Profile of foot ulcer patients with and without diabetes mellitus.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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In the past four decades, over 42–56% of major lower extremity amputations in the United States and Western European countries have been due to diabetes mellitus (DM) [1, 2, 3, 4]. The relative risk of major leg amputations for diabetes ranges from 5.1 to 31.5 times in comparison with that of nondiabetic populations [5, 6]. Extensive efforts have been made to improve the treatment of diabetes in regard to glycemic control and the prevention of diabetic complications, and foot ulcer treatments have improved for diabetic patients [7, 8]. Before 2004, trauma accounted for most amputations in the majority of hospitals, followed by malignancies [9]. However, the most common cause of amputation at present is diabetes mellitus [10, 11].
\nAmputation is the most appropriate therapy for an ischemic or infected limb, but the level at which to amputate is often difficult to determine. Patients who undergo only toe or trans-metatarsal amputation can walk on their own feet; however, those with major amputation require an artificial leg or a cane, which impairs their activities [12, 13]. The aim of this chapter is to describe factors that lead to amputation of a diabetic foot and propose a management strategy to prevent major amputation.
\nA retrospective descriptive study including 152 diabetic patients among 233 patients with leg ulcers who were treated in our medical center was carried out between January 2008 and December 2017. All patients had been diagnosed with type II diabetes. Diabetic foot ulcers represent more than 65 percent of all leg ulcers.
\nTo clarify the clinical characteristics of the diabetic foot, a comparison of foot ulcer patients with and without diabetes mellitus is conducted first, risk factors leading to amputation in cases of diabetic foot ulcer and “major” amputation in cases of diabetic foot are discussed, and a recommended strategy to avoid major leg amputation is presented.
\nStatistical analysis was performed using the Wilcoxon signed-rank test and chi-square test. The value of p < 0.05 was determined as significant.
\nThe ethical committee of our medical center approved this study.
\nProfiles of foot ulcer patients with and without diabetes mellitus are shown in Table 1. Of the 233 patients with a foot ulcer, 63% (147) were men, and 37% (86) were women. Of course, levels of HbA1C and blood sugar in the diabetic foot group were significantly higher than those in the nondiabetic foot group, and men were more likely to develop leg ulcers in the diabetic patient group. There were no significant differences in CRP, WBC, serum albumin, or hemoglobin between the groups.
\nProfile of foot ulcer patients with and without diabetes mellitus.
The severity of leg ulcers at discovery in patients with and without diabetes mellitus is shown in Table 2. In the groups, the ulcer stage based on the Wagner classification showed similar tendencies. About 80% of the diabetic foot group developed infection, being a significantly higher rate than in the nondiabetic foot. Methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible Staphylococcus aureus (MSSA), and Streptococcus were ranked high and accounted for over three-quarters of infections in both groups (Figure 1).
\nSeverity of leg ulcers at discovery in patients with and without diabetes mellitus.
Infection of leg ulcers at discovery in patients with and without diabetes mellitus (MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus).
Because patients with diabetes are likely to develop severe infection, more than 50% of foot ulcer patients with diabetes required immediate debridement surgery, being a significantly higher rate than in the nondiabetic foot group (25%) (Figure 2).
\nThe frequency of foot ulcer patients with and without diabetes, who required immediate debridement surgery.
The frequencies of peripheral artery disease in foot ulcer patients with and without diabetes were 38.2 and 34.6%, respectively. There were no significant differences between the groups.
\nThe frequencies of hemodialysis in patients with and without diabetes were 7.2 and 6.2%, respectively. There were no significant differences between the groups.
\nThe frequencies of amputation in foot ulcer patients with and without diabetes were 53.9 and 34.6%, respectively. More than half of the patients with diabetes underwent amputation surgery, being a significantly higher rate than that in the nondiabetic foot group (Figure 3).
\nThe frequency of amputation in foot ulcer patients with and without diabetes.
We evaluated 85 amputated legs in 152 diabetic foot patients. Sixty-eight percent (104) of the patients were men, and 32% (48) were women. Profiles of diabetic patients with/without leg amputation are shown in Table 3.
\nProfiles of diabetic patients with and without leg amputation.
Men were more likely to require amputation. CRP and WBC were significantly higher, and serum albumin was significantly lower in the major amputation group, suggesting that severe infection and malnutrition are risk factors for major leg amputation in diabetic foot patients.
\nSixty-nine (82%) of 85 amputees and 36 (57.6%) of 67 non-amputees with diabetes developed infection, showing a significant difference between the groups. More than half of amputated and only 17.9% of non-amputated patients with diabetes were complicated by peripheral artery disease, showing a significant difference between the groups (Figure 4). Furthermore, the frequency of hemodialysis in amputated patients (11.8%) was also significantly higher than that in non-amputated patients (1.5%) (Figure 5).
\nThe frequency of amputation in diabetic foot ulcer patients with and without peripheral artery disease.
The frequency of amputation in diabetic foot ulcer patients with and without hemodialysis.
