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Fang et al. Negative pressure wound therapy for diabetic foot limb salvage

group, there was a 70% limb salvage rate with 14.70 (± 10.33) treatment days. The non-PAD
peripheral arterial disease, comparison group had a higher limb salvage rate (100% vs. 70%, respectively), but a longer
limb salvage
treatment time (30.00 vs. 14.70 days, P < 0.05, respectively) when compared to the PAD group.
The 3 patients in the PAD group who failed limb salvage all had issues related to uncontrolled
infection. Conclusion: NPWT is a feasible adjuvant therapy for DFU in patients with PAD, with
a 70% limb salvage rate. Prolonged treatment time was due to the initial severity of the subjects
with multiple comorbidities. The main reason for limb loss was intractable infection.

INTRODUCTION age above 18 years and the presence of type 2
diabetes mellitus. PAD was diagnosed with either
Negative pressure wound therapy (NPWT) has gained Doppler ultrasound or angiography in the PAD study
significant interest in the treatment of complex wounds group. Patients with DFU but not PAD as documented
and decreasing wound healing time. [1-5] Previous by Duplex sonography or angiography were enrolled
studies have suggested that NPWT maximizes blood as a comparison non-PAD group (n = 3). Exclusion
[6]
flow and promotes granulation tissue formation at an criteria included superficial wound (e.g. Wagner Grade I),
[7]
intermittent setting of -125 mmHg. Other research has burn wounds, malignant disease, collagen vascular
also claimed benefits such as oedema reduction, [8,9] an disease, and venous insufficiency.
enhanced wound healing microenvironment, improved
[8]
immunologic response, [10,11] bacterial clearance, Patient information collected included gender,
and higher flap survival rate. [8,12] NPWT was originally age, comorbidities, whether or not percutaneous
developed as a treatment for decubitus ulcers and transluminal angiography (PTA) had been performed,
wounds with vascular dysfunction, [13] but its application admission duration, diabetes diagnosis year (DDY),
has now been diversified to acute complex wounds. [14] wound location, wound size, wound culture, University
However, there are still few articles that discuss the of Texas grading, Wagner grading, DFU score (DFUS),
application of NPWT for the treatment of diabetic foot number of NPWT applications, application duration,
ulcers (DFU) and its potential for limb salvage. and if the affected limb(s) had been amputated after
at least 6-months of follow up. Wound size was
There is a 10-25% risk in diabetics of developing a recorded as width × length (cm × cm). DFU score
foot ulcer, [15] and foot ulcers make up 84% of all non- assessment was followed by the guidelines established
traumatic amputations. [15] Furthermore, patients with by Beckert et al. [21] of examining for a palpable pedal
diabetic foot amputation have a five year mortality pulse, probing to bone, ulcer location, and presence of
rate as high as 55%. [16,17] In addition, 39% of diabetic multiple ulcerations. Patients were negatively selected
patients present with peripheral arterial occlusive in that only subjects who were unlikely to benefit from
disease, [18] and 46% of these patients will sustain standard moist wound therapy, as determined by depth
a limb amputation. [19] Of the few studies on the of the wound, were enrolled in this study. Comorbidities
benefits of NPWT in the diabetic foot over the last ten that were recorded include the presence of end-stage
years, [1,20] the focus on the use of NPWT to achieve renal disease, coronary artery disease, hypertension,
limb salvage in patients with DFU and peripheral and cerebrovascular accidents. Treatment days
[1]
arterial disease (PAD) is even rarer. Armstrong et al. were determined by the days with NPWT application.
in 2005 suggested an increase in the rate of wound Limb salvage was determined by successful wound
healing and granulation tissue formation in patients closure or limb preservation throughout the study for a
with DFU and partial amputation, and Nather et al. [20] minimum of 6 months follow-up.
in 2010 suggested the use of NPWT in preparation for
split-skin graft. However, neither study addressed the Procedure
presence of PAD. Thus, this study aims to investigate Initial treatment for the diabetic foot in both PAD and
the feasibility of the use of NPWT in the treatment of non-PAD subjects involved surgical debridement of
the diabetic foot ulcer in patient with PAD in regards to infected and non-viable tissue around the wound until
limb salvage and clinical course. healthy tissue was exposed. Wound width and length
were measured with a ruler and photos were taken
METHODS with a digital camera after debridement and throughout
the treatment [Figure 1]. NPWT was performed with
A retrospective study of patients with DFU was devices from different companies (Kinetic Concepts
collected following approval by the Institutional Inc., San Antonio, Texas, or RENASYSTM, or Smith
Review Board of Chang Gung Memorial Hospital and Nephew, Hull, UK). Application of NPWT devices
(number 101-3407B). Case inclusion criteria included began with modification of the sterile polyurethane

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