N e ls o n W o lo s k e r, R u b e n M ig u e l A y z in R o s o k y , B a p tis ta M u ra c o N e to , B e rilo L a n g e r ('G ')
M aintenance treatm ent of diabetic patients, associating
arterial obstructive tibio-peroneal disease
Surgical Depar~ment, Hospital das Clinicas, Faculdade
de Medicina,
Universidade de Silo Paulo - Silo Paulo, Brazil
W h e n a m e lito -d ia b e tic p a tie n t p re se n ts tro p h ic in fe cte d in ju ry o n th e lim b , it is e sse n tia l a n e va lu a tio n o f th e circu la to ry co n d itio n s fo r th e ra p e u tic p ro ce d u re s o rie n ta tio n .
In so m e circu m sta n ce s, a lth o u g h a rte ria l p u lsa tio n is a b se n t, th e re is n o isch e m ia o f tissu e s. In th e se ca se s, th e m a in te n a n ce tre a tm e n t, w ith e ve n tu a l re se ctio n o f th e n e cro se d a n d in fe cte d tissu e s m a y b e a d o p te d .
E vo lu tio n o f 7 0 d ia b e tic p a tie n ts w ith tro p h ic in ju rie s o n e xtre m itie s w e re su b m itte d to a m a in te n a n ce tre a tm e n t.. A g e o f p a tie n ts va rie d fro m 2 8 to 8 8 ye a rs, w ith a n a ve ra g e o f 5 6 .8 . T h e m o st o ccu rre n ce w a s ve rifie d in w o m e n , w ith 4 2 ca se s. D ia b e te s n o n -d e p e n d a n t o n in su lin e (typ e II) w a s o b se rve d in 6 4 p a tie n ts (9 1 .5 % ), b e in g th e re m a in in g 6 p a tie n ts o f typ e I. D ia b e tic
re tin o p a th y w a s o b se rve d in 1 4 (2 0 % ) o f th e p a tie n ts, n e u ro p a th y in 2 2 (3 1 % ) a n d n e p h ro p a th y in 8 p a tie n ts (1 1 .4 % ). A ll th e p a tie n ts p re se n te d a rte ria l p u lsa tio n u n til th e p o p lite a l re g io n . T h e y w e re d ivid e d in 2 g ro u p s, co n sid e rin g tru n k a rte rie s o f
le g s: G ro u p I, p e rvia lle g s a rte rie s, co m p o se d b y 4 8 p a tie n ts; G ro u p II, o cclu d e d le g s a rte rie s, w ith 2 2 p a tie n ts.
In w h a t re fe rs to th e a n a to m ic lo ca l G f th e in ju rie s, p a tie n ts w e re cla ssifie d in th re e g ro u p s: G ro u p A , fo rm e d b y 3 2 p a tie n ts (4 5 .7 0 /0 ), p re se n tin g in ju rie s in o n e o r tw o to e s o n ly, w ith o u t a ffe ctin g th e m e ta ta rsic re g io n ; G ro u p B , fo rm e d b y 1 6 p a tie n ts (2 2 .9 % ), tro p h ic
in ju rie s a ffe ctin g th e m e ta ta rsic re g io n a n d G ro u p C , fo rm e d b y 2 2 p a tie n ts (3 1 .4 0 /0 ),in ju rie s a ffe ctifl9 th e ca lca n e o u s re g io n . In ju rie s in b o th o f th e g ro u p s w e re ca u se d b y m e ch a n ica l tra u m a tism . D u ra tio n o f th e in ju ry in th e in fe rio r m e m b e r va rie d fro m 7 to
4 8 d a ys, re su ltin g in a 1 2 d a ys a ve ra g e . A n a lyzin g p e rvica city in tru n k a rte ria s a n d e vo lu tio n o f p a tie n ts, it m a y b e o b se rve d th a t th e re h a s b e e n a sig n ifica n tly b e tte r re su lt in th o se w ith a ll th e p u lse s p re se n t (8 1 .3 0 /0x 4 5 .5 % )(p < 0 ,0 1 ).
S tu d yin g th e in ju ry lo ca ls a sso cia te d to th e e va lu a tio n o f th e ca se s, w e m a y o b se rve th a t fo r in ju rie s in th e e xtre m e d ig ita l, re su lt is sig n ifica n tly b e tte r th a n in lo ca ls m o re n e a rly. W h e n d ista l p u lse s a re a b se n t, th e re is n o sig n ifica n t d iffe re n ce in th e re su lt o f th e
tre a tm e n t, b e in g p e rfo rm e d in d ista l in ju rie s o r in th e m o re n e a r o n e s (p > 0 ,0 5 )(T a b le IV ).