Of the 85 amputees with diabetes, 44 patients underwent minor amputation, and 38 received major amputation. Seventy-one percent (58) were men and 29% (24) were women. Profiles of diabetic patients with/without leg amputation are shown in Table 4. Men were more likely to require major amputation. CRP and WBC were significantly higher, and serum albumin was significantly lower in the major amputation group, suggesting that severe infection and malnutrition are risk factors for major leg amputation in diabetic foot patients.
\nProfiles of diabetic patients who underwent major and minor leg amputation.
Diabetic foot ulcers sometimes lead to minor or major amputation, with a high impact on patients’ life and its quality [14]. Our results suggest that risk factors for leg amputation in diabetic foot patients include male, complication of severe infection, complication of peripheral artery disease, complication of hemodialysis, and malnutrition.
\nThe importance of nutritional support in patients with wounds has been examined. Malnourished patients showed not only a higher frequency of impaired wound healing but also an increased risk of postoperative cardiopulmonary and septic complications [15, 16]. Malnutrition cannot be improved in a short time after developing foot ulcers. Thus, patients requiring surgical treatment should also receive supplemental nourishment in the perioperative period [17]. Luo et al. suggested that the geriatric nutritional risk index was a reliable and effective predictive marker of patients’ amputation-free survival, and it could identify patients early with a high risk of amputation [18]. Appropriate blood sugar control and nutritional support are required for diabetic patients to prevent leg amputation. Malnutrition usually occurs in critical limb ischemia patients as well, because of a lack of appetite and sleeplessness due to chronic pain. These patients with peripheral artery disease also require pain control and nutritional support services [18].
\nThe number of patients requiring hemodialysis has been growing because obesity-related renal diseases such as diabetes mellitus are increasing [19, 20]. Diabetic patients with renal failure had high risks of foot ulceration and lower limb complications [21]. Regarding cutaneous infection, Bencini et al. reported that the incidence of fungal infection in patients undergoing hemodialysis was 67% [22]. Because chronic renal failure patients exhibit impaired cellular immunity due to a decreased T-lymphocyte cell count, this could explain the increased prevalence of fungal infections [23]. Thus, difficulty healing wounds is a frequent problem in patients on hemodialysis [24]. Amputations of limbs are sometimes performed for these complex ulcers, because when patients receiving hemodialysis develop aggressive life-threatening infections such as sepsis, immediate surgical debridement is required in order to salvage the blood access line and save lives [25]. Fujioka reported that 13 of 17 wounds required immediate surgery, including amputation and debridement in patients with DM, while only 1 of 13 required immediate surgery in patients without DM [26].
\nPoor management of foot ulcers in patients receiving hemodialysis leads to prolonged ulceration, gangrene, amputation, depression, and death [27].
\nMarn et al. investigated the association between the implementation of a routine foot check program in diabetic incident hemodialysis patients and concluded that monthly foot checks are associated with a reduction of major lower limb amputations [28]. All patients on hemodialysis should be considered as being at high risk of developing foot complications and undergo foot checks frequently. If infection is suspected, antibiotics should be administered through the dialysis line immediately during dialysis.
\nDiabetic foot infection is a common diabetic complication, which results in lower limb amputation if not treated properly. Patients with diabetes are likely to develop infections, because of the alteration of immune defense mechanisms such as a change in the neutrophil function, suppression of the antioxidant system, and modified humoral activity due to the hyperglycemic environment [29].
\nOnce a diabetic foot develops infection, it progresses rapidly and requires the removal of all necrotizing tissue involving the bone, tendons, and skin (Figure 6).
\nA view of progressing diabetic infection in the big toe, which aggravated rapidly and required the removal of toes and metatarsal bones within 3 weeks.
If the toe infection progresses and spreads widely, the patient may have to undergo major amputation (Figures 7a and b). Thus, early and appropriate debridement to reduce infection is important.
\n(a) A view of necrotizing fasciitis in the left forearm at the first examination, which progressed rapidly to the upper arm, and the patient developed septic shock in 2 days. (b) Amputation of the infected hand at the upper arm was immediately performed to control the aggressive infection.
Soft tissue infections in diabetic patients require multidisciplinary treatment including rapid surgical intervention, antibiotic treatment, and hyperbaric oxygen therapy to restrict the growth of pathogens [30, 31, 32]. Antibiotic therapy should be instituted immediately. The initial antibiotic should act on aerobic Gram-positive and Gram-negative bacteria but also on anaerobic bacteria. Systemic antibiotics have been demonstrated in many trials to be effective in treating acute diabetic foot infections. Tchero et al. performed a systematic review to assess the clinical efficacy of antibiotic regimens in the treatment of diabetic foot infections and concluded that piperacillin/tazobactam should be recommended for severe infections and the adjuvant use of topical agents with systemic antibiotics improved the outcomes compared with systemic antibiotics alone [33]. Mustăţea et al. suggested that an initial combination of third-generation cephalosporin, quinolone, and metronidazole was initially administered. After germ identification, antibiotic therapy was administered according to the antibiogram [29]. Cellulitis, which shows inflammation and infection of the skin and subcutaneous tissue, can be treated with systemic Gram-positive bactericidal antibiotics only. However, if deep tissue infection, especially osteomyelitis, is suspected, removal of the infected bone and soft tissue, followed by 2–4 weeks of antibiotics, is required [30].
