Diabetes-related foot complications are now one of the top 10 causes of disability globally. Diabetes is implicated in 70-80% of all amputations in Australia and New Zealand. There is good evidence that best-practice multi-disciplinary care can reduce the incidence of amputations by 40-60%. Amputation rates are particularly high in First nations people in both countries, and those living in rural and remote locations in Australia. This presentation will give an update on Diabetes Feet Australia activities and possible approaches to improve outcomes of diabetes-related foot complications.

Purpose: Diabetic foot infections (DFIs) are a prevalent complication for patients with diabetes which can often progress to osteomyelitis (DFI-OM). Staphylococcus aureus is the most common pathogen in diabetic foot infections (DFI). Relapse can occur in 40-70% of cases despite initial clearance of the infection. For S. aureus, relapse can be attributed to it “hiding” within adjacent, healthy tissue by adopting the quasi-dormant Small Colony Variant (SCV) state. The aim of this study was to investigate the patient risk factors and bacterial factors which facilitate these persistent infections. Methods: Samples were taken from 153 patients with diabetes; those without foot ulcer or infection, uninfected diabetic foot ulcer (DFU), infected foot ulcers (DFI) and those with DFI-OM (both extracellular and from intracellular bone). Results: S. aureus was identified as the most prevalent pathogen (24 % within the DFI and DFI-OM patients). Also present in DFUs were Pseudomonas aeruginosa (17.7%) and Escherichia coli (8.1%). S. aureus was isolated as different bacterial colony types, with a notable presence of SCV (20% of all infections). Three DFI-OM patients presented with intracellular SCVs in clinically uninfected bone samples. Additionally, two of these patients with SCVs were found to exist co-infection with Corynebacterium striatum. Conclusion: The presence of SCVs highlights the potential of these cells to cause recurrent infection through the formation of dormant, non-pathogenic reservoirs. The survival of these cells in intracellular bone is important. The interactions of C. striatum with S. aureus are a potential risk factor in developing these reservoirs.

Tibial Artery disease is becoming an increasing cause of critical limb ischaemia, most often due to the presence of diabetes. Tibial artery interventions usually involve treatment of long segment stenoses and occlusions. The literature reports fairly poor patency results for plain balloon angioplasty in such lesions. We explore the use of stents and how they may benefit patients with critical limb ischaemia due to below the knee arterial disease

Purpose Chronic pain and phantom limb pain remain significant problems after major amputation. Preemptive regional analgesia via a sciatic nerve block (SNB) may reduce phantom lower limb pain after below knee amputations, when compared to post-amputation surgically sited nerve catheters (PNC). Methodology This was a single-centre, assessor-blinded, parallel, randomised trial of SNB placed preoperatively by anaesthetists compared with PNC placed post-amputation by surgeons during primary and secondary below-knee amputations (BKA). Participants were allocated in a 1:1 ratio. Both interventions delivered an infusion of bupivacaine at 15-25 mg/hr after establishment of the block. The primary aim was to assess the presence of phantom limb pain at 5 days, 6 months, and 12 months. Secondary outcomes included postoperative pain scores, presence of stump pain, opioid use, and patient-reported outcomes of function. Results Eighty patients completed the study, 40 per arm, at a tertiary hospital in Aotearoa New Zealand. There was no difference in presence of phantom limb pain at 5 days (PNC: 47.5% vs SNB: 40%, p = 0.804), 6 months (42.5% vs 47.5%, p = 0.911), or 12 months 35.0% vs 36.5%, p = 0.999) postoperatively. Patients receiving preoperative sciatic nerve catheters had lower pain scores at 4h after surgery (median 0/10 (IQR: 0 to 5.8) vs 3 (0 to 1), p = 0.03) but comparable pain scores at other time points during the first 5 days, and at 6 or 12 months. There were no differences in postoperative opioid use (PNC: 177.5 oral morphine equivalents (IQR 23.8 to 347.5) vs SNB: 60.0 (IQR 17.2 to 432.5), p = 0.569). Patient-reported functional outcomes at 6 and 12 months, rates of complications, and mortality were comparable between groups. Conclusions Preoperative SNB did not decrease the incidence of phantom limb pain in the postoperative period and in one year when compared to post-amputation PNC after below knee amputation.