U N IT E R M S : M e lito -d ia b e tic. T ib io -p e ro n e a l d ise a se . T ro p h ic in ju rie s. V a scu la r d ise a se . D ia b e tic fo o t.
IN T R O D U C T IO N
W
heninfecteda m elito-diabeticinjury on the lim b, it is essentialperson presents trophicanevaluation of the circulatory conditions, in
order to orient the therapeutic procedure (13,14). In the
A d d re s s fo r c o rre s p o n d e n c e : N e ls o n W o lo s k e r
R u a E s p e ria , 3 0
S a o P a u lo - S P - B ra s il- C E P 0 1 4 3 -0 6 0
Berilo Langer (~) - deceased
absence of trunk arterial disease, m aintenance treatm ent
w ithout am putation next to the m etatase, w ith eventual
resection of the necrosed and infected tissues, is .considered
as being the first procedure (3,8,16). W hen the leg arteries
are occluded, perfusion conditions of the m em ber m ust
be carefully evaluated. In certain circum stances, although
arterial pulsation is not present, there is no ischem ia of
tissues. In these cases, the sam e procedure m ay be taken
(1 1 ).
S om e patients presented trophic injuries, show ing
rapid installation and evolution and, therefore, needed
urgently care.
•
+ = P r e s e n t / - = A b s e n t / S = S a tis fa c to r y / N = U n s a tis fa c to r y
R E S U L T S
T a b le 1
D is tr ib u tio n o f th e r e s u lts o b ta in e d in a c c o r d a n c e
w ith th e p r e s e n c e o f a r te r ia l p u ls a tio n
In p a tie n ts p e rta in in g to G ro u p I, re s u lts s h o w e d a s
b e in g s a tis fa c to ry in 3 9 p a tie n ts (8 1 .3 % ) a n d in th e g ro u p
II, it s h o w e d s a tis fa c to ry in 1 0 p a tie n ts .
A n a ly z in g p e rv ic a c ity in tru n k a rte ria a n d p a tie n t
e v o lu tio n , it m a y b e o b s e rv e d th a t th e re h a s b e e n a
s ig n ific a n tly b e tte r re s u lt in th o s e .a ll p u ls e s w e re p re s e n t
(p < O ,O I) (T a b le I)
1 1 2 (2 3 .4 % )
1 4 (5 8 .4 % ) N S
3 9 (7 6 .4 % )
1 0 (4 1 .6 % ) S
P U L S E +
P U L S E
-S tu d y in g th e lo c a l o f th e in ju ry a s s o c ia te d t? th e
p ro g n o s ti'c o f th e c a s e s , w e m a y o b s e rv e th a t fo r th e in ju rie s
in d ig ita l e x tre m itie s , re s u lt is s ig n ific a n tly b e tte r th a n in
th e m o re n e a r o n e s (p < O ,O l)(ta b le II). It s h o w s ' e v e n m u c h
b e tte r w h e n w e a s s o c ia te th e v a ria b le " p u ls e p re s e n t" ,
b e in g o r tib ia l a n t~ rio r, o r p o s te rio r o r o f th e fo o t its e lf
(p < O ,O l)(T a b le III) ..
A ll th e p a tie n ts w e re s u b m itte d to a g e n e ra l s u p p o rt
tre a tm e n t, a n tib y o th ic o th e ra p y o f la rg e s p e c tru m a n d
re s e c tio n o f th e n e c ro s e d a n d in fe c te d tis s u e s .
S ta tis tic a l a n a ly s is w a s d o n e b a s e d o n th e F is h e r
e x a c t te s t, m o n o m o d a l, u s in g v a lu e 0 .0 5 a s th e c ritic a l
le v e l.
E v a lu a tio n o f th e re s u lts ~ a s b a s e d in th e s tu d y o f'
th e g e n e ra l c lin ic a l c o n d itio n s o f th e p a tie n ts a n d o f th e
le g a ffe c te d , w h e n th e y re tire d fro m n o s p ita l.