\nRegarding surgical intervention, early and appropriate debridement to reduce infection is recommended to achieve infection control (Figure 8).
\nViews of debridement for necrotizing fasciitis in the diabetic patient’s right sole. All necrotizing, contaminated tissue was removed immediately.
If the infection invades deeper to the tendon, the lesions can often be extended and spread upward rapidly along the tendon tract, which can lead to systematic sepsis and require immediate limb amputation (Figure 9a and b). As the infection developing in the diabetic patients’ limbs progresses rapidly, physicians must decide on whether to carry out debridement before the infected lesion spreads upward.
\n(a) A view of necrotizing fasciitis in the right big toe, which spreads upward rapidly. (b) Intraoperative view showing the contaminated lesion extending along the extensor tendon tract.
Case presentations
\nCase 1. A 51-year-old man developed diabetic foot gangrene with osteomyelitis of the fifth toe, which had progressed for 2 weeks (Figure 10a). The patient underwent fourth and fifth toe amputation immediately, and cleansing to reduce infection was performed for 2 weeks (Figure 10b). As abundant granulation tissue developed on the wound surface, he underwent free skin grafting (Figure 10c). The wound had completely resurfaced by 1 month after skin grafting, and the patient could walk without a cane (Figure 10d).
\n(a) Case 1. A view of diabetic foot gangrene with osteomyelitis of the fifth toe. (b) After fourth and fifth toe amputation, cleansing was performed for 2 weeks. (c) Intraoperative view showing free skin grafting on the wound. (d) A view of the foot 1 month after surgery showing favorable coverage of the wound.
Peripheral artery disease (PAD) is observed in up to 50% of patients with a diabetic foot ulcer, and the presence of PAD is an important consideration in their management [34]. PAD affects the distal vessels and results in occlusion, which is one of the major causes of ulcer development and an increased risk of amputation. The treatment for these patients often requires challenging distal revascularization surgery or angioplasty to prevent limb amputation [35]. Revascularization is commonly performed in patients with critical limb ischemia and a diabetic foot ulcer, and the ulcer-healing rate after revascularization ranges from 46 to 91% [36]. Hinchliffe et al. reviewed the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD 1 year after surgery and reported that limb salvage rates showed a median of 85% following open surgery, and more than 60% of ulcers had healed following revascularization. They concluded that revascularization improved rates of limb salvage compared with the results of conservatively treated patients [34].
\nCase presentations
\nCase 2. A 67-year-old man developed a diabetic foot ulcer of the right heel, which had progressed for 2 months (Figure 11a). His posterior tibial artery was not palpable. Enhanced computed tomography (CT) showed that circulation of his right lower leg was poor, with an ankle brachial pressure index (ABI) of only 0.53, which suggested that his leg ulcer might not heel spontaneously. We fashioned femoral-popliteal artery (FP) bypass to increase distal blood flow, and ABI improved to 0.83(Figure 11b). As the patient’s foot received sufficient flow, he could safely undergo resurfacing surgery using a reversed sural flap successfully and could walk 3 months after surgery (Figure 11c–f).
\n(a) Case 2. A view of a diabetic foot ulcer of the right heel. (b) Enhanced computed tomography scan image showing the poor circulation of the patient’s right lower leg due to obstruction of the right femoral artery (circles). After fashioning the femoral-popliteal artery bypass, increased distal blood flow was seen (small arrows). (c) Intraoperative view showing the debrided heel ulcer and design of the reversed sural flap. (d) Intraoperative view of heel reconstruction showing the transferred reversed sural flap. (e) A view of the reconstructed heel 3 months after surgery revealed favorable coverage of the wound. (f) The patient could walk 3 months after surgery.
Case 3. A 60-year-old man developed a diabetic foot ulcer and osteomyelitis of the calcaneus (Figure 12a). Following the removal of a sequester, he underwent FP bypass angioplasty, and ABI improved from 0.67 to 1.01 (Figure 12b). The bone-exposing wound was resurfaced using a free superficial circumflex iliac perforator (SCIP) flap (Figure 12c–e). One year after the surgery, good circulation had been achieved without infection or ulcer relapse (Figure 12f).
\n(a) Case 3. A view of a diabetic foot ulcer and osteomyelitis of the calcaneus. (b) Enhanced computed tomography scan image showing poor circulation of the patient’s right lower leg due to obstruction of right femoral artery (circle). After fashioning the femoral-popliteal artery bypass, increased distal blood flow was seen. (c) Intraoperative view showing the design of a free superficial circumflex iliac perforator flap. (d) Intraoperative view of the elevated SCIP flap. The arrow indicates the perforator of superficial circumflex iliac vessels. (e) Intraoperative view of the harvested SCIP flap. (f) A view of the reconstructed foot 1 year after surgery showing favorable coverage of the wound.
