Minimally invasive offloading osteotomy in the treatment of diabetic foot ulcer: Analysis of 25 patients

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Panel B: anteroposterior radiograph of the loaded foot, the arrows point to the osteotomies performed on the second and third metatarsal. Panel C: Appearance at 23 days." ] ] ] "textoCompleto" => "IntroductionDiabetes mellitus (DM) is a global pandemic that has shown a significant increase in prevalence and incidence in recent years. It is one of the major health problems due to its morbidity and mortality and high economic cost.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Chronic complications, together with acute decompensation of DM, account for a large part of the cost of the disease to the National Health System (NHS). In 2012, the impact of DM on national healthcare expenditure was 5809 million euros, 8.2% of total expenditure. Spending on complications amounted to 2143 million euros, which represents 37% of the total expenditure on the disease.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>About 25% of patients with DM will develop a diabetic foot ulcer (DFU) in their lifetime. In developed countries, the prevalence of DFU varies between 1 and 11% and its annual incidence is around 2%, with 60% associated with peripheral arterial disease (PAD). The most serious consequence of DFU, after the associated mortality, is amputation. Approximately 1% of patients with DM suffer a lower limb amputation and 85% of these are preceded by an ulcer.<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>There are 3 types of off-loading: temporary off-loading, which is applied when there is an active ulcer (e.g. adhesive felts); definitive off-loading, which is applied when the ulcer has healed (e.g. off-loading plantar orthoses); and surgical off-loading (e.g. off-loading osteotomy), which is indicated when there is an area of a hyperpressure, or an ulcer without osteomyelitis that cannot be corrected with the other types of off-loading.<a class="elsevierStyleCrossRefs" href="#bib0025">5,6</a>In this study we will describe the results of a series of patients in whom off-loading osteotomy has been used as a therapeutic procedure.Patients and methodsRetrospective descriptive study of a series of 23 patients with DM having a total of 25 neuropathic ulcers refractory to previous treatment (18) or pre-ulcerous lesions (7) as a complication of the disease. They underwent minimally invasive outpatient surgery to relieve pressure on the foot. The data were obtained from a clinical care database at our centre, including operations performed in the last 3 years. Patients underwent follow-up for a minimum of 12 months.The interventions were performed on an outpatient basis in the Endocrinology and Nutrition department, with an average duration of 45 min.The variables collected were: age, sex, body mass index (BMI), smoking, HTN, type of DM, years of DM duration, mean HbA1c in the last year, hospital admissions due to DF complications, mean length of hospital stays, time of evolution of DFU, time of resolution of DFU after intervention and immediate complications due to the intervention.For the review of the data, a descriptive statistical analysis was performed, obtaining: mean ± standard deviation (SD), median (plus interquartile range [IQR]) and percentages for qualitative data.ResultsA total of 25 interventions (right side 52%) in 23 patients were included. The baseline characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The presence of chronic diabetes complications is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Of the entire series, a total of 18 ulcers were refractory to previous conservative treatment with a median duration of 16 months (IQR 6−24 months). Ulcers were reported to have been present for a median of 20.5 months (IQR 7.25–42 months). The median ulcer area was 1.53 cm2 (IQR 0.63−2.83 cm2).The remaining 7 interventions were performed on patients who had undergone a previous ostectomy to achieve resolution of a DFU and it was decided to perform an osteotomy to prevent the development of a new DFU when a point of overload was detected in the foot.The results of the osteotomy response are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Of the total number of cases, only 3 had a mild infection in the site of intervention, which resolved with 7–14 day oral antibiotic therapy. All were diagnosed with PAD.Before being treated with off-loading osteotomy, 69.5% of the patients had suffered at least one diabetic foot infection that required hospitalisation and 31.2% of these patients were readmitted on at least one other occasion for this reason. In our series, prior to off-loading osteotomy, there were a total of 28 infections, involving 474 days of hospitalisation, with a mean of 1.22 ± 0.52 hospital admissions per patient and 16.92 days of hospitalisation. Within our series we found a mean of 0.69 ± 0.33 amputations prior to the intervention, there were 11 patients with previous amputation with a total of 16 amputations.The following figure shows the changes in one of the cases in our series. Patient with a neuropathic ulcer in the second and third metatarsal, secondary to overloading due to previous amputation of the first radius (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, panel A). The X-ray shows the osteotomies and hypertrophy of the metatarsal cortex due to overloading (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, panel B). After 23 days, no area of hyperpressure and resolved ulcer (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, panel C).