S a tis fa c to ry re s u lt (S ) w a s c o n s id e re d in th e c a s e s
w h e re th e a m p u ta tio n n e a r th e m e ta ta rs ic re g io n w a s n o t
n e c e s s a ry . U n s a tis fa c to ry re s u lt (N S ) w a s th e o n e w h e re
th e a m p u ta tio n a b o v e th e m e ta ta rs ic re g io n w a s n e c e s s a ry . E v o lu tio n o f 7 0 d ia b e tic p a tie n ts p re s e n tin g in fe c tio n
a n d n e c ro s e in th e in fe rio r m e m b e rs , tre a te d a t th e F irs t
A id U n ity o f th e H o s p ita l d a s C lfn ic a s d a F a c u ld a d e d e
M e d ic in a d a U n iv e rs id a d e d e S a o P a u lo fro m J a n u a ry ,
1 9 8 7 till J a n u a ry , 1 9 9 0 .
A g e o f p a tie n ts v a rie d fro m 2 8 to ' 8 8 y e a rs , w ith a
5 6 .8 o f a v e ra g e . W o m e n w e re th e m o s t a tta c k e d , w ith 4 2
c a s e s .
D ia b e te s n o n -in s u lin e d e p e n d e n t (ty p e II) w a s
o b s e rv e d in 6 4 o f th e p a tie n ts (9 1 .5 % ), b e in g th e o th e r 6
o f ty p e I.
A ll. th e p a tie n ts p re s ~ n te d a rte ria l p u ls a tio n till th e
p o p lite a l re g io n . T h e y w e re d iv id e d in tw o g ro u p s w ith
re la tio n to th e tru n k a rte ria o f th e le g s :
G ro u p I - P e rv ia lle g s a rte rie s , fo rm e d b y 4 8 p a c ie n ts ,
a v e ra g e o f 5 5 y e a rs
G ro u p II - O c c lu d e d le g s a rte rie s , fo rm e d b y 2 2
p a tie n ts w ith a b s e n c e o f a rte ria l p u ls a tio n in th e p o s te rio r
tib ia l a rte rie s , a n te rio r a n d d o rs a l, o f th e le g . A lth o u g h
w ith a rte ria l o b s tru c tiv e tib io -p e ro n e a l d is e a s e , p a tie n ts
p re s e n te d a n a p p a re n tly g o o d p e rife ric p e rfu s io n . A v e ra g e
w a s o f 6 0 .1 y e a rs .
In w h a t c o n c e rn s to th e a n a to m ic lo c a liz a tio n o f th e
in ju rie s , p a tie n ts w e re d iv id e d in th re e g ro u p s :
G ro u p A - F o rm e d b y 3 2 p a tie n ts (4 5 .7 % ), w ith o n e
o r tw o to e s a ffe c te d o n ly , w ith o u t re a c h in g th e m e ta ta rs ic
re g io n
G ro u p B - F o rm e d b y 1 6 p a tie n ts (2 2 .9 % ), w ith
tro p h ic in ju rie s , a ffe c tin g th e m e ta ta rs ic re g io n
G ro u p C - F o rm e d b y 2 2 p a tie n ts (3 1 .4 % ), w ith
in ju rie s a ffe c tin g c a lc a n e o u s re g io n
In ju rie s in b o th o f th e g ro u p s w e re c a u s e d b y
m e c h a n ic a l tra u m a tis m . N o p a tie n t p e rta in in g to G ro u p I.
p re s e n te d v a s c u la r c la im b e fo re th e tra u m a , w h ile 7 o f th e
p a tie n ts p e rta in in g to g ro u p II re p o rte d p re v io u s in te rm ite n t
c lu m s in e s s , n o t lim ita tin g .
T im e o f th e in ju ry p re s e n c e in th e in fe rio r m e m b e r
v a rie d fro m 7 to 4 8 d a y s , re p re s e n tin g a 1 2 d a y s a v e ra g e '.
D ia b e tic re tin o p a th y w a s v e rifie d in 1 4 .(2 0 % ) o f th e
p a tie n ts , n e u ro p a th y in 2 2 (3 1 % ) a n d n e p h ro p a th y in 8 o f
th e m (1 1 .4 % ).
C A S U IS T IC A N D M E T H O D
E v o lu tio n o f th e d ia b e tic p a tie n ts w ith tro p h ic in ju rie s
in e x tre m e tie s w a s s tu d ie d , a n d p a tie n ts w e re s u b m itte d
to m a in te n a n c e tre a tm e n t.
