A PROSPECTIVE ANALYTICAL STUDY ON LIMB SALVAGE PROCEDURES IN DIABETIC FOOT ULCERS
Journal Title: Journal of Evolution of Medical and Dental Sciences - Year 2017, Vol 6, Issue 54
Abstract
BACKGROUND The world is currently experiencing a pandemic of diabetes mellitus, particularly of type 2 or adult onset. The magnitude of the problem of diabetes is enormous. India will have the largest number of persons with diabetes. Approximately, 15% of these patients will develop foot problems and 1% of these patients are likely to lose a limb due to some foot pathology or the other. However, the blessing in disguise is that the foot problems seen in Indian diabetic patients are mainly neuropathic-infective and not ischaemic-infective. The latter are extraordinarily more difficult to treat than neuropathic ulcers. This study is to assess the usefulness of various screening procedures and limb salvaging interventions in diabetic foot ulcers and to bring out strategies for prevention of future foot problems. This study is to evaluate the incidence of sensory neuropathy, vasculopathy, infection and its association to diabetic foot ulcers and to compare the effectiveness of wound healing in diabetic foot ulcers between application of platelet derived growth factor and saline dressings and between retrograde venous perfusion and intravenous administration of antibiotics. MATERIALS AND METHODS This study was conducted at Government Theni Medical College, Theni from August 2013 to August 2016. It included 100 patients with diabetic foot ulcers, who got admitted in surgical wards. Sensory neuropathy was evaluated using foot imprints with Harris mat and biothesiometry. The areas of high pressure in the foot, which is marked by the presence of more ink in the imprints and a vibration perception threshold of more than 25v in biothesiometry are taken as presence of sensory neuropathy. A working diagnosis of lower extremity ischaemia was made by a combination of clinical and non-invasive vascular studies. Clinical signs were based on the absence of one or more foot pulses of the involved foot. Non-invasive criteria included an Ankle-Brachial Index (ABI) of < 0.80. Clinical signs and/or the presence of abnormal non-invasive values make a diagnosis of lower extremity vascular insufficiency. The diagnosis of infection was made using clinical criteria. All the patients were treated with insulin. In infected cases, the role of retrograde venous perfusion of antibiotic was compared with intravenous antibiotic with respect to the decrease in ulcer area on days 0, 7, 14, 21 and 28. Before the institution of retrograde venous perfusion, assessment of vascular status of the limb was done by Doppler study. Combination of Heparin (100 units), Sodium bicarbonate (2 mL), Piperacillin + Tazobactam (4.5 g) and Lignocaine (4 mL) made to 120 mL with normal saline was injected into leg vein with application of tourniquet at the thigh for 20 minutes. Intravenous piperacillin + tazobactam alone was given in the intravenous group. Antibiotics were given for a period of 14 days in both the groups. In non-infected diabetic foot ulcers, the effectiveness of wound healing was compared between the application of platelet derived growth factor and saline dressings. Daily application of platelet derived growth factor was done for a period of one month and normal saline dressing in the control group and the ulcer area was assessed on days 0, 7, 14, 21 and 28 in both the groups. Ulcer healing in all the groups were categorised as A- Completely healed, B- Improved (> 80% reduction in ulcer area), C- Partially healed (< 50% reduction in ulcer area) and D- Worsened. Data analysis was done with the help of computer using Epidemiological Information Package (EIP 2010) developed by Centre for Disease Control, Atlanta. Using this software range frequencies, percentages, means, standard deviations, chi-square and ‘p’ values were calculated with KruskalWallis chi-square test. RESULTS In our study, we had taken 100 patients with diabetic foot ulcer admitted in ward and they were grouped intoGroup A- Saline group- 25 patients. Group B- PDGF group- 25 patients. Group C- RGVP- 25 patients. Group D- Intravenous group- 25 patients. In our study foot ulcers were more common in male population, that too between the age group of 50 - 60 years. Majority (more than 60%) of the cases in all the four groups were males. Except a single case in PDGF and another case in intravenous group, all the other 98 cases studied were of Diabetes Mellitus type 2. Mean duration of Diabetes Mellitus in all the diabetic foot ulcer patients was more than 7 years. Percentage of smokers was highest in Group B among the males. Hypertension was present in more than 50% of the patients with diabetic foot ulcers. Mean ABI- right values were less than the normal value (0.8) in all the 4 groups. The ulcer area decrease was more (36.9 + 16.5) in the PDGP group. Two cases in the saline group and 8 cases in the PDGF group were completely healed. Two cases in RGVP group and three in intravenous group were done SSG. None of the cases were amputated. CONCLUSION In our study in diabetic foot ulcer by adequate control of blood sugar, proper foot care and judicious use of modalities like platelet derived growth factor application and retrograde venous perfusion of antibiotics most of the diabetic limbs can be saved.
Authors and Affiliations
Muthuraj Subramanian, Sangaia Raja Pandian
Keywords
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- EP ID EP225802
- DOI 10.14260/Jemds/2017/883
- Views 95
- Downloads 0
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