Academic Department of Surgery, Greenville Hospital System University Medical, Center, Greenville, SC, USA.
J Am Coll Surg. 2011 Apr;212(4):532-45; discussion 546-8. doi: 10.1016/j.jamcollsurg.2010.12.027.
For patients with diabetic neuropathic foot ulceration, the current treatment paradigm is heavily weighted toward limb revascularization; aligning incentives to perform more surgery and less ulcer management/prevention. Our purpose was to perform an analysis of functional outcomes to assess this current treatment paradigm.
Nine hundred and seventeen neuropathic ulcerated feet in 706 patients with diabetes were analyzed. Four hundred and sixty limbs (50.2%) had concomitant ischemia, 219 of which were revascularized (137 angioplasty and 82 open surgery). Outcomes measured included ulcer healing, survival, limb salvage, amputation-free survival, maintenance of ambulation, and independence. Independent predictors of outcomes were measured using an Extended Cox Model.
Overall outcomes (n = 917) were: ulcer healed, n = 250 (27%; mean time to healing 33 weeks); functionally healed, n = 488 (53%; mean time to functional healing 29 weeks); 5-year limb salvage, 68%; survival, 38%; amputation-free survival, 30%; maintenance of ambulation, 64%; and maintenance of independence, 74%. There was little difference in ulcer healing rates for patients with or without ischemia (28.5% versus 26%; p = 0.4). However, ischemia was a significant marker of poor outcomes (nonischemic ulcer, ischemic ulcer revascularized, and ischemic ulcer not revascularized: 5-year limb salvage of 80%, 61%, and 51%; p < 0.001); survival (47%, 37%, and 24%; p = 0.03); amputation-free survival (37%, 28%, and 17%; p < 0.001); maintenance of ambulation (74%, 55%, and 55%; p < 0.001); and maintenance of independence (82%, 72%, and 58%; p = 0.01). Wound healing was an independent predictor of survival and amputation-free survival (survival: hazard ratio = 0.58; 95% CI,0.46-0.73; amputation-free survival: hazard ratio = 0.42; 95% CI, 0.33-0.53).
The current treatment paradigm is associated with relatively poor healing rates and substantial late morbidity and mortality. Although revascularization is effective treatment for ischemia, it is probably overvalued when compared with the potential improvement afforded by better medical foot wound management.
对于患有糖尿病性神经病变性足部溃疡的患者，目前的治疗模式主要侧重于肢体血运重建；激励措施倾向于进行更多的手术，而减少溃疡管理/预防。我们的目的是分析功能结果，以评估当前的治疗模式。
对 706 例糖尿病患者的 917 只患有神经病变性溃疡的足部进行了分析。460 条肢体（50.2%）存在伴随性缺血，其中 219 条进行了血运重建（137 条经皮血管成形术和 82 条开放手术）。测量的结果包括溃疡愈合、生存、肢体保存、免于截肢的生存、维持步行能力和独立。使用扩展 Cox 模型测量了结局的独立预测因素。
917 例患者的总体结局为：溃疡愈合，n = 250（27%；平均愈合时间为 33 周）；功能愈合，n = 488（53%；平均功能愈合时间为 29 周）；5 年肢体保存率为 68%；生存率为 38%；免于截肢的生存率为 30%；维持步行能力为 64%；维持独立性为 74%。有或没有缺血的患者的溃疡愈合率差异不大（28.5%比 26%；p = 0.4）。然而，缺血是不良结局的显著标志（非缺血性溃疡、缺血性溃疡血运重建和缺血性溃疡未血运重建：5 年肢体保存率分别为 80%、61%和 51%；p < 0.001）；生存率（分别为 47%、37%和 24%；p = 0.03）；免于截肢的生存率（分别为 37%、28%和 17%；p < 0.001）；维持步行能力（分别为 74%、55%和 55%；p < 0.001）；以及维持独立性（分别为 82%、72%和 58%；p = 0.01）。伤口愈合是生存和免于截肢的独立预测因素（生存率：危险比 = 0.58；95%CI，0.46-0.73；免于截肢的生存率：危险比 = 0.42；95%CI，0.33-0.53）。
目前的治疗模式与相对较差的愈合率以及大量晚期发病率和死亡率相关。虽然血运重建是治疗缺血的有效方法，但与更好的医学足部伤口管理所带来的潜在改善相比，它可能被高估了。