T a b le II
D is trib u tio n o f th e re s u lts o b ta in e d a c c o rd in g to lo c a l o f th e tro p h ic in ju rie s
S
N ST a b le IV
D is trib u tio n o f th e re s u lts o b ta in e d , c o n s id e rin g a rte ria l p u ls a tio n a b s e n c e a n d lo c a l o f th e tro p h ic
in ju rie s
S
=
S a tis fa c to ry / N S=
U n s a tis fa c to ry G R O U P AG R O U P 8 G R O U P C
2 8 (8 7 .5 0 /0 ) 8 (5 0 % ) 1 3 (5 9 .1 % )
4 (1 2 .5 % ) 8 (5 0 % ) 9 (4 0 .9 % )
G R O U P A 2 G R O U P 8 2 G R O U P C 2
S
4 (5 7 .1 % ) 2 (4 0 % ) 4 (4 0 % )
N S
3 (4 2 .9 % ) 3 (6 0 0 /0 ) 6 (6 0 0 /0 )
T a b le III
D is trib u tio n o f th e re s u lts o b ta in e d c o n s id e rin g th e p re s e n c e o f a rte ria l p u ls a tio n a n d lo c a liz a tio n o f th e
tro p h ic in ju ry ,
A 2 - G ro u p o f p a tie n ts w ith a rte ria l p u ls a tio n a b s e n t a n d tro p h ic in ju ry a ffe c tin g o n ly th e to e s
8 2 - G ro u p o f p a tie n ts w ith a rte ria l p u ls a tio n a b s e n t a n d tro p h ic in ju ry a ffe c tin g m e ta ta rs ic re g io n
8 3 - G ro u p o f p a tie n ts w ith a rte ria l p u ls a tio n a b s e n t a n d tro p h ic in ju ry a ffe c tin g c a lc a n e o u s re g io n
S = S a tis fa c to ry / N S
=
U n s a tis fa c to ryS
N SD IS C U S S IO N
W h e n th e d is ta l p u ls e s a re a b s e n t, th e re a re n o t
s ig n ific a n t d iffe re n c e s in th e re s u lts o f tre a tm e n t, b e in g
p e rfo rm e d in d ig ita l in ju rie s o r in m o re n e a rly o n e s
(p > O ,0 5 ) (ta b le IV ).
R e la tio n b e tw e e n d ia b e te s m e llitu s a n d lo o s e o f
tro p h ic in te g rity o f th e in fe ri~ r m e m b e rs d u e to is c h e m ia
a n d /o r in fe c tio n , a re v e ~ y fre q u e n t (4 ).
U n til fe w y e a rs a g o , it w a s a c c e p te d th a t, w ith th e
e v o lu tio n o f d ia b e te s , o b s tru c tio n o f th e le g a ite rie s w a s
c o n s id e re d th e d ia b e tic m ic ro a n g io p a th y (9 ). T o d a y , th is
A 1 - G ro u p o f p a tie n ts w ith n o rm a l a rte ria l p u ls a tio n a n d tro p h ic in ju ry a ffe c tin g o n ly th e to e s
A 2 - G ro u p o f p a tie n ts w ith n o rm a l a rte ria l p u ls a ~ io n a n d tro p h ic in ju ry a ffe c tin g th e m e ta ta rs ic re g io n A 3 - G ro u p o f p a tie n ts w ith n o rm a l a rte ria l p u ls a tio n a n d
tro p h ic in ju ry a ffe c tin g c a lc a n e o u s re g io n S
=
S a tis fa c to ry / N S=
U n s a tis fa c to rya ffirm a tio n , m o re th a n q u e s tio n e d , is b e in g le ft a s id e (1 2 ).
M ic ro a n g io p a th y is th e m o d ific a tio n a t c a p ila r le v e l a n d
th e tib io -p e ro n e a l o b s tru c tio n is n o t its .n e a re r e x te n s io n .
B e fo re th e o b s tru c tio n o f th e -le g a rte ria s a n d b e fo re
re a c h in g th e c a p ila r m ic ro c irc u la tio n , th e re a re s m a ll tru n k
a rte ria l s e g m e n ts , m a in ly in th e fo o t, th a t m a y b e p e rv ia l
a n d , th e re fo re , re a c h a b le b y th e n e w te c h n iq u e s o f a rte ria l
re s to ra tio n (1 ,7 ,1 5 ). S o , th e re is a n a rte ria l o b s tru c tiv e
tib io -p e ro n e a l d is e a s s e d is tin g u is h e d fro m th e d ia b e tic
m ic ro a n g io p a th y a n d d iffe re n t fro m th e o b lite ra tin g
p e rife ric a te rio e s c le ro s is o b s e rv e d in n o n -d ia b e tic s .