Standard stump plasty requires shortening of the remaining fine and vivid bone end to resurface the bone-exposing amputation stump (Figure 13a and b).
\n(a) A view of diabetic gangrene extending the first and second metatarsal bones. After removal of the necrotic bone, the navicular was exposed. (b) Intraoperative view of Chopart amputation followed by resurfacing with a local flap of the sole.
On the other hand, free flap transfer enables surgeons to maintain the bone length, which is a potential advantage, especially when amputation is performed at the trans-metatarsal lesion (Figure 14a–c).
\n(a) A view of a diabetic foot ulcer with osteomyelitis of the first and second metatarsal bones. (b) Intraoperative view of the harvested anterolateral thigh (ALT) flap. (c) A view of the reconstructed foot using a free ALT flap 1 year after surgery, showing favorable coverage, and the patient could walk without a cane.
This is because Chopart or transtibial amputation results in more debilitating functional outcomes than transmetatarsal amputation. Furthermore, transmetatarsal amputation preserves maximal foot length, allowing patients to achieve a better quality of life [37, 38].
\nRegarding the flap choice, the ideal flap is thought to be a good vascularized skin paddle with the same thickness and width as the wound and requiring a single-stage operation [39]. Perforator flaps are defined as flaps consisting of skin and/or subcutaneous fat, with a blood supply from isolated perforating vessels of a stem artery [40]. The development of perforator flaps has increased the number of potential donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity can be reduced [41, 42]. Furthermore, the advantage of this skin flap is that it is less invasive, so that the operation can be performed under local anesthesia if the wound is small.
\nCase presentation
\nCase 4. A 32-year-old man developed a diabetic foot ulcer on the step (Figure 15a). Following debridement, he underwent resurfacing surgery using a free superficial circumflex Iliac artery perforator flap (Figure 12b and c). As free SCIP flap transfer is less invasive, the operation can be performed under local anesthesia (Figure 15d). One year after the surgery, good circulation had been achieved without infection or ulcer relapse (Figure 15e).
\n(a) Case 4. A view of a diabetic foot ulcer of the step. (b) Intraoperative view showing the design of a free superficial circumflex iliac perforator flap. (c) Intraoperative view showing the design of a free SCIP flap. (d) Intraoperative view showing that an SCIP flap transfer is less invasive, so the patient was awake and talking with the surgeon. (e) A view of the reconstructed foot 2 months after surgery revealed favorable wound coverage.
The SCIP flap is recommended because it minimizes sacrifice at the donor site, causing no damage to the main vessels or muscles beneath the flap. The only disadvantage is that the pedicle vessel is sometimes short when a suitable recipient vessel cannot be found near the wound [43]. Identifying an acceptable recipient vessel around the contaminated area is not always easy. Chronic inflammation in recipient vessels caused by infection and fibrosis may be one of the factors leading to thrombosis of the anastomosed vessel [44]. So, it is important to select a flap with a long pedicle, as the suitable recipient vessel may be distant from the wound. The anterolateral thigh (ATL) flap is often chosen because it is supplied by the descending branch of the lateral femoral circumflex artery, which has an external diameter of more than 2 mm at the proximal end with a pedicle of more than 8 cm in length [45, 46]. This flap is also a perforator flap, so that a larger cutaneous or fasciocutaneous flap can be harvested from the thigh while avoiding the sacrificing of underlying muscle and large vessels [47, 48].
\nCase presentation
\nCase 5. A 66-year-old man developed a diabetic foot ulcer with osteomyelitis of the left fourth and fifth toes (Figure 16a). He had already undergone right below the knee amputation due to diabetic gangrene. Thus, he desired to preserve his left leg to walk. Following debridement, he underwent resurfacing surgery using a free ALT flap (Figure 16b and c). Two months after the surgery, good resurfacing had been achieved, and he could walk with an artificial right leg (Figure 16d).
\n(a) Case 5. A view of a diabetic foot ulcer. The fourth and fifth toes were amputated due to osteomyelitis. (b) Intraoperative view showing the elevation of an anterolateral thigh (ALT) flap. (c) Intraoperative view showing resurfacing of the bone-exposing wound with an ALT flap. (d) A view of the reconstructed foot 2 months after surgery revealed that favorable resurfacing had been achieved and he could walk without a cane.
I conclude that the risk factors of leg amputation due to a diabetic foot are complications of severe infection and PAD, so diabetic ulcer management should include the immediate removal of necrotic tissue and control of infection. The only way to prevent major amputation of a diabetic ischemic foot is angioplasty of the occluded lower extremity arteries, and reconstruction of the amputation stump using free flap transfers to preserve the foot length is a good option for preserving the walking function.
