limb loss in a tertiary medical center in Mexico City. We conducted a retrospective review in diabetic patients with infected foot ulcers from 1997 to 2014. Diabetic foot was defined according to the World Health Organization (WHO), the bacteriology of wound cultures and the impact of microorganisms in limb loss (major amputation) was studied. Patient's demographics, comorbidities, wound characteristics, and other factors associated in clinical outcomes were determined. A total of 165 subjects with soft tissue infections and/or osteomyelitis and positive cultures were included. One hundred and five (64%) were male, with a mean age of 60 year old +/? 15. One hundred fifty‐nine (96%) had Type 2 diabetes mellitus, 68 (41%) history of peripheral arterial disease (PAD) and 97 (59%) patients had osteomyelitis. In 89 patients (54%), cultures were polymicrobial and one single organism was isolated in 76 cultures (46%). During the follow up, 96 (58%) patients preserved their limbs and 69 (42%) required major amputation (above or below knee). Sixty percent of patients that suffered from limb loss had polymicrobial culture (p = 0.13). Growth of Escherichia coli and Enterococcus faecium (p = 0.03) and E. coli and Morganella morgagnii (p = 0.03) was associated to limb loss. Among monomicrobial cultures, infections associated with Proteous mirabilis had higher rate of progression to limb loss (p = 0.03). PAD was associated to limb loss (p = 0.001). Management of diabetic foot requires a multimodality approach. In this study, in patients that received appropriate antibiotic therapy and optimal surgical management, we observed that history of PAD, polymicrobial and isolated P. mirabilis infections were variables associated with higher rate of limb loss.     

Regulation of VEGF in Diabetic Patients with Critical Limb Ischemia

Diabetic patients are at a 10- to 20-fold increased risk for the development of critical limb ischemia. Vascular endothelial growth factor (VEGF) is critical for the development of collateral blood vessels, which can effectively bypass peripheral arterial occlusions. We therefore set out to determine if the regulation of VEGF in patients with peripheral vascular disease differs in diabetic and nondiabetic patients. Diabetic and nondiabetic patients with peripheral vascular disease were divided into those with or without critical limb ischemia as defined by clinical criteria (rest pain, nonhealing ulcer). Monocytes from peripheral blood were isolated from all patients and the hypoxic induction of VEGF was determined in vitro. In patients without diabetes, we found that there was no significant difference in the hypoxic induction of VEGF between patients with or without critical limb ischemia. However, in diabetic patients we found that patients with critical limb ischemia produced significantly more VEGF than patients without critical limb ischemia (6.3 +/- 1.3 vs. 2.1 +/- 0.3, p < 0.015). We conclude that diabetic patients with critical limb ischemia do not have an impairment in the ability to produce VEGF with hypoxia. Contrary to current dogma, treatment paradigms directed at increasing VEGF production in the diabetic patient with critical limb ischemia might not be beneficial.     

Pedal Bypass for Limb Salvage: Impact of Diabetes on Long-Term Outcome

Use of pedal bypass can salvage limbs of patients with critical ischemia. The aim of this study was to evaluate the results of surgical revascularization of pedal arteries in diabetic patients and to assess the impact of diabetes on long-term outcome. We performed a retrospective analysis of all consecutive pedal bypasses done between January 1, 1987 and December 31, 1997. Demographic data, surgical indications, operative variables, and postoperative results including graft patency and limb salvage were compared between diabetic and nondiabetic patients. The results of this comparison showed that pedal bypass can safely and effectively relieve critical ischemia in diabetic patients. Diabetics have less early graft thrombosis and superior long-term graft patency. Despite higher incidence of renal insufficiency or failure and more tissue loss, diabetics can achieve similar excellent limb salvage rates. This outcome justifies aggressive revascularization of pedal arteries in diabetic as well as nondiabetic patients with critical limb ischemia.     

Cilostazol prevents foot ulcers in diabetic patients with peripheral vascular disease

Diabetic patients are at high risk of foot ulcerations that may lead to limb amputations with important socio‐economic impact. Peripheral vascular disease may be frequently associated in diabetes mellitus type II with its main symptom, intermittent claudication. Many studies reported the known efficacy of cilostazol in treating vascular claudication. Metalloproteinase‐9 (MMP‐9) seems to be a biochemical marker implicated in chronic wounds and in particular in diabetic foot ulcers. Cilostazol appears to have a lowering effect on MMP‐9 levels and this may suggest a beneficial effect in order to prevent or retard the onset of foot ulcer in diabetic patients. In our study, two groups of diabetic patients with peripheral vascular disease were divided into two groups according to the presence of claudication in order to receive cilostazol. Group A (31 patients without claudication) were not eligible to receive cilostazol whereas Group B (47 patients with claudication) received cilostazol administration for 24 weeks (100 mg orally twice daily). Median follow up was of 16 months. During the follow up, 4·25% of patients of Group B and 35·48% of patients of Group A (P < 0·01) showed onset of foot ulceration. Although further randomised and controlled studies are required cilostazol seems to show beneficial effects for primary prevention of diabetic foot ulcers.     

