Amputations in patients with diabetes

Sir,

We share the philosophy of this excellent leading paper. However foot ulcers are more likely to be of neuropathic origin and its side effect: feet bad-position and foot-bone fractures, than vascular¹. Otherwise, the author mentions that hyperbaric oxygen might be effective. However, oxygen-ozone therapy might be a superior method and became the first alternative for prevention and treatment of infective ulcerations in vascular disorders² and diabetic foot. Due its complex reactions over infection, blood cells and oxidative-stress related diseases, among others, improves diabetes, blood circulation, neuritis and healing⁴. This low cost, safe and effective method can be applied by general or topical ways⁵.

Rafael Martinez-Sanz, Ramiro de la Llana, Ibrahim Nassar
Canarian Cardiovascular Institute, University of La Laguna
rmsanz@ull.es

References

1- Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. The Lancet 2005;366:1719-1724.

2- Bocci V, Zanardi I, Travagli V: Ozone. A New Therapeutic Agent in Vascular Diseases.

Am J Cardiovasc Drugs 2011;11:73-82.

3- Bocci V, Zanardi I, Huijberts MSP, Travagli V. Diabetes and chronic oxidative stress. A perspective based on the possible usefulness of ozone therapy. Diab Met Syndr: Clin Res Rev 2011; 5:45-49.

4- Bocci V, Zanardi I, Michaeli D, Travagli V. Mechanisms of action and chemical-biological interactions between ozone and body compartments: a critical appraisal of the different administration routes. Curr Drug Ther 2009;4:159-173.

5- Martínez-Sánchez G, Al-Dalain SM, Menéndez S et al. Therapeutic efficacy of ozone in patients with diabetic foot. Eur J Pharmacol 2005;523:151-161.

• Commentor: Rafael Martinez-Sanz, Ramiro de la Llana, Ibrahim Nassar - Canarian Cardiovascular Institute, University of La Laguna
• Date: Dec 29, 2011

Sir,

The author highlights important, current issues regarding the management of patients with type II diabetes and foot ulceration. The natural history of diabetic ulceration is well documented with persistent ulceration of up to 25%, a major amputation rate of 5.3% (11% including minor amputations) and a mortality rate of 17% at one year (1).

We too have embraced the concept of involving a wide multidisciplinary team with the aim of reducing the number of major adverse events for this patient group, seeking to maximise function without causing excess mortality. The amputation rate is a headline priority, but we are also concerned by frequent, multiple and often-protracted admissions to diabetic wards with foot-related sepsis and a high attendant mortality.

Validated scoring systems are available, and widely used to identify the foot at risk of sepsis and amputation. At present we use the University of Texas scale (2, 3) but a weakness of this particular tool is the lack of a robust definition of ischaemia (the absence of a palpable pedal pulse).

A major issue, alluded to by the author, is the identification of those patients who may benefit from arterial intervention, either surgical or radiological. Defining ischaemia in diabetic patients with disease confined to the infra-geniculate arterial segment alone is not straightforward. Proving that the patient has benefitted is another challenge. Measuring amputation-free survival rates tells only part of the story. In our view, breaking the cycle of multiple readmissions and recurring sepsis, and recording functional outcome merit equal status.

Keith Hussey [1], Brian Kennon [2] and Wesley Stuart [1]

1. Vascular Surgical Unit, Western Infirmary, Glasgow
2. Department of Diabetes and Endocrinology, Southern General Hospital Glasgow
keithhussey79@hotmail.com

References

1. Jeffcoate WJ, Chipchase SY, Ince P and Game FL. Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. Diabetes Care 29(8): 2006; 1784-1787

2. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996; 35: 528–531.

3. Armstrong DG, Lavery LA and Harkless LB. Validation of a wound classification system: The contribution of depth, infection and ischaemia to risk of amputation. Diabetes Care. 21(5): 1998; 855-859

• Commentor: Keith Hussey, Brian Kennon and Wesley Stuart - Glasgow
• Date: Dec 16, 2011