A systematic review of various types of conventional and modern diabetic foot ulcer surgeries and their outcomes: A beginners digest

Document Type : Review

Authors

1 Associate Professor, Department of General Surgery, Vilasrao Deshmukh govt. Medical College, Latur, India

2 Junior Resident, Department of General Surgery, Vilasrao Deshmukh govt. Medical College, Latur, India

3 Professor and HOD, Department of General Surgery, Vilasrao Deshmukh govt. Medical College, Latur, India

Abstract

Background: The diabetic foot constitutes one of the major diabetes-related morbidity. Diabetic foot ulcers (DFUs) are a disastrous consequence of the illness's course and are brought on by peripheral neuropathy, peripheral vascular disease, immunosuppression, and loss of glycemic control. Chronic ulcers must be treated surgically to prevent recurrences in cases with DFU. Every surgeon has to deal with this condition from very early in his career.
Objectives: To investigate the various forms of traditional and modern DFU procedures and their consequences, this study can provide very fruitful guidance to the surgeons.
Methods: In this study, we searched Google Scholar, PubMed, Embase, Cochrane Library, Web of Science, and Scopus from 2013 to 2023. The inclusion criteria were patients with DFUs, and patients with a known history of diabetes mellitus (type I or type II); the parameters included in the study were the occurrence of adverse responses, the rate of amputation, fatalities, recurrence rate and some other indications. Using the review manager (RevMan version 5.4), the risk of bias evaluation was done in this study, with risk assessment domains classified as high, unclear, or low risk. To check for biases for example reporting bias, performance bias, attrition bias, selection bias, etc., a recommended approach was used.
Results: The current review included 8 studies in total, with a total of 888 cases of DFUs. A recurrence rate of 24.51% was noted for the entire patient population. The recurrences noted in none of the three investigations. Overall mortality was 14.26%, according to three investigations.
Conclusions: It can be concluded that the patients treated with surgery show a lower recurrence rate of DFU as compared to the patients treated with only drug treatment. It is crucial to implement a new surgical treatment for DFUs to increase their success rate. A recently developed treatment program utilizing a multidisciplinary team approach and cooperation with referral hospitals is urgently required to improve the outcomes of DFU.

