The International Journal of Lower Extremity Wounds

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In the present study, a total of 428 South Indian subjects were divided into four different groups, consisting of individuals with type 2 diabetes without any other complications (T2DM), T2DM subjects with stage 2 and 3 diabetic kidney disease (CKD), T2DM subjects with grade 2 or 3 diabetic foot ulcer (DFU) and T2DM subjects having both diabetic kidney disease and diabetic foot ulcer (CKDDFU). The study was conducted ambispectively by comparing the changes in renal function among two consecutive periods, i.e., the period prior to the development of grade 2 and 3 diabetic foot ulcer (retrospectively) and after the development of DFU (prospectively). A gradual and uniform reduction of eGFR was observed throughout the study period in the subjects affected with either CKD or DFU alone. Whereas in subjects with both CKD and DFU, there was a sharp decline in the eGFR during the six months prior to the baseline, i.e., the period in which the development of ulcer and its progression to grade 2 or 3 happened. Remarkable elevations in the levels of TGF-β1 and CCN2 (CTGF), as well as a significant reduction in the level of CCN3 (NOV), were observed in the serum of CKDDFU group subjects, compared to the other groups. Increased production of TGF-β1 in response to the inflammatory stimulus from multiple sites in CKDDFU subjects caused a subsequent down-regulation of CCN3, followed by the activation of a large quantity of CCN2.

Charcot neuroarthropathy is a devastating consequence of diabetes mellitus and peripheral neuropathy. Because of its rarity, the condition is often misdiagnosed or poorly managed. When misadventure occurs, patients with Charcot neuroarthropathy can suffer ulceration, infection, amputation, and death. When patients have Charcot-related foot ulcers, the risks are amplified. Utilizing advanced electronic medical record analysis, a 30-month investigation was undertaken to determine if patients with diabetes mellitus and a concomitant diagnosis of Charcot-related foot ulcer were at greater risk of complications because of location setting of initial treatment for their condition. Charcot foot–related ulcers that are diagnosed in the outpatient setting had established foot specialist care. The outpatient management of the condition lead to a significant reduction in the amount of admissions to a higher acuity setting. However, patient outcomes did not vary once established and dedicated limb salvage efforts were employed. In this large contemporary population managed in a tertiary health system, patients with Charcot-related foot ulcer had negative outcomes when they were initially treated in an inpatient setting and had a significantly greater likelihood of readmission as compared with individuals who had established focused limb salvage care.

The current Wagner and Texas classifications of diabetic foot ulcers (DFUs) are used worldwide to assess the extent of foot lesions, but wound treatment principles based on both the classification systems are lacking. We have summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification systems. The STAGE principles refer to the principles of surgical intervention during wound treatment of DFUs and emphasize that “based on anatomical layers, the management focuses on blood supply and includes layer-by-layer incision to the infected area, maintenance of effective wound drainage, and step-by-step treatment of the wound.” During treatment, microcirculation improvement and microvascular angiogenesis (A) are essential for granulation tissue formation in the bone (skeleton, S) and tendons (T) and healing of the wound with reepithelialization (E). We defined the above mentioned steps as the STAGE principles, namely, layer-by-layer incision and step-by-step management (Phase A is essential for the treatments in Phases S-T and G-E). Ulcers or gangrene formed during Phases S-T or T should be treated according to the STAGE or TAGE principles, respectively. Similar treatment principles are applied in the other phases. However, treatments at each phase are not isolated and can be performed simultaneously. The STAGE principle can be combined with the tissue, infection, moisture, and wound edge (TIME) and TIME-H chronic wound treatment principles to eliminate the shortcomings of a single principle in wound management.

A distal third of lower extremity defect is challenging for plastic surgeons. The standard for treatment is microsurgery. Recently, perforator flap has been reported for small to medium defects. The objective was to analyze the outcomes of perforator flaps for distal third of lower extremity defects and to establish surgical guidelines. A retrospective review of patients with defects in distal third of lower extremities was conducted. Patients with multiple levels of lower extremity defects were excluded. A total of 8 patients with distal third of lower extremity defects were included. Seven patients were male. Overall mean age was 35.3 (18-60) years. Patients had 3 anterior, 3 lateral, and 2 medial defects. Lateral and anterior defects in 6 patients were closed using a peroneal-based propeller perforator flap with an angle of rotation of 90° to 160°. Medial defects in 2 patients were closed using a posterior tibial-based perforator advancement flap. Three patients (37.5%) developed venous congestion. No complications occurred for patients with medial defect closure using an advancement posterior tibial-based perforator flap. No total flap loss was observed. The perforator flap provides a similar texture to the skin at recipient area and a wide range of rotation. Perforator flaps should be the first choice for defects reconstruction in distal third lower extremities. Perforator flaps can be used for small to large defects, and can be moved by propeller or advancement depending on the perforator location. A guideline for perforator flaps reconstruction of the distal third of lower extremity defects was established.

Venous leg ulcers are a manifestation of lower extremity chronic venous disorder. Venous hypertension caused by abnormal venous blood flow is considered to be the primary mechanism of venous ulcers. The etiology of lower extremity venous ulcer is complicated, and it is difficult to be treated. At present, it has achieved a certain effect for venous leg ulcers through the combination of drugs, pressure therapy, and surgical treatment. Budd-Chiari syndrome is a rare syndrome characterized by portal hypertension and/or inferior vena cava syndrome. Treatment of Budd-Chiari syndrome includes anticoagulation, thrombolysis, angioplasty, stenting, transjugular intrahepatic portosystemic shunt, and liver transplantation. This article reports an elderly female patient with recurrent ulceration of both lower extremities that healed poorly after long-term dressing and skin grafting. During further examination, she was found to have Budd-Chiari syndrome. Through multidisciplinary treatment, which includes removing the inferior vena cava stenosis and implanting the ulcer wound, the ulcer wounds then healed.