Purpose: Diabetes is an important risk factor for the development of PAD. In this study, we aimed to assess the influence of diabetes on patients with PAD undergoing interventions. Methodology: Using AVA data from 2010-2021, we identified adult patients undergoing peripheral arterial interventions. Cross tabulations were performed for diabetes versus categorical outcomes, with corresponding frequencies, percentages, Chi-Square statistics, and P-values. Unadjusted and adjusted binary logistic regressions were performed, adjusting for the potential confounders: Age, Gender, ASA status, Diabetes, Hypertension, Smoking, IHD, ESKD, and Year. A p-value <0.0001 was considered to be statistically significant due to the large sample size. Results: There were 158712 patients included in the analysis. 76520 patients had diabetes (48.2%). The diabetic group had higher odds of presenting with infection (Adjusted Odds Ratio (aOR)=6.66, 95% confidence interval (CI): 6.31, 7.03, p<0.0001) and tissue loss (aOR=2.34, 95% CI: 2.29, 2.40, p<0.0001). The most common segment treated was Infrapopliteal (aOR=2.52 95% CI: 2.44, 2.60, p<0.0001). The presence of diabetes increased the number of emergent & semi-urgent interventions, and unplanned readmissions within 30 days. The diabetic group had higher odds of a long length of hospital stay (aOR=1.94, 95% CI:1.86, 2.02, p<0.0001). Although mortality was not significantly higher in diabetics, they had higher odds of amputations (aOR=2.39, 95% CI: 2.30, 2.48, p<0.0001). For every year from 2010, the proportion of interventions associated with diabetes increased by 3.9% (aOR=1.039, 95% CI: 1.035, 1.042, p value<0.0001). Conclusions: The presence of diabetes is associated with a higher likelihood of presentation with infection, tissue loss, and Infrapopliteal segment involvement. Diabetic patients are more likely to undergo amputations and have a longer hospital stay.

Background: There is no doubt that direct angiosome revascularization is important and effective in the healing and limb salvage of ischaemic ulcer. However, pedal arch quality is also an important influence in the rates and duration of healing especially in diabetic foot ulcers. Aim of this study is to determine outcomes of ischaemic diabetic foot ulcers (DFU) in relation to pedal arch patency. Methods: A total of 396 patients who were admitted under Diabetic Foot Ulcer (Vascular) Unit in Monash Health Hospitals (Dandenong Hospital and Monash Medical Centre) from 1 January 2015 to 31 Dec 2019 and had undergone digital subtraction angiography (DSA) with foot ulcers/ gangrene were included. Results of angiography were evaluated to determine the types of pedal arch patency according to Kawarada classification. Chi-square test was used to determine the association between pedal arch and wound healing. Survival analyses using Kaplan-Meier test were applied to duration to healing and overall survival. Results: There’s significant association between complete pedal arch patency and rate of wound healing. Complete pedal arch increases 23% of wound healing compared to absent pedal arch within a year. About 40% of these patients would have major amputation and 25% of them did not survive within 2 years. Patients who have complete pedal arch patency, have 28% higher survival rate than those with absent arch within 2 years. Conclusion: Type 1 pedal arch patency hastens wound healing and predicts better overall survival rate in ischaemic DFU. Unfortunately, most of them would eventually have major amputation within 2 years with 25% mortality rate.

Purpose: The treatment of femoropopliteal in-stent restenoses (ISR) is under investigation due to the advance of debulking devices and drug-eluting technologies. Directional atherectomy has traditionally been avoided in-stent due to the fear of stent capture. Our aim was to demonstrate the safety and effectiveness of combination treatment of HawkOne directional atherectomy and paclitaxel-coated balloon angioplasty for in-stent restenosis in the femoropopliteal segment. Methods: Analysis was performed using a prospectively collected single-centre registry on all patients undergoing directional atherectomy and DCB angioplasty from September 2016 to June 2021. Demographic, clinical, and procedural data was collected. Effectiveness outcomes included primary patency and freedom from TLR at 12 and 24 months. Technical success rate, complication rates, amputation and mortality were also recorded. Results: 160 femoropopliteal ISR lesions were treated over the study period. Drug-coated balloon angioplasty was performed in all lesions. Technical success was achieved in 98.6% of patients. Two of the treated lesions required bailout stenting due to intra-procedure Class 1A stent fractures. Primary patency at 12 months and 24 were 86.2% and 70.5% respectively; freedom from TLR was 77.3% and 55.5% and secondary patency was 100% at 1 year (in 3 patients). There were no major amputations performed. Conclusion: Treatment with directional atherectomy and drug-coated balloon angioplasty is safe for femoropopliteal ISR when in experienced hands. Directional atherectomy provides the benefit of targeted debulking of neointimal hyperplasia, resulting in increased luminal diameter and in aiding both the effects of angioplasty as well as potentially allowing better penetration of paclitaxel into these usually recalcitrant neointimal hyperplastic lesions. Importantly, this combination treatment can be safely repeated in the same diseased in-stent segments, with low occlusion rates and high rates of limb salvage.

In 2015 the podiatry north and north west took part in a study that concluded that there needed to be revisions to the delivery of high risk foot management. There was a high percentage of Northern Tasmanians who have diabetes and high risk of amputation. This started a relationship with the vascular surgeons in the Royal Hobart Hospital and a development of a high risk foot vascular service. This presentation talks about the benefits of this and the implication to high risk foot management in northern Tasmania and outcomes for patients.