Keywords


  1. Singer AJ, Tassiopoulos A, Kirsner RS. Evaluation and Management of Lower-Extremity Ulcers. N Engl J Med. 2018; 378(3):302-303. doi:10.1056/NEJMc1715237
  2. Alavi A, Sibbald RG, Mayer D, Goodman L, Botros M, Armstrong DG, et al. DFU's: Part I. Pathophysiology and prevention. J Am Acad Dermatol. 2014;70:1 e1-18 doi:10.1016/j.jaad.2013.07.048 PMid:24355276
  3. Hunt NA, Liu GT, Lavery LA. The economics of limb salvage in diabetes. Plast Reconstr Surg, 2011; 127 Suppl 1: 289S-295S. doi:10.1097/PRS.0b013e3181fbe2a6 PMid:21200304
  4. Jeffcoate WJ, Vileikyte L, Boyko EJ, Armstrong DG, Boulton AJ. Current challenges and opportunities in the prevention and management of diabetic foot ulcers. Diabetes Care. 2018;41(4):645-52. doi:10.2337/dc17-1836 PMid:29559450
  5. Alvarsson A, Sandgren B, Wendel C, Alvarsson M, Brismar K. A retrospective analysis of amputation rates in diabetic patients: can lower extremity amputations be further prevented?. Cardiovasc Diabetol. 2012;11(1):1-1. doi:10.1186/1475-2840-11-18 PMid:22385577 PMCid:PMC3362773
  6. Wang AH, Xu ZR, Ji LN. Clinical characteristics and medical costs of diabetics with amputation at central urban hospitals in China. Zhonghua Yi XueZaZhi. 2012; 92:224-227.
  7. Armstrong DG, Boulton AJM, Bus SA. DFUs and Their Recurrence. N Engl J Med. 2017;376(24):2367-2375 doi:10.1056/NEJMra1615439 PMid:28614678
  8. Mutluoglu M, Uzun G, Turhan V, Gorenek L, Ay H, Lipsky BA. How reliable are cultures of specimens from superficial swabs compared with those of deep tissue in patients with DFUs? J Diabetes Complications. 2012;26(3):225-9. doi:10.1016/j.jdiacomp.2012.03.015 PMid:22520404
  9. Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population‐based cohort from the United Kingdom. Diabet Med. 2016;33(11):1493-8. doi:10.1111/dme.13054 PMid:26666583
  10. Goodridge D, Trepman E, Embil JM. Health-related quality of life in diabetic patients with foot ulcers: a literature review. J Wound Ostomy Continence Nurs. 2005; 32(6):368-77. doi:10.1097/00152192-200511000-00007 PMid:16301902
  11. Skrepnek GH, Mills Sr JL, Lavery LA, Armstrong DG. Health care service and outcomes among an estimated 6.7 million ambulatory care diabetic foot cases in the US. Diabetes Care. 2017;40(7):936-42. doi:10.2337/dc16-2189 PMid:28495903
  12. Guest JF, Fuller GW, Vowden P. Diabetic foot ulcer Management in clinical practice in the UK: costs and outcomes. Int Wound J 2018; 15(1): 43-52 doi:10.1111/iwj.12816 doi:10.1111/iwj.12814 PMCid:PMC7950152
  13. Lavery LA, Davis KE, Berriman SJ, Braun L, Nichols A, Kim PJ, et al. WHS guidelines update: diabetic foot ulcer treatment guidelines. Wound Repair Regen. 2016;24(1):112-26.. doi:10.1111/wrr.12391 PMid:26663430
  14. Cheuy VA, Hastings MK, Commean PK, Mueller MJ. Muscle and joint factors associated with forefoot deformity in the diabetic neuropathic foot. Foot Ankle Int. 2016;37(5):514-21. doi:10.1177/1071100715621544 PMid:26666675 PMCid:PMC5111819
  15. Bus SA, Maas M, Michels RP, Levi M. Role of intrinsic muscle atrophy in the etiology of claw toe deformity in diabetic neuropathy may not be as straightforward as widely believed. Diabetes Care. 2009;32(6):1063-7. doi:10.2337/dc08-2174 PMid:19279305 PMCid:PMC2681028
  16. Tamir E, Daniels TR, Finestone A, Nof M. Off-loading of the hindfoot and midfoot neuropathic ulcers using a fiberglass cast with a metal stirrup. Foot Ankle Int. 2007;28(10):1048-52. doi:10.3113/FAI.2007.1048 PMid:17923053
  17. Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavacek P, et al. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev. 2008;24(Suppl 1): S162-80. doi:10.1002/dmrr.850 PMid:18442178
  18. Bus SA, van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev. 2016; 32(Suppl 1):16-24 doi:10.1002/dmrr.2696 PMid:26334001
  19. Pound N, Chipchase S, Treece K, Game F, Jeffcoate W. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med. 2005;22(10): 1306-9. doi:10.1111/j.1464-5491.2005.01640.x PMid:16176187
