INTRODUCTIONDiabetic foot wounds are serious complications of diabetes mellitus. Surgical debridement is a very important part of the management of diabetic wounds. Sharp debridement using the scalpel is normally performed. Versajet II hydrosurgery system is an alternative technique for debridement. To our knowledge, this is the fi rst study conducted to evaluate the use of hydrosurgery debridement for diabetic foot wounds.

MATERIALS AND METHODSThis pilot study included 15 consecutive patients with diabetic foot wounds who were admitted to the National University Hospital (NUH) and were managed by the Diabetic Foot Team from June 2012 to December 2012. All wounds underwent hydrosurgery debridement. Patients' demographic details, clinical details on wound assessments, and outcome were recorded and analysed.

RESULTSThe Versajet II hydrosurgery system was found to show some advantages over standard surgical scalpel debridement. It allowed adequate debridement whilst preserving more viable tissue to promote rapid healing. It could be manoeuvred over complex wound terrain. The time required for debridement was short--an average of 9.5 minutes. Good wound healing was achieved in all 15 cases. Only 1 Versajet debridement was required in 13 cases and 2 required an extra debridement. Twelve wounds were healed by split thickness skin grafting (STSG) and 3 wounds by secondary healing. Two of the STSG were infected but they were subsequently healed by dressings via secondary healing.

CONCLUSIONAlthough good wound healing was achieved in all 15 cases, further study that uses a larger cohort and a randomised controlled trial is required to fully evaluate the effectiveness, or otherwise, of the Versajet II hydrosurgery system for the debridement of diabetic foot wounds.

Adult ; Aged ; Debridement ; methods ; Diabetic Foot ; surgery ; Female ; Humans ; Male ; Middle Aged ; Pilot Projects ; Prospective Studies ; Treatment Outcome ; Water ; Wound Healing

Adult ; Age Factors ; Aged ; Aged, 80 and over ; Amputation ; economics ; Cerebrovascular Disorders ; epidemiology ; Cohort Studies ; Comorbidity ; Conservative Treatment ; Costs and Cost Analysis ; Diabetes Mellitus ; economics ; Diabetic Foot ; economics ; epidemiology ; therapy ; Female ; Foot Deformities, Acquired ; economics ; epidemiology ; therapy ; Foot Injuries ; economics ; epidemiology ; therapy ; Health Care Costs ; Hospitalization ; economics ; Humans ; Hypertension ; epidemiology ; Joint Diseases ; economics ; epidemiology ; therapy ; Length of Stay ; economics ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Myocardial Ischemia ; epidemiology ; Peripheral Vascular Diseases ; epidemiology ; Retrospective Studies ; Singapore ; epidemiology ; Wound Infection ; economics ; epidemiology ; therapy ; Young Adult

INTRODUCTIONThis study aims to evaluate the results of foot screening performed in a study population of 2137 diabetics (3926 feet) screened from 2006 to 2008 by the National University Hospital (NUH) multi-disciplinary team for diabetic foot problems.

MATERIALS AND METHODSA standardised protocol was designed. Foot screening consisted of detailed history taking and clinical examination including assessment for sensory neuropathy by Semmes Weinstein monofilament (SWMF) and neurothesiometer and assessment of vasculopathy by ankle-brachial index (ABI) and total body irradiation (TBI). The foot screening was performed by a trained staff nurse. All patients were classified according to King's College Classification.

RESULTSMajority of the patients were in the fifth (27.9%) and sixth (30.0%) decades of life. Two thousand sixty-four had type II diabetes, and only 73 had type I diabetes. Neuropathy was found in 1307 (33.3%) feet based on 5.07 SWMF. Vasculopathy was recorded in 510 (13.0%) and 546 (13.9%) feet based on ABI <0.8 and TBI <0.7. According to King's Classification, 1069 (50.0%) were Stage 1: Normal and 615 (28.8%) were Stage 2: At-Risk.

CONCLUSIONFoot screening should be performed as early as possible to detect "At-Risk" feet and prevent the development of diabetic foot complications, thereby further reducing the risk of major amputations.

Adolescent ; Adult ; Aged ; Child ; Comorbidity ; Diabetes Mellitus, Type 1 ; complications ; epidemiology ; Diabetes Mellitus, Type 2 ; complications ; epidemiology ; Diabetic Foot ; classification ; diagnosis ; Female ; Humans ; Male ; Mass Screening ; methods ; Middle Aged ; Prospective Studies ; Referral and Consultation ; Young Adult

INTRODUCTIONThis study evaluated the effect of autologous bone marrow derived adult Mesenchymal Stem Cells (MSCs) on the biological healing of weight bearing diaphyseal bone allograft in the tibia of adult rabbits.

