Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis

Linton, C. S.; Searle, Angela; Hawke, Fiona; Tehan, Peta Ellen; Sebastian, Mathew; Chuter, Vivienne

doi:10.1177/1479164120928868

Cited by 6 publications

(1 citation statement)

References 46 publications

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“…A skin perfusion pressure greater than 40 mm Hg showed a positive likelihood ratio ranging from 4.86 to 6.40 and corresponding negative likelihood ratios between 0.03 and 0.40 for ulcer healing . Another meta-analysis of 4 studies with 104 patients reported that a toe systolic blood pressure less than 30 mm Hg had a 2.09 times higher relative risk (RR) of a nonhealing wound postamputation compared with values of 30 mm Hg or greater (95% CI, 1.37-3.20; P = .001 [absolute rates not provided]) . These data are summarized in Table 2.…”

Section: Assessing Diabetic Foot Ulcersmentioning

confidence: 99%

Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

119

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ImportanceApproximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.ObservationsNeurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.Conclusions and RelevanceDiabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

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Section: Assessing Diabetic Foot Ulcersmentioning

confidence: 99%

Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

119

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The Role of Technology in Managing Vascular Wounds

Günther¹,

Mani²

2023

Chronic Wound Management

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Utility of Toe-Brachial Index

Del Valle

2024

Journal for Vascular Ultrasound

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Introduction: The toe-brachial index is typically an adjunctive examination to the ankle-brachial index, which has long been the primary physiologic modality for diagnosing peripheral arterial disease. The goal of this project was to determine toe-brachial index reliability, particularly with patients with diabetes. Methods: We compared duplex ultrasound to the ankle-brachial index and toe-brachial index on 100 patients (200 legs) with suspected symptomatic peripheral arterial disease. Duplex ultrasound stenosis in the femoral/popliteal/infrapopliteal arteries was at least a doubling of velocity between adjacent segments. A blunted systolic Doppler waveform was consistent with proximal occlusive disease. Normal physiologic ranges were arbitrarily set as ankle-brachial index 1.2 to 0.9 and toe-brachial index 0.9 to 0.5. We calculated overall sensitivity/specificity values by averaging. Results: Both physiologic modalities had overall low sensitivity (ankle-brachial index 62%, toe-brachial index 56%). In diabetics, ankle-brachial index sensitivity was 61% and toe-brachial index sensitivity was 57%. Sensitivity improved in the presence of inflow disease (ankle-brachial index 78%, toe-brachial index 63%). Both modalities had good overall specificity (ankle-brachial index 96%, toe-brachial index 86%). In patients with diabetes, the ankle-brachial index specificity was 94% and toe-brachial index specificity was 79%. Both physiologic modalities had identical accuracy (0.43) in comparison to duplex ultrasound. Conclusion: Routine toe-brachial index in conjunction with the ankle-brachial index may not be clinically productive.

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Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis

Cited by 6 publications

References 46 publications

Diabetic Foot Ulcers

Diabetic Foot Ulcers

The Role of Technology in Managing Vascular Wounds

Utility of Toe-Brachial Index

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