  20. Armstrong DG, Boulton AJ, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-75. doi:10.1056/NEJMra1615439 PMid:28614678
  21. Falanga V. Wound healing and its impairment in the diabetic foot. Lancet. 2005;366(9498):1736-43. doi:10.1016/S0140-6736(05)67700-8 PMid:16291068
  22. Galiano RD, Tepper OM, Pelo CR, Bhatt KA, Callaghan M, Bastidas N, et al. Topical vascular endothelial growth factor accelerates diabetic wound healing through increased angiogenesis and by mobilizing and recruiting bone marrow-derived cells. Am J Pathol. 2004;164(6):1935-47. doi:10.1016/S0002-9440(10)63754-6 PMid:15161630
  23. Maruyama Y, Maruyama K, Kato Y, Kajiya K, Moritoh S, Yamamoto K, et al. The effect of podoplanin inhibition on lymphangiogenesis under pathological conditions. Invest Ophthalmol Vis Sci. 2014;55(8):4813-22. doi:10.2353/ajpath.2007.060018 PMid:17392158 PMCid:PMC1829452
  24. Gibran NS, Jang YC, Isik FF, Greenhalgh DG, Muffley LA, Underwood RA, et al. Diminished neuropeptide levels contribute to the impaired cutaneous healing response associated with diabetes mellitus. J Surg Res. 2002;108(1):122-8. doi:10.1006/jsre.2002.6525 PMid:12443724
  25. Lobmann R, Ambrosch A, Schultz G, Waldmann K, Schiweck S, Lehnert H. Expression of matrix-metalloproteinases and their inhibitors in the wounds of diabetic and non-diabetic patients. Diabetologia. 2002;45:1011-6. doi:10.1007/s00125-002-0868-8 PMid:12136400
  26. Stojadinovic O, Brem H, Vouthounis C, Lee B, Fallon J, Stallcup M, et al. Molecular pathogenesis of chronic wounds: the role of β-catenin and c-myc in the inhibition of epithelialization and wound healing. Am J Pathol. 2005;167(1):59-69. doi:10.1016/S0002-9440(10)62953-7 PMid:15972952
  27. Brem H, Stojadinovic O, Diegelmann RF, Entero H, Lee B, Pastar I, et al. Molecular markers in patients with chronic wounds to guide surgical debridement. Mol Med. 2007;13(1):30-9. doi:10.2119/2006-00054.Brem PMid:17515955 PMCid:PMC1869625
  28. Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. Wound Repair Regen. 2002;10(6):354-9. doi:10.1046/j.1524-475X.2002.10603.x PMid:12453138
  29. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg. 1996;183 (1):61-4.
  30. Steed DL. Debridement. Am J Surg. 2004; 187(5):S71-4 doi:10.1016/S0002-9610(03)00307-6 PMid:15147995
  31. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. Executive summary: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54 (12):1679-84 doi:10.1093/cid/cis460 PMid:22619239
  32. Braun L, Kim PJ, Margolis D, Peters EJ, Lavery LA. What's new in the literature: An update of new research since the original WHS diabetic foot ulcer guidelines in 2006. Wound Repair Regen. 2014;22(5):594-604. doi:10.1111/wrr.12220 PMid:25139424
  33. Game FL, Apelqvist J, Attinger CE, Hartemann A, Hinchliffe RJ, Löndahl M, et al. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes/Metabol Res Rev. 2016;32:154-68 doi:10.1002/dmrr.2707 PMid:26344936
  34. Elraiyah T, Domecq JP, Prutsky G, Tsapas A, Nabhan M, Frykberg RG, et al. A systematic review and meta-analysis of débridement methods for chronic diabetic foot ulcers. J Vasc Surg. 2016; 63 (2):37S-45S doi:10.1016/j.jvs.2015.10.002 PMid:26804366
  35. Hinchliffe RJ, Valk GD, Apelqvist J, Armstrong DG, Bakker K, Game FL, et al. A systematic review of the effectiveness of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes/Metabol Res Rev. 2008;24(S1):S119-44 doi:10.1002/dmrr.825 PMid:18442185
  36. Bakker K, Apelqvist J, Schaper NC, International Working Group on the Diabetic Foot Editorial Board. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/Metabol Res Rev. 2012;28:225-31 doi:10.1002/dmrr.2253 PMid:22271742
  37. Yavuz M, Ersen A, Hartos J, Schwarz B, Garrett AG, Lavery LA, et al. Plantar shear stress in individuals with a history of diabetic foot ulcer: an emerging predictive marker for foot ulceration. Diabetes Care. 2017;40(2):e14-5 doi:10.2337/dc16-2204 PMid:27899495 PMCid:PMC5250693
  38. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008;51:747-55 doi:10.1007/s00125-008-0940-0 PMid:18297261 PMCid:PMC2292424