MATERIALS AND METHODSForty Adult New Zealand White Rabbits divided into 3 groups (Autograft, Allograft or Allograft impregnated with MSCs) with 12 rabbits in each group were used for the study. A 1.5 cm of cortical bone segment was excised from the rabbit's right tibia. The segment was replaced by an Autograft, Allograft or Allograft loaded with MSCs, depending on which group the rabbit was assigned. Internal fixation was performed using a 9-hole Mini-compression Plate and Cerclage Wires. Rabbits were sacrificed at end of observation periods of 12, 16 and 24 weeks. Specimens procured were assessed clinically and radiologically and fixed in 10% buffered formalin. For each specimen, 5 μm undecalcified sections were cut and stained with Von Kossa and Toluidine Blue stains. Histomorphometery was then performed.

RESULTSOur study showed that addition of autologous MSCs to diaphyseal allograft segments enhances and accelerates not just the union at host graft junctions and also the biological incorporation of the allograft segment as shown by Resorption Index, New-Bone Formation Index and Osteocyte Index.

CONCLUSIONSThe addition of autologous MSCs to deep frozen cortical allograft segments improved the host - allograft union rate and biological incorporation of diaphyseal allografts as shown by resorption activity, new bone formation and osteocyte cell counts.

Animals ; Disease Models, Animal ; Male ; Mesenchymal Stem Cell Transplantation ; methods ; Mesenchymal Stromal Cells ; Rabbits ; Tibia ; abnormalities ; Transplantation, Homologous ; Wound Healing

INTRODUCTIONThis is the fi rst prospective study done locally to determine the effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers.

MATERIALS AND METHODSAn electronic vacuum pump was used to apply controlled negative pressure evenly across the wound surface. Changes in wound dimension, presence of wound granulation and infection status of diabetic foot ulcers in 11 consecutive patients with diabetes were followed over the course of VAC therapy.

RESULTSHealing was achieved in all wounds. Nine wounds were closed by split-skin grafting and 2 by secondary closure. The average length of treatment with VAC therapy was 23.3 days. Ten wounds showed reduction in wound size. All wounds were satisfactorily granulated and cleared of bacterial infection at the end of VAC therapy.

CONCLUSIONSVAC therapy was useful in the treatment of diabetic foot infection and ulcers, which after debridement, may present with exposed tendon, fascia and/or bone. These included ray amputation wounds, wounds post-debridement for necrotising fasciitis, wounds post-drainage for abscess, a heel ulcer and a sole ulcer. It was able to prepare ulcers well for closure via split-skin grafting or secondary closure in good time. This reduced cost of VAC therapy, as therapy was not prolonged to attain greater reduction in wound area. VAC therapy also provides a sterile, more controlled resting environment to large, exudating wound surfaces. Large diabetic foot ulcers were thus made more manageable.

Adult ; Debridement ; Diabetic Foot ; classification ; surgery ; therapy ; Female ; Humans ; Male ; Middle Aged ; Negative-Pressure Wound Therapy ; Prospective Studies ; Wound Healing

INTRODUCTIONThis study aims to evaluate the predictive factors affecting the clinical outcome of Below Knee Amputations (BKA) performed in diabetic foot patients admitted to National University Hospital (NUH) Multi-Disciplinary Diabetic Foot Team.

MATERIALS AND METHODSThis is a prospective cohort study of 151 patients admitted to the Department of Orthopaedic Surgery, NUH, for Diabetic Foot Problems (DFP) from January 2006 to January 2010. All had undergone BKA performed by NUH Multi-Disciplinary Diabetic Foot Team. Statistical analyses (univariate and multivariate analysis with logistic regression) were carried out using SPSS version 18.0, for factors such as demographic data, diabetic duration and control, clinical findings and investigations, indications for surgery, preoperative investigations and evaluation, microbiological cultures, and these were compared to the clinical outcome of the patient. A good clinical outcome is defined as one not requiring proximal re-amputation and whose stump healed well within 6 months. The ability to ambulate with successful use of a prosthesis after 1 year was documented. Statistical significance was set at P <0.050.

RESULTSMean age of study population was 55.2 years with a male to female ratio of about 3:2. Mean follow up duration was 36 months. Of BKAs, 73.5% gave a good outcome. Univariate analysis showed that smoking, previous limb surgery secondary to diabetes, high Total White Count (TW), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Urea, Creatinine (Cr), Neutrophils, absence of posterior tibial and popliteal pulses, low Ankle Brachial Index (ABI) and Toe Brachial Index (TBI) were associated with poor clinical outcome. Multivariate analysis showed that high CRP, ESR, Neutrophils, absence of popliteal pulse and low ABI were associated with poor clinical outcome. Of patients, 50.3% attained mobility with prosthesis after 1 year. Mortality rate was 21.2% within 6 months of operation, with sepsis being the most significant cause of death.