\nIn the past four decades, over 42–56% of major lower extremity amputations in the United States and Western European countries have been due to diabetes mellitus (DM) [1, 2, 3, 4]. The relative risk of major leg amputations for diabetes ranges from 5.1 to 31.5 times in comparison with that of nondiabetic populations [5, 6]. Extensive efforts have been made to improve the treatment of diabetes in regard to glycemic control and the prevention of diabetic complications, and foot ulcer treatments have improved for diabetic patients [7, 8]. Before 2004, trauma accounted for most amputations in the majority of hospitals, followed by malignancies [9]. However, the most common cause of amputation at present is diabetes mellitus [10, 11].
\nAmputation is the most appropriate therapy for an ischemic or infected limb, but the level at which to amputate is often difficult to determine. Patients who undergo only toe or trans-metatarsal amputation can walk on their own feet; however, those with major amputation require an artificial leg or a cane, which impairs their activities [12, 13]. The aim of this chapter is to describe factors that lead to amputation of a diabetic foot and propose a management strategy to prevent major amputation.
\nA retrospective descriptive study including 152 diabetic patients among 233 patients with leg ulcers who were treated in our medical center was carried out between January 2008 and December 2017. All patients had been diagnosed with type II diabetes. Diabetic foot ulcers represent more than 65 percent of all leg ulcers.
\nTo clarify the clinical characteristics of the diabetic foot, a comparison of foot ulcer patients with and without diabetes mellitus is conducted first, risk factors leading to amputation in cases of diabetic foot ulcer and “major” amputation in cases of diabetic foot are discussed, and a recommended strategy to avoid major leg amputation is presented.
\nStatistical analysis was performed using the Wilcoxon signed-rank test and chi-square test. The value of p < 0.05 was determined as significant.
\nThe ethical committee of our medical center approved this study.
\nProfiles of foot ulcer patients with and without diabetes mellitus are shown in Table 1. Of the 233 patients with a foot ulcer, 63% (147) were men, and 37% (86) were women. Of course, levels of HbA1C and blood sugar in the diabetic foot group were significantly higher than those in the nondiabetic foot group, and men were more likely to develop leg ulcers in the diabetic patient group. There were no significant differences in CRP, WBC, serum albumin, or hemoglobin between the groups.
\nProfile of foot ulcer patients with and without diabetes mellitus.
The severity of leg ulcers at discovery in patients with and without diabetes mellitus is shown in Table 2. In the groups, the ulcer stage based on the Wagner classification showed similar tendencies. About 80% of the diabetic foot group developed infection, being a significantly higher rate than in the nondiabetic foot. Methicillin-resistant Staphylococcus aureus (MRSA), methicillin-susceptible Staphylococcus aureus (MSSA), and Streptococcus were ranked high and accounted for over three-quarters of infections in both groups (Figure 1).
\nSeverity of leg ulcers at discovery in patients with and without diabetes mellitus.
Infection of leg ulcers at discovery in patients with and without diabetes mellitus (MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus).
Because patients with diabetes are likely to develop severe infection, more than 50% of foot ulcer patients with diabetes required immediate debridement surgery, being a significantly higher rate than in the nondiabetic foot group (25%) (Figure 2).
\nThe frequency of foot ulcer patients with and without diabetes, who required immediate debridement surgery.
The frequencies of peripheral artery disease in foot ulcer patients with and without diabetes were 38.2 and 34.6%, respectively. There were no significant differences between the groups.
\nThe frequencies of hemodialysis in patients with and without diabetes were 7.2 and 6.2%, respectively. There were no significant differences between the groups.
\nThe frequencies of amputation in foot ulcer patients with and without diabetes were 53.9 and 34.6%, respectively. More than half of the patients with diabetes underwent amputation surgery, being a significantly higher rate than that in the nondiabetic foot group (Figure 3).
\nThe frequency of amputation in foot ulcer patients with and without diabetes.
We evaluated 85 amputated legs in 152 diabetic foot patients. Sixty-eight percent (104) of the patients were men, and 32% (48) were women. Profiles of diabetic patients with/without leg amputation are shown in Table 3.
\nProfiles of diabetic patients with and without leg amputation.
Men were more likely to require amputation. CRP and WBC were significantly higher, and serum albumin was significantly lower in the major amputation group, suggesting that severe infection and malnutrition are risk factors for major leg amputation in diabetic foot patients.
\nSixty-nine (82%) of 85 amputees and 36 (57.6%) of 67 non-amputees with diabetes developed infection, showing a significant difference between the groups. More than half of amputated and only 17.9% of non-amputated patients with diabetes were complicated by peripheral artery disease, showing a significant difference between the groups (Figure 4). Furthermore, the frequency of hemodialysis in amputated patients (11.8%) was also significantly higher than that in non-amputated patients (1.5%) (Figure 5).
\nThe frequency of amputation in diabetic foot ulcer patients with and without peripheral artery disease.
The frequency of amputation in diabetic foot ulcer patients with and without hemodialysis.