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>DiscussionBefore starting the study we conducted a literature search in Pubmed where we found few case series assessing the efficacy of metatarsal osteotomies in patients with DFU, with a meta-analysis of 4 studies with a total of 119 patients being the most relevant publication.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Regarding the results of this study, the success rate is found to be 100% for ulcer healing, with an ulcer resolution time of 3.2 ± 1.01 weeks (median 3 weeks, IQR 2.14–4 weeks) and 16.6% for DFU transfer. It is worth mentioning that in minimally invasive osteotomies one of the most common complications is local infection, which usually occurs in the immediate postoperative period. In our series it occurred in 12% of cases, and was resolved on an outpatient basis with oral antibiotic therapy for 7–14 days. In any case, infections resulting from non-resolution of the diabetic foot ulcer are much more serious (cellulitis, osteomyelitis), sometimes leading to septicaemia and requiring admission to intensive care units.In the literature, series show success rates similar to those of our study, close to 99%, with a healing time of 6.5 ± 1.2 weeks and DFU transfer rates of 10.3%.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Regarding local infections in the immediate postoperative period, in studies with larger samples, infections occur in approximately 3.7% of cases.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>With regard to the cost of the interventions, we have already mentioned the high cost to the NHS of DM complications. We compared the cost of minimally invasive outpatient surgery with the cost of hospitalisation for low severity foot surgery, which were ;120 and ;5450 respectively. Obtaining the price of admission for foot surgery from the Official Gazette of the Balearic Islands (GRD number 314, severity 1, weight 0.7609) and estimating the cost of outpatient surgery, adding the cost of radiography in 2 foot projections, consumables and specific instruments, assuming that, as in our series, the operations are performed in the consulting room without the need to use an operating theatre. The cost of outpatient surgery is 2.2% of the cost of an admission for foot surgery.Secondary prevention is crucial, as all patients in this study had a previous history of DFU or amputations, therefore, a follow-up carried out in a diabetic foot unit by an expert podiatrist could prevent recurrences and compensate for new points of hyperpressure after load redistribution.The main limitations of this study are the retrospective design, which limits the available data to those recorded in the past, the small sample size and the fact that it is a case series without a comparator arm, which makes it difficult to generalise the statistical results obtained.ConclusionsMinimally invasive outpatient off-loading osteotomy is a technically simple procedure with a high success rate and minimal complications in our series, in line with results previously published in the literature.<a class="elsevierStyleCrossRefs" href="#bib0035">7–9</a>It is the technique of choice for recurrent and recalcitrant ulcers, with rapid resolution of the ulcers after the procedure. As it is performed in the doctor's office, it considerably reduces costs and waiting time for the intervention.Secondary prevention is crucial, as all patients in this study had a previous history of DFU or amputations.Ethical considerationsThe authors declare that no patient data appear in this article.FundingNo funding has been obtained.Conflict of interestNone." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres2149155" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material, methods and objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1824132" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2149156" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material, métodos y objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1824131" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Ethical considerations" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-07-08" "fechaAceptado" => "2023-11-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1824132" "palabras" => array:5 [ 0 => "Amputation" 1 => "Diabetic foot ulcer" 2 => "Minimally invasive surgery" 3 => "Offloading osteotomy" 4 => "Osteomyelitis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1824131" "palabras" => array:5 [ 0 => "Amputación" 1 => "Úlcera del pie diabético" 2 => "Cirugía mínimamente invasiva" 3 => "Osteotomía de descarga" 4 => "Osteomielitis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionDiabetes mellitus and its complications are one of the main burdensome health problems at the present time. The diabetic foot is one of the most characteristic complications. Material, methods and objectiveThe objective of this work is to describe the results and complications obtained in a series of 25 cases of diabetic foot treated by minimally invasive offloading osteotomies. ResultsOf the total number of interventions, 18 were performed on refractory ulcers with prior conservative treatment, for a mean (±SD) duration of 29.28 ± 18.42 months. The mean follow-up period was 26.46 ± 4.89 months. Weighted pooled rates of response to treatment were as follows: 100% for ulcer healing (with a mean healing time of 22.41 ± 7.01 days), 5.56% for ulcer recurrence, and 16.67% for ulcer transfer. In 7 cases, a preventive intervention was performed on areas with pre-ulcerative lesions. Of the total number of cases, only 3 presented mild infection in the intervention area. ConclusionsMinimally invasive offloading osteotomy is a technically simple intervention, which presents a high success rate with minimal complications in our series." