The International Journal of Lower Extremity Wounds

Diabetic foot ulceration is a serious complication of diabetes mellitus; it is the cause of more than half of nontraumatic lower limb amputations. Diabetic foot ulcers are the major cause of hospital admission for diabetic patients. Treatment costs are high. There have been advances in managing diabetic foot ulceration with the development of new dressings, growth factors, skin substitutes, and other novel approaches to stimulating wound healing. The management of vascular disease in the patient with diabetes mellitus is an essential and important consideration. However, the need for a multidisciplinary team to provide good foot care to diabetic patients is still vital for the prevention and treatment of diabetic foot ulceration.

The aims of this study were to compare variations of the transcutaneous oxygen pressure (TcPO₂) and blood rheology in diabetic patients. Diabetic patients with critical limb ischemia were compared with those who were either asymptomatic or had mild peripheral vascular disease (PVD). The results showed a significant decrease in TcPO₂ in patients with critical limb ischemia. Low shear rate blood viscosity, red blood cell (RBC) aggregation, plasma viscosity, and fibrinogen level were significantly higher in the group with critical severe limb ischemia. The group with critical limb ischemia was subdivided on the basis of clinical outcomes after 1 year and the prognostic values of these measurements examined. A TcPO₂ value of 10 mm Hg was associated with a positive predictive value of 94%. RBC aggregation index and fibrinogen levels offered positive predictive values of 89% and 88%, respectively, when cut off values were derived from means + 1 SD of same parameters in patients with asymptomatic or mild PVD. TcPO₂ is useful to follow the deterioration of diabetics with critical limb ischemia.

Toe amputations are becoming more prevalent in the diabetic population. To prevent toe amputations, those individuals with the highest risk must be identified prior to developing a precipitating event. There are obvious risk factors for toe amputations, such as digital deformity, diabetic neuropathy, and ischemia. Other, less obvious, systemic comorbidities may be linked to toe amputations. This study also shows that gender plays a significant role as a risk factor for toe amputation. A foot infection, foot abscess, osteomyelitis, diabetic retinopathy, and diabetic nephropathy were also significant risk factors for toe amputations. This suggests a significant relationship between these complications and comorbidities that put these individuals at a higher risk for toe amputations.

Healing of chronic lower extremity wounds is a global problem, especially in the developing world where it is often only folk and traditional medicine that can be afforded. In the structured health services of the developed world, there are usually a wider range of possible therapies. In India, traditional medicines flourish in parallel with Western systems, and those who treat wounds may use the expertise of more than one system. Ayurveda is a traditional system that has evolved in India over centuries using especially native plant sources as remedies. Like many Asian systems, its theoretical basis concerns balance and energy in the individual. In this perspective paper, the author advocates awareness of plant products available for wound healing and a study of the extent of their utilization. They must be developed for safe use and their efficacy reviewed, taking into account cure well-being and patient satisfaction as well as cost. Developing a list of products and classifying them appropriately is a beginning for such studies.

Research on wound healing drugs is a developing area in modern biomedical sciences. Scientists who are trying to develop newer drugs from natural resources are looking toward the Ayurveda, the Indian traditional system of medicine. Several drugs of plant, mineral, and animal origin are described in the Ayurveda for their wound healing properties under the term Vranaropaka. Most of these drugs are derived from plant origin. Some of these plants have been screened scientifically for the evaluation of their wound healing activity in different pharmacological models and patients, but the potential of most remains unexplored. In a few cases, active chemical constituents were identified. Some Ayurvedic medicinal plants, namely, Ficus bengalensis, Cynodon dactylon, Symplocos racemosa, Rubia cordifolia, Pterocarpus santalinus, Ficus racemosa, Glycyrrhiza glabra, Berberis aristata, Curcuma longa, Centella asiatica, Euphorbia nerifolia, and Aloe vera, were found to be effective in experimental models. This paper presents a limited review of plants used in Ayurvedic medicine.

Chronic wounds of the lower extremity are a therapeutic dilemma. In India, chronic wounds are caused by factors other than impaired circulation and diabetes, which account for most of this clinical problem in Western societies. A study of 2 topical agents, placental extract and phenytoin powder, is presented in this paper. One hundred fifty patients were randomly assigned to these treatments or to saline dressings (control). It was observed that patients receiving active topical treatments responded better than those in the control group. The importance of this finding should be viewed with the perspective that these topical treatments are inexpensive and easily available in India. The study also piloted measurements of angiogenic responses in 1 group, and the findings encourage further exploration with the technique and topical agent.

Necrotising fasciitis (NF) is an unusual though well-described soft tissue infection of the deeper tissues resulting in a progressive synergistic bacterial gangrene. In a small retrospective study in a single center, an association was observed between NF and diabetes, age, peripheral arterial disease, and high mortality.