  39. Wu Z, Li J, Li Z, Huang H, Shi Y, Li X. Plastic surgical repair of ulcer wounds of diabetic foot patients through systemic treatment and local infection control. Ann Palliat Med. 2022;11(4):1453-61. doi:10.21037/apm-22-352 PMid:35523753
  40. Sikhondze MM, Twesigye D, Odongo CN, Mutiibwa D, Tayebwa E, Tibaijuka L, et al. Diabetic foot ulcers: Surgical characteristics, treatment modalities and short-term treatment outcomes at a tertiary hospital in South-Western Uganda. Open Access Surg. 2022:75-87 doi:10.2147/OAS.S384235
  41. Hutting KH, aan de Stegge WB, van Netten JJ, Ten Cate WA, Smeets L, Welten GM, et al. Surgical treatment of diabetic foot ulcers complicated by osteomyelitis with gentamicin-loaded calcium sulphate-hydroxyapatite biocomposite. J Clin Med. 2021; 10(2):371 doi:10.3390/jcm10020371 PMid:33478085 PMCid:PMC7835819
  42. Thewjitcharoen Y, Sripatpong J, Krittiyawong S, Porramatikul S, Srikummoon T, Mahaudomporn S, et al. Changing the patterns of hospitalized diabetic foot ulcer (DFU) over a 5-year period in a multi-disciplinary setting in Thailand. BMC Endocr Disord. 2020; 20:1-1 doi:10.1186/s12902-020-00568-7 PMid:32571283 PMCid:PMC7310152
  43. Lakhani DJ, Dave JP, Ramani JK, Agrawal KK, Makadiya CR, Solanki PV. Diabetic foot ulcer and its surgical management
  44. Finestone AS, Tamir E, Ron G, Wiser I, Agar G. Surgical offloading procedures for diabetic foot ulcers compared to best non-surgical treatment: a study protocol for a randomized controlled trial. J Foot Ankle Res. 2018;11:1-9 doi:10.1186/s13047-018-0248-3 PMid:29467829 PMCid:PMC5819289
  45. Khan AA, Singh S, Singh V, Khan S. Diabetic foot ulcer: a clinical study. Int Surg J. 2016;3(4):2098-103 doi:10.18203/2349-2902.isj20163581
  46. Mummidi DS, Dharmendra D, Mishra RK, Jatasankar M, Houghton TT. Clinicopathological study: management of diabetic foot and its complications. J Pharm Biomed Sci. 2015; 5(4):308-11
  47. Doğruel H, Aydemir M, Balci MK. Management of diabetic foot ulcers and the challenging points: An endocrine view. World J Diabetes. 2022;13(1):27 doi:10.4239/wjd.v13.i1.27 PMid:35070057 PMCid:PMC8771264
  48. Sukri MB, Singh A, Singh LH, bin Abdul Wahid AM, Ortho MS. Knowledge and attitude of nurses towards diabetic foot care in a secondary health care centre in Malaysia. Med J Malaysia. 2020;75 (4):391
  49. Rubio JA, Jiménez S, Lázaro-Martínez JL. Mortality in patients with diabetic foot ulcers: causes, risk factors, and their association with evolution and severity of ulcer. J Clin Med. 2020 ;9(9):3009 doi:10.3390/jcm9093009 PMid:32961974 PMCid:PMC7565534
  50. Huang ZH, Li SQ, Kou Y, Huang L, Yu T, Hu A. Risk factors for the recurrence of diabetic foot ulcers among diabetic patients: a meta‐analysis. Int Wound J. 2019;16(6):1373-82 doi:10.1111/iwj.13200 PMid:31489774 PMCid:PMC7949075
  51. Dubský M, Jirkovska A, Bem R, Fejfarova V, Skibova J, Schaper NC, Lipsky BA. Risk factors for recurrence of diabetic foot ulcers: prospective follow‐up analysis in the Eurodiale subgroup. Int Wound J. 2013;10(5):555-61 doi:10.1111/j.1742-481X.2012.01022.x PMid:22712631 PMCid:PMC7950559
  52. Khalifa WA. Risk factors for diabetic foot ulcer recurrence: a prospective 2-year follow-up study in Egypt. The Foot. 2018;35:11-5. doi:10.1016/j.foot.2017.12.004 PMid:29753996
  53. Xiaoxia C, Li Y, Fang W. Analysis of clinical and related factors in patients with diabetic fool after discharge. Chinese Nurs Res. 2017;31(36)
  54. Mo Z, Chen D, Gao Y. Risk factors for foot ulcer recurrence in diabetic patients with new‐onset foot ulcers. China Trop Med. 2018;18(07):716-9
  55. Waaijman R, De Haart M, Arts ML, Wever D, Verlouw AJ, Nollet F, Bus SA. Risk factors for plantar foot ulcer recurrence in neuropathic diabetic patients. Diabetes Care. 2014;37(6):1697-705 doi:10.2337/dc13-2470 PMid:24705610
  56. Aalaa M, Malazy OT, Sanjari M, Peimani M, Mohajeri-Tehrani MR. Nurses' role in diabetic foot prevention and care; a review. J Diabetes Metabol Disord. 2012;11:1-6 doi:10.1186/2251-6581-11-24 PMid:23497582 PMCid:PMC3598173