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material, methods and objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa diabetes mellitus y sus complicaciones suponen uno de los mayores problemas sanitarios en la actualidad. La úlcera del pie diabético es una de las complicaciones más características. Material, métodos y objetivoEl objetivo es describir los resultados y complicaciones obtenidos en una serie de 25 casos de úlcera neuropática tratada mediante osteotomías de descarga mínimamente invasivas y ambulatorias. ResultadosDel total de intervenciones, 18 fueron sobre úlceras refractarias a un tratamiento conservador previo de una duración media ± desviación estándar de 29,28 ± 18,42 meses. El período de seguimiento fue 26,46 ± 4,89 meses. Las tasas agrupadas de respuesta al tratamiento fueron: 100% cicatrización de la úlcera (tiempo medio de cicatrización 22,41 ± 7,01 días), 5,56% recurrencia de la úlcera, 16,67% translocación de la úlcera. En 7 casos se realizó una intervención preventiva sobre áreas con lesiones pre-ulcerosas. Del total, únicamente 3 presentaron infección leve en la zona de la intervención. ConclusionesLa osteotomía de descarga mínimamente invasiva ambulatoria es un procedimiento técnicamente sencillo, que presenta una alta tasa de éxito con mínimas complicaciones en nuestra serie." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material, métodos y objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 892 "Ancho" => 1340 "Tamanyo" => 149050 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Panel A: the arrow points to a neuropathic ulcer with a large mechanical component. Panel B: anteroposterior radiograph of the loaded foot, the arrows point to the osteotomies performed on the second and third metatarsal. Panel C: Appearance at 23 days." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (53−65.50) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex (% male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BMI (kg/m)2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 (29.40−35.50) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HTN (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">69.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM1 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM2 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other types DM (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of DM (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 (12−20.75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HbA1c (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.50 (6.70−8.35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.99 (0.78−1.33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Glomerular filtration rate (ml/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">79 (54−99) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3541867.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Baseline patient characteristics (n = 23)." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nephropathy (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (11/22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ischaemic heart disease (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (3/23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cerebrovascular disease (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 (1/23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Retinopathy (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">73.7 (14/19) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peripheral arterial disease (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52.2 (12/23) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Peripheral polyneuropathy (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 (23/23) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3541869.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Chronic DM complications." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous ulcer (n = 18) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preventive (n = 7) \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulcer area (cm)2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.53 (0.63−2.83) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative treatment time (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (6−24) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Resolution time after intervention (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 (15−28) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulcer healing after surgery (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications after surgery (%)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulcer recurrence (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.88 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ulcer transfer (%)<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16.67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up time (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24.20 (19.60−30.50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26.90 (24.46−31.68) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3541868.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Local infection. 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Clinical report