CONCLUSIONSuccess rate of BKA was 73.5%, with mortality rate being 21.2% within 6 months. In this cohort, 50.3% were able to attain eventual mobility with prosthesis after 1 year. Sepsis was the most significant cause of death. Markers of infection such as high CRP, ESR, neutrophils; and indicators of poor vascularity such as absence of popliteal pulse and low ABI were significantly associated with poor clinical outcome.

Adult ; Aged ; Aged, 80 and over ; Amputation ; methods ; Diabetic Foot ; surgery ; Female ; Humans ; Knee ; Male ; Middle Aged ; Prospective Studies ; Treatment Outcome

Adult ; Aged ; Aged, 80 and over ; Amputation ; methods ; Cohort Studies ; Diabetic Foot ; surgery ; Female ; Humans ; Male ; Middle Aged ; Prospective Studies ; Treatment Outcome ; Young Adult

We present five patients with vibrio necrotising fasciitis, a lethal and disabling disease. Two of these patients had a history of exposure to either warm seawater or raw/live seafood, three had underlying chronic liver disease, and four presented with hypotension and fever. There were three deaths and four patients required intensive care unit stays. Among the two survivors, one had high morbidity. Only one patient met the criteria of Laboratory Risk Indicator for Necrotising Fasciitis score > 6. A clinician should suspect possible vibrio necrotising fasciitis if the following are present: contact with fresh seafood/warm seawater, a known history of chronic liver disease and pain that is out of proportion to cutaneous signs. All patients must be managed via intensive care in high dependency units. We recommend a two-step surgical protocol for patient management involving an initial local debridement, followed by a second-stage radical debridement and skin grafting.
Aged ; Aged, 80 and over ; Debridement ; End Stage Liver Disease ; complications ; Fasciitis, Necrotizing ; diagnosis ; microbiology ; surgery ; Female ; Fever ; complications ; Hepatitis B ; complications ; Humans ; Hypotension ; complications ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors ; Seafood ; Seawater ; Severity of Illness Index ; Singapore ; Skin Transplantation ; Vibrio ; Vibrio Infections ; diagnosis ; surgery

INTRODUCTION: Syme amputation has been shown to have value in patients with diabetic foot infections, but it has inherent drawbacks. A potential alternative is the modified Pirogoff amputation. Our objective was to evaluate the outcome of modified Pirogoff amputation using internal fixation with 6.5-mm cannulated screws in the management of diabetic foot. METHODS: This is a prospective study of 13 patients admitted from January 2012 to June 2015. Inclusion criteria were infection limited to the forefoot, presence of a palpable posterior tibial pulse and an ankle-brachial index of more than 0.7. Internal fixation of the calcaneum to the tibial was performed using two 6.5-mm cannulated screws under image intensifier control. RESULTS: In ten cases, the wounds were healed at three weeks. Osseous union was observed in ten cases; the time taken for its occurrence was 2-5 months. Removal of screws was performed in five cases. Five cases developed technical complications of screw tract infection, with two cases having distal screw migration. Good results, defined as cases not requiring a below-knee amputation for two years postoperatively, were obtained in 10 (77%) cases. At the three-year follow-up, three additional cases required proximal amputation, leaving 7 (54%) cases with good outcomes. CONCLUSION Our prospective study showed that with careful selection of patients, good postoperative results can be obtained. There is a definite role for modified Pirogoff amputation in the management of diabetic foot problems.

This paper discussed the importance of prevention of diabetic foot ulcers and our institution's protocol for prevention, reviewing the existing evidence in the literature regarding the effectiveness of the preventive approach. Diabetes mellitus is the second most significant cause of disease in Singapore after ischaemic heart disease. National University Hospital, Singapore, adopts a two-pronged strategy for the management of diabetic foot ulcers. The most important strategy is prevention, and education is key. Education should mainly be directed at patients and caregivers, but also professionals (general practitioners, allied health professionals and nurses) so that they can effectively educate patients and caregivers. Patient education includes care of diabetes mellitus, care of the foot and use of appropriate footwear. Patients also tend to have poor foot hygiene. Annual foot screening for diagnosed diabetics plays an important role. However, prolonged and sustained government intervention is necessary to provide education and screening on a national scale.