Of the 85 amputees with diabetes, 44 patients underwent minor amputation, and 38 received major amputation. Seventy-one percent (58) were men and 29% (24) were women. Profiles of diabetic patients with/without leg amputation are shown in Table 4. Men were more likely to require major amputation. CRP and WBC were significantly higher, and serum albumin was significantly lower in the major amputation group, suggesting that severe infection and malnutrition are risk factors for major leg amputation in diabetic foot patients.
\nProfiles of diabetic patients who underwent major and minor leg amputation.
Diabetic foot ulcers sometimes lead to minor or major amputation, with a high impact on patients’ life and its quality [14]. Our results suggest that risk factors for leg amputation in diabetic foot patients include male, complication of severe infection, complication of peripheral artery disease, complication of hemodialysis, and malnutrition.
\nThe importance of nutritional support in patients with wounds has been examined. Malnourished patients showed not only a higher frequency of impaired wound healing but also an increased risk of postoperative cardiopulmonary and septic complications [15, 16]. Malnutrition cannot be improved in a short time after developing foot ulcers. Thus, patients requiring surgical treatment should also receive supplemental nourishment in the perioperative period [17]. Luo et al. suggested that the geriatric nutritional risk index was a reliable and effective predictive marker of patients’ amputation-free survival, and it could identify patients early with a high risk of amputation [18]. Appropriate blood sugar control and nutritional support are required for diabetic patients to prevent leg amputation. Malnutrition usually occurs in critical limb ischemia patients as well, because of a lack of appetite and sleeplessness due to chronic pain. These patients with peripheral artery disease also require pain control and nutritional support services [18].
\nThe number of patients requiring hemodialysis has been growing because obesity-related renal diseases such as diabetes mellitus are increasing [19, 20]. Diabetic patients with renal failure had high risks of foot ulceration and lower limb complications [21]. Regarding cutaneous infection, Bencini et al. reported that the incidence of fungal infection in patients undergoing hemodialysis was 67% [22]. Because chronic renal failure patients exhibit impaired cellular immunity due to a decreased T-lymphocyte cell count, this could explain the increased prevalence of fungal infections [23]. Thus, difficulty healing wounds is a frequent problem in patients on hemodialysis [24]. Amputations of limbs are sometimes performed for these complex ulcers, because when patients receiving hemodialysis develop aggressive life-threatening infections such as sepsis, immediate surgical debridement is required in order to salvage the blood access line and save lives [25]. Fujioka reported that 13 of 17 wounds required immediate surgery, including amputation and debridement in patients with DM, while only 1 of 13 required immediate surgery in patients without DM [26].
\nPoor management of foot ulcers in patients receiving hemodialysis leads to prolonged ulceration, gangrene, amputation, depression, and death [27].
\nMarn et al. investigated the association between the implementation of a routine foot check program in diabetic incident hemodialysis patients and concluded that monthly foot checks are associated with a reduction of major lower limb amputations [28]. All patients on hemodialysis should be considered as being at high risk of developing foot complications and undergo foot checks frequently. If infection is suspected, antibiotics should be administered through the dialysis line immediately during dialysis.
\nDiabetic foot infection is a common diabetic complication, which results in lower limb amputation if not treated properly. Patients with diabetes are likely to develop infections, because of the alteration of immune defense mechanisms such as a change in the neutrophil function, suppression of the antioxidant system, and modified humoral activity due to the hyperglycemic environment [29].
\nOnce a diabetic foot develops infection, it progresses rapidly and requires the removal of all necrotizing tissue involving the bone, tendons, and skin (Figure 6).
\nA view of progressing diabetic infection in the big toe, which aggravated rapidly and required the removal of toes and metatarsal bones within 3 weeks.
If the toe infection progresses and spreads widely, the patient may have to undergo major amputation (Figures 7a and b). Thus, early and appropriate debridement to reduce infection is important.
\n(a) A view of necrotizing fasciitis in the left forearm at the first examination, which progressed rapidly to the upper arm, and the patient developed septic shock in 2 days. (b) Amputation of the infected hand at the upper arm was immediately performed to control the aggressive infection.
Soft tissue infections in diabetic patients require multidisciplinary treatment including rapid surgical intervention, antibiotic treatment, and hyperbaric oxygen therapy to restrict the growth of pathogens [30, 31, 32]. Antibiotic therapy should be instituted immediately. The initial antibiotic should act on aerobic Gram-positive and Gram-negative bacteria but also on anaerobic bacteria. Systemic antibiotics have been demonstrated in many trials to be effective in treating acute diabetic foot infections. Tchero et al. performed a systematic review to assess the clinical efficacy of antibiotic regimens in the treatment of diabetic foot infections and concluded that piperacillin/tazobactam should be recommended for severe infections and the adjuvant use of topical agents with systemic antibiotics improved the outcomes compared with systemic antibiotics alone [33]. Mustăţea et al. suggested that an initial combination of third-generation cephalosporin, quinolone, and metronidazole was initially administered. After germ identification, antibiotic therapy was administered according to the antibiogram [29]. Cellulitis, which shows inflammation and infection of the skin and subcutaneous tissue, can be treated with systemic Gram-positive bactericidal antibiotics only. However, if deep tissue infection, especially osteomyelitis, is suspected, removal of the infected bone and soft tissue, followed by 2–4 weeks of antibiotics, is required [30].