Minimally invasive offloading osteotomy in the treatment of diabetic foot ulcer: Analysis of 25 patients

Osteotomía de descarga ambulatoria mínimamente invasiva en el tratamiento de la úlcera de pie diabético: análisis de 25 pacientes

José Vicente Gil Boixa,

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josevicente_gil_boix@hotmail.com

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, Melchor Lladó Vidala, Elena Mena Ribasa, Jordi Viadé Juliàb, Francisco Javier Fanjul Losac, Santiago Tofé Povedanoa

a Servicio de Endocrinología y Nutrición, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain

b Servicio de Endocrinología y Nutrición, Hospital Universitario Trias i Pujol, Badalona, Barcelona, Spain

c Servicio de Medicina Interna, Hospital Universitario Son Espases, Palma, Balearic Islands, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Panel A&#58; the arrow points to a neuropathic ulcer with a large mechanical component&#46; Panel B&#58; anteroposterior radiograph of the loaded foot&#44; the arrows point to the osteotomies performed on the second and third metatarsal&#46; Panel C&#58; Appearance at 23 days&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus &#40;DM&#41; is a global pandemic that has shown a significant increase in prevalence and incidence in recent years&#46; It is one of the major health problems due to its morbidity and mortality and high economic cost&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Chronic complications&#44; together with acute decompensation of DM&#44; account for a large part of the cost of the disease to the National Health System &#40;NHS&#41;&#46; In 2012&#44; the impact of DM on national healthcare expenditure was 5809 million euros&#44; 8&#46;2&#37; of total expenditure&#46; Spending on complications amounted to 2143 million euros&#44; which represents 37&#37; of the total expenditure on the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">About 25&#37; of patients with DM will develop a diabetic foot ulcer &#40;DFU&#41; in their lifetime&#46; In developed countries&#44; the prevalence of DFU varies between 1 and 11&#37; and its annual incidence is around 2&#37;&#44; with 60&#37; associated with peripheral arterial disease &#40;PAD&#41;&#46; The most serious consequence of DFU&#44; after the associated mortality&#44; is amputation&#46; Approximately 1&#37; of patients with DM suffer a lower limb amputation and 85&#37; of these are preceded by an ulcer&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are 3 types of off-loading&#58; temporary off-loading&#44; which is applied when there is an active ulcer &#40;e&#46;g&#46; adhesive felts&#41;&#59; definitive off-loading&#44; which is applied when the ulcer has healed &#40;e&#46;g&#46; off-loading plantar orthoses&#41;&#59; and surgical off-loading &#40;e&#46;g&#46; off-loading osteotomy&#41;&#44; which is indicated when there is an area of a hyperpressure&#44; or an ulcer without osteomyelitis that cannot be corrected with the other types of off-loading&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this study we will describe the results of a series of patients in whom off-loading osteotomy has been used as a therapeutic procedure&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Retrospective descriptive study of a series of 23 patients with DM having a total of 25 neuropathic ulcers refractory to previous treatment &#40;18&#41; or pre-ulcerous lesions &#40;7&#41; as a complication of the disease&#46; They underwent minimally invasive outpatient surgery to relieve pressure on the foot&#46; The data were obtained from a clinical care database at our centre&#44; including operations performed in the last 3 years&#46; Patients underwent follow-up for a minimum of 12 months&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The interventions were performed on an outpatient basis in the Endocrinology and Nutrition department&#44; with an average duration of 45&#8239;min&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The variables collected were&#58; age&#44; sex&#44; body mass index &#40;BMI&#41;&#44; smoking&#44; HTN&#44; type of DM&#44; years of DM duration&#44; mean HbA1c in the last year&#44; hospital admissions due to DF complications&#44; mean length of hospital stays&#44; time of evolution of DFU&#44; time of resolution of DFU after intervention and immediate complications due to the intervention&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For the review of the data&#44; a descriptive statistical analysis was performed&#44; obtaining&#58; mean&#8239;&#177;&#8239;standard deviation &#40;SD&#41;&#44; median &#40;plus interquartile range &#91;IQR&#93;&#41; and percentages for qualitative data&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">A total of 25 interventions &#40;right side 52&#37;&#41; in 23 patients were included&#46; The baseline characteristics of the patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The presence of chronic diabetes complications is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Of the entire series&#44; a total of 18 ulcers were refractory to previous conservative treatment with a median duration of 16 months &#40;IQR 6&#8722;24 months&#41;&#46; Ulcers were reported to have been present for a median of 20&#46;5 months &#40;IQR 7&#46;25&#8211;42 months&#41;&#46; The median ulcer area was 1&#46;53&#8239;cm<span class="elsevierStyleSup">2</span> &#40;IQR 0&#46;63&#8722;2&#46;83&#8239;cm<span