D is c u s s io n is to k n o w if th e a rte ria l o b s tru c tiv e tib io -'
p e ro n e a l D IS E A S E c o rre s p o n d s to a n a rte ria l in ju ry c a u s e d
b y th e d i~ b e te s m e llitu s o r if it is a v a ria n c e m o re d is ta l o f
th e o b lite ra tin g p e rife ric a te rio e s c le ro s is th a t a p p e a rs
s p e c ific a lly in d ia b e tic s .
M a in te n a n c e tre a tm e n t w a s s tu d ie d in d ia b e tic
p a tie n ts w ith tro p h ic in fe c te d in ju rie s o f th e in fe rio r
m e m b e rs th a t w e re n o t s u b m itte d to re v a s c u la riz a tio n a s
p re s e n tin g g o o d p e rfu s io n c o n d itio n s . E v e n p a tie n ts
p re s e n tin g a b s e n c e o f tru n k a rte ria l p u ls e s w e re tre ~ te d '
th is s a m e w a y , a s th e c lin ic a l e v a lu a tio n p re s e n te d g o o d
p e rife ric p e rfu s io n , s u g g e s tin g p re s e n c e o f h ig h c o la te ra l
c irc u la tio n . T h is s itu a tio n , th e o ric a lly , e n a b le s p e rfo rrria n c e
o f lo c a l d e b rid e m e n ts , w ith o u t n e e d o f p e rife ric
re v a s c u la riz a tio n . T h e m o s t c rll:c ia l p ro b le m a t th e m o m e n t
o f h o s p ita liz a tio n s e e m e d to b e in fe c tio n , w ith its lo c a l
s y s te m ic m a n ife s ta tio n s , a n d n o t th e is c h e m ia o f th e
in fe rio r m e m b e r a s a w h o le .
1 (4 0 /0 ) 5 (4 5 .5 % ) 3 (2 5 % ) 2 4 (9 6 % )
6 (5 4 .5 % ) 9 (7 5 % ) T o e s
In s te p H e e l
All the patients
of this
serial
were
submitted
to
immediate
treatment
of the
infected
injuries,
with
antiobyothicotherapy
and surgical
debridement.
Functional
prevention
of the member was described
as the
final
condition
of the
treatment
in
which
debridement,
including
amputation
limited to the toes or
instep,
enable
patient
to walk
without
the help
of a
substitutive
prothesis.
In patients without trunk periferic arterial obstruction,
functional
preservation
levels
were significantly
higher
than in the patients
with arterial obstructive
tibio-peroneal
disease
(83.1 % against
45.5%).
It keeps
evident
the
importance
of the pervicacity
of the high volume vases in
situations
of ischemia
and periferic tissue infection. Based
on this data, we began to do arteriography
in all the patients
with trophic injuries
of trunk arteria obstruction,
with the
purpose
of finding
some
small
arteria
segments
for
possible
distal revascularization
in our unity as in other
centers
(2,5,6).
In the trophic injuries
limited
to the toes, functional
preservation
of the inferior
member
was higher
than in
other anatomic localizations.
In patients with all the arterial
periferic pulses detected
and distal injuries,
result is better
than the one of the other groups.
CONCLUSIONS
1. Necrotic
and infectious
injuries
in the inferior
members of patients with arterial obstructive
tibio-peroneal
DISEASES
have a more serious evolution
than the patients
with the same type of injuries, but presenting
arterial distal
pulses.
2. When these injuries
are localizated
in the toes of
the feets, evolution
is significantly
better than in the more
near injuries, specially when there is no arterial obstru~tive
tibio-peroneal
disease.
REFERENCES
1 . A N D R O S , G .A .; H A R R IS , R .W .; S A L L E S -C U N H A , S .X .;
D U L A W A , L .B .
&
O B L A T H , R .W . - L a te ra l p la n ta r a rte ryb y p a ss g ra ftin g : D e fin in g th e lim its o f fo o t re v a sc u la riz a tio n .
J
V a sc S u rg 1 0 : 5 1 1 -5 2 1 , 1 9 8 9 .2 . A U E R , A J.; T W E E D IE , M .C .K .; W E S T , C .R .; E V A N S , P .
&
H E R S E ~ F .B .,- D ista l tib ia l v e in s g ra fts fo r lim b sa lv a g e . A rc h S u rg 1 1 8 : 5 9 7 ,1 9 8 3 .3 . B A R R E T , J.P .