腔镜深筋膜下交通静脉结扎治疗下肢静脉曲张

目的　观察腔镜深筋膜下交通静脉结扎 (SEPS)在下肢静脉曲张治疗中的疗效。　方法　 1 999年 1 1月～ 2 0 0 0年 1 2月手术治疗静脉曲张 1 0 8例 ,其中 34例 41侧患肢行 SEPS。男 1 6例 ,女 1 8例 ,年龄 2 0～ 79岁。病程 1～45年 ,平均 1 6.1年。双下肢病变 7例。 2 6例 30侧患肢有静脉性溃疡 ,溃疡直径 1 .5～ 1 2 .0 cm不等 ;8例 1 1侧患肢有色素沉着 ,皮肤病损 1个月～ 1 5年。根据病情分别或同时选用大隐静脉高位结扎和抽剥、小腿曲张浅静脉连续环形缝扎、股静脉瓣膜外修复成形和 SEPS术。　结果　 34例手术顺利 ;术后 1 9侧患肢溃疡 1个月内愈合 ,7侧患肢溃疡 3个月内愈合 ,4侧患肢行游离植皮后溃疡愈合。经术后 9～ 2 2个月的随访 ,溃疡无复发。　结论　 SEPS促进了静脉性溃疡的愈合 ,是治疗下肢静脉功能不全的重要方法之一。     

Update and validation of the Society for Vascular Surgery wound,ischemia, and foot infection threatened limb classification system

The diagnosis of critical limb ischemia, first defined in 1982, was intended to delineate a patient cohort with a threatened limb and at risk for amputation due to severe peripheral arterial disease. The influence of diabetes and its associated neuropathy on the pathogenesis-threatened limb was an excluded comorbidity, despite its known contribution to amputation risk. The Fontaine and Rutherford classifications of limb ischemia severity have also been used to predict amputation risk and the likelihood of tissue healing. The dramatic increase in the prevalence of diabetes mellitus and the expanding techniques of arterial revascularization has prompted modification of peripheral arterial disease classification schemes to improve outcomes analysis for patients with threatened limbs. The diabetic patient with foot ulceration and infection is at risk for limb loss, with abnormal arterial perfusion as only one determinant of outcome. The wound extent and severity of infection also impact the likelihood of limb loss. To better predict amputation risk, the Society for Vascular Surgery Lower Extremity Guidelines Committee developed a classification of the threatened lower extremity that reflects these important clinical considerations. Risk stratification is based on three major factors that impact amputation risk and clinical management: wound, ischemia, and foot infection. This classification scheme is relevant to the patient with critical limb ischemia because many are also diabetic. Implementation of the wound, ischemia, and foot infection classification system in critical limb ischemia patients is recommended and should assist the clinician in more meaningful analysis of outcomes for various forms of wound and arterial revascularizations procedures required in this challenging, patient population.     

自体骨髓基质干细胞移植治疗糖尿病下肢血管病变

目的探讨自体骨髓基质干细胞(BMSC)移植治疗糖尿病下肢血管病变的可行性和临床效果。方法糖尿病致双下肢血管病变的患者30例(60条下肢),双侧下肢的病变程度接近。以患者自体BMSC对一侧下肢进行治疗,以另一侧下肢为自身对照,对双侧肢体肤色、肢体疼痛、冷感、溃疡、皮温改变、间歇性跛行变化及实验室检查进行比较,观察自体BMSC治疗糖尿病周围血管病变的安全性和有效性。结果治疗侧下肢在肤色、疼痛感、冷感、溃疡、皮温等方面均明显好于对照组,间隙性跛行亦有改善;术后6个月时行数字减影动脉血管造影,治疗组可见丰富的侧支血管形成。结论自体BMSC移植治疗糖尿病下肢血管病变具有可行性,可明显改善症状,效果肯定。     

Relationship between transcutaneous oxygen tension, ankle blood pressure, and clinical outcome of vascular surgery in diabetic and nondiabetic patients

We measured ankle systolic blood pressure (ABP) and limb transcutaneous oxygen tension (TcPO2) before and after 53 vascular procedures performed to relieve limb-threatening ischemia. We compared changes in ABP and TcPO2 and also compared these measurements of limb hemodynamics with the clinical outcome of the vascular procedures. For the procedures performed on patients without diabetes, both ABP and TcPO2 registered similar changes after surgery. Furthermore, those nondiabetic patients who had a postoperative ABP greater than 75 mm Hg or TcPO2 greater than 20 mm Hg showed resolution of the clinical symptoms within 60 days after surgery. All patients falling below these levels underwent a subsequent limb amputation. The results differed somewhat for procedures performed on patients with diabetes. First, a number of diabetic patients showed high ABP in conjunction with low TcPO2. We attribute these observations to the high incidence in diabetic patients of calcific medial stenosis leading to artificially elevated ABP measurements. Second, the clinical outcome among diabetic patients was uncorrelated with the postoperative ABP and was poorly correlated with postoperative TcPO2. Those diabetic patients with postoperative TcPO2 below 20 mm Hg showed unfavorable clinical outcomes, but many patients with postoperative TcPO2 greater than 20 mm Hg and postoperative ABP greater than 75 mm Hg also showed unfavorable clinical outcome (slow healing of ulcers, persistence of rest pain, and/or an amputation on the limb). These data suggest that among our patients with diabetes, simple relief of limb ischemia was not sufficient to result in a trouble-free clinical course. We conclude that TcPO2 is a useful replacement or adjunct to ABP measurements for evaluating the hemodynamic outcome of vascular surgery. Our results also suggest that it is extremely important to evaluate the outcome of such surgeries separately in patients with and without diabetes.     