class="elsevierStyleSup">2</span>&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The remaining 7 interventions were performed on patients who had undergone a previous ostectomy to achieve resolution of a DFU and it was decided to perform an osteotomy to prevent the development of a new DFU when a point of overload was detected in the foot&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The results of the osteotomy response are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">Of the total number of cases&#44; only 3 had a mild infection in the site of intervention&#44; which resolved with 7&#8211;14 day oral antibiotic therapy&#46; All were diagnosed with PAD&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Before being treated with off-loading osteotomy&#44; 69&#46;5&#37; of the patients had suffered at least one diabetic foot infection that required hospitalisation and 31&#46;2&#37; of these patients were readmitted on at least one other occasion for this reason&#46; In our series&#44; prior to off-loading osteotomy&#44; there were a total of 28 infections&#44; involving 474 days of hospitalisation&#44; with a mean of 1&#46;22&#8239;&#177;&#8239;0&#46;52 hospital admissions per patient and 16&#46;92 days of hospitalisation&#46; Within our series we found a mean of 0&#46;69&#8239;&#177;&#8239;0&#46;33 amputations prior to the intervention&#44; there were 11 patients with previous amputation with a total of 16 amputations&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The following figure shows the changes in one of the cases in our series&#46; Patient with a neuropathic ulcer in the second and third metatarsal&#44; secondary to overloading due to previous amputation of the first radius &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; panel A&#41;&#46; The X-ray shows the osteotomies and hypertrophy of the metatarsal cortex due to overloading &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; panel B&#41;&#46; After 23 days&#44; no area of hyperpressure and resolved ulcer &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; panel C&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Before starting the study we conducted a literature search in Pubmed where we found few case series assessing the efficacy of metatarsal osteotomies in patients with DFU&#44; with a meta-analysis of 4 studies with a total of 119 patients being the most relevant publication&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding the results of this study&#44; the success rate is found to be 100&#37; for ulcer healing&#44; with an ulcer resolution time of 3&#46;2&#8239;&#177;&#8239;1&#46;01 weeks &#40;median 3 weeks&#44; IQR 2&#46;14&#8211;4 weeks&#41; and 16&#46;6&#37; for DFU transfer&#46; It is worth mentioning that in minimally invasive osteotomies one of the most common complications is local infection&#44; which usually occurs in the immediate postoperative period&#46; In our series it occurred in 12&#37; of cases&#44; and was resolved on an outpatient basis with oral antibiotic therapy for 7&#8211;14 days&#46; In any case&#44; infections resulting from non-resolution of the diabetic foot ulcer are much more serious &#40;cellulitis&#44; osteomyelitis&#41;&#44; sometimes leading to septicaemia and requiring admission to intensive care units&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the literature&#44; series show success rates similar to those of our study&#44; close to 99&#37;&#44; with a healing time of 6&#46;5&#8239;&#177;&#8239;1&#46;2 weeks and DFU transfer rates of 10&#46;3&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Regarding local infections in the immediate postoperative period&#44; in studies with larger samples&#44; infections occur in approximately 3&#46;7&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">With regard to the cost of the interventions&#44; we have already mentioned the high cost to the NHS of DM complications&#46; We compared the cost of minimally invasive outpatient surgery with the cost of hospitalisation for low severity foot surgery&#44; which were &#59;120 and &#59;5450 respectively&#46; Obtaining the price of admission for foot surgery from the Official Gazette of the Balearic Islands &#40;GRD number 314&#44; severity 1&#44; weight 0&#46;7609&#41; and estimating the cost of outpatient surgery&#44; adding the cost of radiography in 2 foot projections&#44; consumables and specific instruments&#44; assuming that&#44; as in our series&#44; the operations are performed in the consulting room without the need to use an operating theatre&#46; The cost of outpatient surgery is 2&#46;2&#37; of the cost of an admission for foot surgery&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Secondary prevention is crucial&#44; as all patients in this study had a previous history of DFU or amputations&#44; therefore&#44; a follow-up carried out in a diabetic foot unit by an expert podiatrist could prevent recurrences and compensate for new points of hyperpressure after load redistribution&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">The main limitations of this study are the retrospective design&#44; which limits the available data to those recorded in the past&#44; the small sample size and the fact that it is a case series without a comparator arm&#44; which makes it difficult to generalise the statistical results obtained&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0115" class="elsevierStylePara elsevierViewall">Minimally invasive outpatient off-loading osteotomy is a technically simple procedure with a high success rate and