&
M O O N E Y , V . - N e u ro p a th y a n d d ia b e t~ cp re ssu re le sio n s. O rth o p C lin N o rth A m 4 :4 3 , 1 9 7 3 .
4 . B E L L , E .T . - A th e ro sc le ro tic g a n g re n e o f th e lo w e r
e x tre m itie s in d ia b e tic a n d n o n d ia b e tic p e rso n s. A m
J
C linP a th o l 2 8 :2 7 , 1 9 5 7 .
5 . B U C H B IN D E R , D .; P A S C H , A .R .; R O L L IN S , D .L .; .
D IL L O N , B .C .; D O U G L A S , D .J.; S C H U L E R , J.J. &
F L A N IG A N , P .L . - R e su lts o f a rte ria l re c o n stru c tio n o f .th e
fo o t. A rc h S u rg 1 2 1 :6 7 3 , 1 9 8 6 .
6 . B U C H B IN D E R , D .; P A S C H , A .R .
&
V E R T A , M .J. - A n k leb y p a ss: " S h o u ld w e g o th e d ista n c e ? " A m
J
S u rg 1 5 0 :2 1 6 , 1 9 8 5 .7 . D A R D IK , H .; IB R A H IN , I.M .
&
D A R D IK , I.I. - T h e ro le o fth e p e ro n e a l a rte ry fo r lim b sa lv a g e , A n n S u rg 1 8 9 : 1 8 9 ,
1 9 7 9 .
8 . G IB B O N S , G .W . - T h e d ia b e tic fo o t: a m p u ta tio n s a n d
d ra in a g e o f in fe c tio n .
J
V a sc S u rg 5 :7 9 1 -7 9 , 1 9 8 7 .9 . K IL O , C .; V O G L E R , N . & W IL L IA M S O N , 1 .R . - M u sc le
c a p ila ry b a se m e n t m e m b ra n e c h a n g e s re la te d to a g in g a n d
to d ia b e te s m e llitu s. D ia b e te s 2 1 : 8 8 1 -8 8 5 , 1 9 7 5 .
1 0 . L A N G E R , B . - E d ito ria l: A th e ro sc le ro se o b lite ra n te
p e rife ric a . R e v P a u l M e d 1 0 8 : 1 9 5 -1 9 9 , 1 9 9 0 .
1 1 . L E V IN , M .E .
&
O 'N E A L , L .W . - T h e d ia b e tic fo o t. S t.L o u is, M isso u ri. M o sb y , 1 9 8 8 .
1 2 . L O G E R F O , F .W .
&
C O F F M A N , J.D . - V a sc u la r a n dm ic ro v a sc u la r d ise a se o f th e fo o t in d ia b e te s. N E n g l
J
M e d3 1 1 : 1 6 1 5 , 1 9 8 4 .
1 3 . P A L U M B O , P J.
&
M E L T O N , L .1 . -III: P e rip h e ra l v a sc u la rd ise a se a n d d ia b e te s. In H a rris, M .l., a n d H a m m a n , R .F .,
e d ito rs: D ia b e te s in A m e ric a , N IH P u b . N o 8 5 -1 4 6 8 ,
B e th e sd a , M d ., 1 9 8 5 , U .S . D e p a rtm e n t o f H e lth a n d H u m a n
S e rv ic e s, N a tio n a l In stitu te s o f H e a lth , N a tio n a l In stitu te o f
A rth ritis, D ia b e te s, a n d D ig e sti v e a n d K id n e y D ise a se s.
1 4 . R O S E N Q V IS T , U . - A n e p id e m io lo g ic a l su rv e y o f d ia b e tic
fo o t p ro b le m s in th e S to c k h o lm C o u n ty . A c ta M e d S c a n d
S u p p I6 8 7 (S u p p l): 5 5 , 1 9 8 4 .
1 5 . S C H U L E R , 1 .1 .;F L A N IG A N , P .; W IL L IA M S , L .R .; R Y A N ,
T .T .
&
C A S T R O N U O V O , J.J. - E a rly e x p e rie n c e w ithp o p lite a l to in fra p o p lite a l b y p a ss fo r lim b sa lv a g e . A rc h S u 'rg
1 1 8 :4 7 2 , 1 9 8 3 .
1 6 . S IZ E R , J.S .
&
W H E E L O C K , F .C . - D ig ita l a m p u ta tio n s ind ia b e tic p a tie n ts. S u rg e ry 7 2 : 9 8 0 , 1 9 7 2 .