\nRegarding surgical intervention, early and appropriate debridement to reduce infection is recommended to achieve infection control (Figure 8).
\nViews of debridement for necrotizing fasciitis in the diabetic patient’s right sole. All necrotizing, contaminated tissue was removed immediately.
If the infection invades deeper to the tendon, the lesions can often be extended and spread upward rapidly along the tendon tract, which can lead to systematic sepsis and require immediate limb amputation (Figure 9a and b). As the infection developing in the diabetic patients’ limbs progresses rapidly, physicians must decide on whether to carry out debridement before the infected lesion spreads upward.
\n(a) A view of necrotizing fasciitis in the right big toe, which spreads upward rapidly. (b) Intraoperative view showing the contaminated lesion extending along the extensor tendon tract.
Case presentations
\nCase 1. A 51-year-old man developed diabetic foot gangrene with osteomyelitis of the fifth toe, which had progressed for 2 weeks (Figure 10a). The patient underwent fourth and fifth toe amputation immediately, and cleansing to reduce infection was performed for 2 weeks (Figure 10b). As abundant granulation tissue developed on the wound surface, he underwent free skin grafting (Figure 10c). The wound had completely resurfaced by 1 month after skin grafting, and the patient could walk without a cane (Figure 10d).
\n(a) Case 1. A view of diabetic foot gangrene with osteomyelitis of the fifth toe. (b) After fourth and fifth toe amputation, cleansing was performed for 2 weeks. (c) Intraoperative view showing free skin grafting on the wound. (d) A view of the foot 1 month after surgery showing favorable coverage of the wound.
Peripheral artery disease (PAD) is observed in up to 50% of patients with a diabetic foot ulcer, and the presence of PAD is an important consideration in their management [34]. PAD affects the distal vessels and results in occlusion, which is one of the major causes of ulcer development and an increased risk of amputation. The treatment for these patients often requires challenging distal revascularization surgery or angioplasty to prevent limb amputation [35]. Revascularization is commonly performed in patients with critical limb ischemia and a diabetic foot ulcer, and the ulcer-healing rate after revascularization ranges from 46 to 91% [36]. Hinchliffe et al. reviewed the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD 1 year after surgery and reported that limb salvage rates showed a median of 85% following open surgery, and more than 60% of ulcers had healed following revascularization. They concluded that revascularization improved rates of limb salvage compared with the results of conservatively treated patients [34].
\nCase presentations
\nCase 2. A 67-year-old man developed a diabetic foot ulcer of the right heel, which had progressed for 2 months (Figure 11a). His posterior tibial artery was not palpable. Enhanced computed tomography (CT) showed that circulation of his right lower leg was poor, with an ankle brachial pressure index (ABI) of only 0.53, which suggested that his leg ulcer might not heel spontaneously. We fashioned femoral-popliteal artery (FP) bypass to increase distal blood flow, and ABI improved to 0.83(Figure 11b). As the patient’s foot received sufficient flow, he could safely undergo resurfacing surgery using a reversed sural flap successfully and could walk 3 months after surgery (Figure 11c–f).
\n(a) Case 2. A view of a diabetic foot ulcer of the right heel. (b) Enhanced computed tomography scan image showing the poor circulation of the patient’s right lower leg due to obstruction of the right femoral artery (circles). After fashioning the femoral-popliteal artery bypass, increased distal blood flow was seen (small arrows). (c) Intraoperative view showing the debrided heel ulcer and design of the reversed sural flap. (d) Intraoperative view of heel reconstruction showing the transferred reversed sural flap. (e) A view of the reconstructed heel 3 months after surgery revealed favorable coverage of the wound. (f) The patient could walk 3 months after surgery.
Case 3. A 60-year-old man developed a diabetic foot ulcer and osteomyelitis of the calcaneus (Figure 12a). Following the removal of a sequester, he underwent FP bypass angioplasty, and ABI improved from 0.67 to 1.01 (Figure 12b). The bone-exposing wound was resurfaced using a free superficial circumflex iliac perforator (SCIP) flap (Figure 12c–e). One year after the surgery, good circulation had been achieved without infection or ulcer relapse (Figure 12f).
\n(a) Case 3. A view of a diabetic foot ulcer and osteomyelitis of the calcaneus. (b) Enhanced computed tomography scan image showing poor circulation of the patient’s right lower leg due to obstruction of right femoral artery (circle). After fashioning the femoral-popliteal artery bypass, increased distal blood flow was seen. (c) Intraoperative view showing the design of a free superficial circumflex iliac perforator flap. (d) Intraoperative view of the elevated SCIP flap. The arrow indicates the perforator of superficial circumflex iliac vessels. (e) Intraoperative view of the harvested SCIP flap. (f) A view of the reconstructed foot 1 year after surgery showing favorable coverage of the wound.