Infrainguinal revascularization in end-stage renal disease

Patients with end-stage renal disease are being maintained for longer periods with dialysis or renal transplantation. Although renal failure itself is associated with occlusive peripheral vascular disease, such patients often have additional comorbid risk factors. In this series, 88% of patients were diabetic, 93% were hypertensive, and 44% were smokers, all factors that exacerbate the severity of their vasculopathy. As a consequence, the vascular surgeon is increasingly being confronted with limb-threatening peripheral vascular disease in this population. We performed 34 infrainguinal bypasses in 27 patients during an 8-year period from 1986 to 1993. Fifty percent of these were bypasses to the infrapopliteal level. The 12- and 48-month graft patency was 64% and 38%, respectively, by life-table analysis. The limb salvage rate was 65% and 58% at 12 and 48 months. The perioperative mortality rate was 5.9% and the morbidity rate was 37%. Most of the limb loss (66%) occurred during the first 3 months after surgery as a result of acute graft occlusion or nonhealing of an ulcer or minor amputation site. We believe that this reflects an increasingly aggressive approach to limb salvage in patients with end-stage renal disease. Four limbs were lost despite a patent graft. Infrainguinal bypass is a viable management option for limb salvage in patients with end-stage renal disease. These procedures can be undertaken with acceptable perioperative mortality and with a 12-month limb salvage rate of 65%.Presented at the Eighteenth Annual Meeting of the Peripheral Vascular Surgery Society, Washington, D.C., June 6, 1993.     

The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden.Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%.Infection develops in 50%–60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers.Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.     

The diabetic foot: perspectives from Chennai, South India

Foot ulcers are a significant complication of diabetes mellitus and often precede lower extremity amputation. The most frequent underlying etiologies are neuropathy, trauma, deformity, high plantar pressures, and peripheral arterial disease. Loss of protective sensation is the primary factor in foot ulceration in diabetics. Mechanical stresses resulting from joint deformity, limited joint mobility, and poor foot care/footwear are important in the causal pathway of both neuropathic and ischemic ulcers. It was shown that the recurrence of foot infection was common among Indian diabetic patients (52%). A lesser prevalence of peripheral vascular disease (13%) among Indians was noted when compared with those in Western countries (48%). Smoking increases the risk by reducing blood circulation in the legs and reducing sensation in the feet. Prompt and aggressive treatment of diabetic foot ulcers can often prevent exacerbation of the problem and eliminate the potential for amputation. The aim of the therapy should be early intervention to allow prompt healing of the lesion and prevent recurrence once it is healed. Multidisciplinary management programs that focus on prevention, education, regular foot examinations, aggressive intervention, and optimal use of therapeutic footwear have demonstrated significant reductions in the history of lower extremity amputations.     

Operative lumbar sympathectomy for severe lower limb ischaemia: still a valuable treatment option.

Over a 5-year period, 132 operative lumbar sympathectomies were performed on 118 patients with severe peripheral vascular disease unsuitable for vascular reconstruction. In 62 patients local ulcer débridement or toe amputation was performed at the same time. There was a 45% subsequent limb loss, which occurred predominantly in the first 6 months after sympathectomy. The risk of limb loss was independent of diabetes, hypertension, ischaemic heart disease, cerebrovascular disease or concomitant reconstructive surgery. Of the limbs that survived, rest pain had resolved in 86% within 6 months and 64% recovered from all trophic changes over a similar period. This series suggests that lumbar sympathectomy coupled with local tissue management remains a valuable treatment option for the severely ischaemic limb not amenable to reconstructive surgery.     

A safe, pre-fabricated, immediate postoperative prosthetic limb system for rehabilitation of below-knee amputations

Thirty-eight below-knee amputees were treated with a commercially available pneumatic prosthetic limb system, applied immediately postoperatively, that would allow immediate weight bearing following lower extremity amputation. Thirty-four limbs were amputated for peripheral vascular insufficiency and four were amputated due to trauma. Weight bearing was initiated an average of 4.7 days following surgery and patients were discharged with a non-removable temporary prosthesis at an average of 8.9 days. Thirty-three healed and were uneventfully fit with standard below-knee prosthetic limbs. Three required revision to the above-knee level. In a controlled setting, early weight bearing in the peripheral vascular insufficiency patient can be initiated with a low risk of local wound complication.