Healing below the ankle is possible in patients with diabetes mellitus and a forefoot gangrene

Elgzyri, Targ; Apelqvist, Jan; Lindholm, Eero; Örneholm, Hedvig; Gershater, Magdalena Annersten

doi:10.1177/20503121211029180

Cited by 1 publication

(10 citation statements)

References 43 publications

(84 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…27 Six studies examined a threshold of toe pressure ≥30 mmHg with three of the studies finding a PLR between 0.67 and 1.29. [23][24][25] The other three studies reported higher PLRs at this threshold. 17,35,37 Kalani et al 37 reported a PLR of 5.0, indicating a greater than 25% increase in the probability of healing; however, the corresponding NLR was 0.88, indicating that the toe pressure at this threshold could not predict who did not heal.…”

Section: Toe-brachial Index or Toe Pressurementioning

confidence: 72%

“…Thresholds used to investigate the prognostic capacity of ankle pressure for DFU healing, healing after minor amputation, and having a major amputation were highly variable generally ranging from <50 mmHg to <80 mmHg. 17,19,20,[23][24][25]35 Systolic pressures more than these thresholds were not consistently associated with healing, while having pressures <50 mmHg or <80 mmHg was not consistently associated with the increased pretest probability of amputation. 17,25 The lack of prognostic capacity of ankle pressure for healing even at low thresholds is consistent with limitations in diagnostic accuracy of ankle pressure in people with severe ischaemia with a study (55% with diabetes and therefore ineligible for this review), demonstrating ankle pressure alone failed to diagnose chronic limb threatening ischaemia in over 40% of cases.…”

Section: Discussionmentioning

confidence: 89%

“…The prognostic tests evaluated by the studies included: ABI in 9 studies 27,[30][31][32][33][34]36,39,40 ; ankle pressures in 10 studies 17,19,20,[23][24][25]27,32,33,35 ; TBI in 4 studies 27,[30][31][32] ; toe pressures in 9 studies 17,19,[23][24][25]27,32,35,37 ; TcPO 2 in 7 studies 29,30,32,33,37,38,41 ; skin perfusion pressure in 5 studies 16,18,34,35,42 ; continuous wave Doppler (pedal waveforms) in 2 studies 26,28 ; pedal pulses in 3 studies; 20,21,41 and Doppler ankle peak systolic velocity (threshold 35 cm/s) by 1 study.…”

Section: Evaluation Of Prognostic Testsmentioning

confidence: 99%

“…33 For healing post-minor amputation, thresholds for ankle pressure were inconsistent and included ≥75 mmHg and ≥80 mmHg. 27 demonstrated that ankle pressure <75 mmHg was strongly prognostic of not healing (NLR 0.16), while Elgyzri et al 23 found the test to be of no benefit (NLR 1.09). One study evaluated healing in people with DFU or postminor amputation and reported only a small increase in pre-test probability of healing with an ankle pressure ≥50 mmHg or ankle pressure ≥80 mmHg (PLRs 1.25 and 2.67, respectively).…”

Section: Ankle-brachial Index or Ankle Pressurementioning

confidence: 99%

“…23,27 PLRsT A B L E 3 QUIPS quality assessment results. Note: +, low quality; ++, moderate quality; +++, high quality.…”

mentioning

confidence: 99%

See 4 more Smart Citations

Performance of non‐invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review

Chuter

Schaper

Hinchliffe

et al. 2023

Diabetes Metabolism Res

View full text Add to dashboard Cite

IntroductionThe presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes‐related foot ulcer (DFU). Determining performance of non‐invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non‐invasive bedside tests for PAD to predict DFU healing, healing post‐minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene.MethodsA database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non‐invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6‐month follow‐up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool.ResultsFrom 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle‐brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe‐brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post‐minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non‐healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10).ConclusionsPrognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post‐revascularisation bedside testing, and heterogenous subpopulations.

show abstract