Standard stump plasty requires shortening of the remaining fine and vivid bone end to resurface the bone-exposing amputation stump (Figure 13a and b).
\n(a) A view of diabetic gangrene extending the first and second metatarsal bones. After removal of the necrotic bone, the navicular was exposed. (b) Intraoperative view of Chopart amputation followed by resurfacing with a local flap of the sole.
On the other hand, free flap transfer enables surgeons to maintain the bone length, which is a potential advantage, especially when amputation is performed at the trans-metatarsal lesion (Figure 14a–c).
\n(a) A view of a diabetic foot ulcer with osteomyelitis of the first and second metatarsal bones. (b) Intraoperative view of the harvested anterolateral thigh (ALT) flap. (c) A view of the reconstructed foot using a free ALT flap 1 year after surgery, showing favorable coverage, and the patient could walk without a cane.
This is because Chopart or transtibial amputation results in more debilitating functional outcomes than transmetatarsal amputation. Furthermore, transmetatarsal amputation preserves maximal foot length, allowing patients to achieve a better quality of life [37, 38].
\nRegarding the flap choice, the ideal flap is thought to be a good vascularized skin paddle with the same thickness and width as the wound and requiring a single-stage operation [39]. Perforator flaps are defined as flaps consisting of skin and/or subcutaneous fat, with a blood supply from isolated perforating vessels of a stem artery [40]. The development of perforator flaps has increased the number of potential donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity can be reduced [41, 42]. Furthermore, the advantage of this skin flap is that it is less invasive, so that the operation can be performed under local anesthesia if the wound is small.
\nCase presentation
\nCase 4. A 32-year-old man developed a diabetic foot ulcer on the step (Figure 15a). Following debridement, he underwent resurfacing surgery using a free superficial circumflex Iliac artery perforator flap (Figure 12b and c). As free SCIP flap transfer is less invasive, the operation can be performed under local anesthesia (Figure 15d). One year after the surgery, good circulation had been achieved without infection or ulcer relapse (Figure 15e).
\n(a) Case 4. A view of a diabetic foot ulcer of the step. (b) Intraoperative view showing the design of a free superficial circumflex iliac perforator flap. (c) Intraoperative view showing the design of a free SCIP flap. (d) Intraoperative view showing that an SCIP flap transfer is less invasive, so the patient was awake and talking with the surgeon. (e) A view of the reconstructed foot 2 months after surgery revealed favorable wound coverage.
The SCIP flap is recommended because it minimizes sacrifice at the donor site, causing no damage to the main vessels or muscles beneath the flap. The only disadvantage is that the pedicle vessel is sometimes short when a suitable recipient vessel cannot be found near the wound [43]. Identifying an acceptable recipient vessel around the contaminated area is not always easy. Chronic inflammation in recipient vessels caused by infection and fibrosis may be one of the factors leading to thrombosis of the anastomosed vessel [44]. So, it is important to select a flap with a long pedicle, as the suitable recipient vessel may be distant from the wound. The anterolateral thigh (ATL) flap is often chosen because it is supplied by the descending branch of the lateral femoral circumflex artery, which has an external diameter of more than 2 mm at the proximal end with a pedicle of more than 8 cm in length [45, 46]. This flap is also a perforator flap, so that a larger cutaneous or fasciocutaneous flap can be harvested from the thigh while avoiding the sacrificing of underlying muscle and large vessels [47, 48].
\nCase presentation
\nCase 5. A 66-year-old man developed a diabetic foot ulcer with osteomyelitis of the left fourth and fifth toes (Figure 16a). He had already undergone right below the knee amputation due to diabetic gangrene. Thus, he desired to preserve his left leg to walk. Following debridement, he underwent resurfacing surgery using a free ALT flap (Figure 16b and c). Two months after the surgery, good resurfacing had been achieved, and he could walk with an artificial right leg (Figure 16d).
\n(a) Case 5. A view of a diabetic foot ulcer. The fourth and fifth toes were amputated due to osteomyelitis. (b) Intraoperative view showing the elevation of an anterolateral thigh (ALT) flap. (c) Intraoperative view showing resurfacing of the bone-exposing wound with an ALT flap. (d) A view of the reconstructed foot 2 months after surgery revealed that favorable resurfacing had been achieved and he could walk without a cane.
I conclude that the risk factors of leg amputation due to a diabetic foot are complications of severe infection and PAD, so diabetic ulcer management should include the immediate removal of necrotic tissue and control of infection. The only way to prevent major amputation of a diabetic ischemic foot is angioplasty of the occluded lower extremity arteries, and reconstruction of the amputation stump using free flap transfers to preserve the foot length is a good option for preserving the walking function.
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El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. 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