minimal complications in our series&#44; in line with results previously published in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">It is the technique of choice for recurrent and recalcitrant ulcers&#44; with rapid resolution of the ulcers after the procedure&#46; As it is performed in the doctor&#39;s office&#44; it considerably reduces costs and waiting time for the intervention&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Secondary prevention is crucial&#44; as all patients in this study had a previous history of DFU or amputations&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical considerations</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">No funding has been obtained&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Diabetes mellitus and its complications are one of the main burdensome health problems at the present time&#46; The diabetic foot is one of the most characteristic complications&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material&#44; methods and objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The objective of this work is to describe the results and complications obtained in a series of 25 cases of diabetic foot treated by minimally invasive offloading osteotomies&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Of the total number of interventions&#44; 18 were performed on refractory ulcers with prior conservative treatment&#44; for a mean &#40;&#177;SD&#41; duration of 29&#46;28&#8239;&#177;&#8239;18&#46;42 months&#46; The mean follow-up period was 26&#46;46&#8239;&#177;&#8239;4&#46;89 months&#46; Weighted pooled rates of response to treatment were as follows&#58; 100&#37; for ulcer healing &#40;with a mean healing time of 22&#46;41&#8239;&#177;&#8239;7&#46;01 days&#41;&#44; 5&#46;56&#37; for ulcer recurrence&#44; and 16&#46;67&#37; for ulcer transfer&#46; In 7 cases&#44; a preventive intervention was performed on areas with pre-ulcerative lesions&#46; Of the total number of cases&#44; only 3 presented mild infection in the intervention area&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Minimally invasive offloading osteotomy is a technically simple intervention&#44; which presents a high success rate with minimal complications in our series&#46;</p></span>"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La diabetes mellitus y sus complicaciones suponen uno de los mayores problemas sanitarios en la actualidad&#46; La &#250;lcera del pie diab&#233;tico es una de las complicaciones m&#225;s caracter&#237;sticas&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material&#44; m&#233;todos y objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El objetivo es describir los resultados y complicaciones obtenidos en una serie de 25 casos de &#250;lcera neurop&#225;tica tratada mediante osteotom&#237;as de descarga m&#237;nimamente invasivas y ambulatorias&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Del total de intervenciones&#44; 18 fueron sobre &#250;lceras refractarias a un tratamiento conservador previo de una duraci&#243;n media&#8239;&#177;&#8239;desviaci&#243;n est&#225;ndar de 29&#44;28&#8239;&#177;&#8239;18&#44;42 meses&#46; El per&#237;odo de seguimiento fue 26&#44;46&#8239;&#177;&#8239;4&#44;89 meses&#46; Las tasas agrupadas de respuesta al tratamiento fueron&#58; 100&#37; cicatrizaci&#243;n de la &#250;lcera &#40;tiempo medio de cicatrizaci&#243;n 22&#44;41&#8239;&#177;&#8239;7&#44;01 d&#237;as&#41;&#44; 5&#44;56&#37; recurrencia de la &#250;lcera&#44; 16&#44;67&#37; translocaci&#243;n de la &#250;lcera&#46; En 7 casos se realiz&#243; una intervenci&#243;n preventiva sobre &#225;reas con lesiones pre-ulcerosas&#46; Del total&#44; &#250;nicamente 3 presentaron infecci&#243;n leve en la zona de la intervenci&#243;n&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La osteotom&#237;a de descarga m&#237;nimamente invasiva ambulatoria es un procedimiento t&#233;cnicamente sencillo&#44; que presenta una alta tasa de &#233;xito con m&#237;nimas complicaciones en nuestra serie&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material&#44; m&#233;todos y objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 892
            "Ancho" => 1340
            "Tamanyo" => 149050
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Panel A&#58; the arrow points to a neuropathic ulcer with a large mechanical component&#46; Panel B&#58; anteroposterior radiograph of the loaded foot&#44; the arrows point to the osteotomies performed on the second and third metatarsal&#46; Panel C&#58; Appearance at 23 days&#46;</p>"
        ]
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      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;53&#8722;65&#46;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex &#40;&#37; male&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BMI &#40;kg&#47;m&#41;<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32 &#40;29&#46;40&#8722;35&#46;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Smoking &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HTN &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">69&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM2 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other types DM &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of DM &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;12&#8722;20&#46;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HbA1c &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;50 &#40;6&#46;70&#8722;8&#46;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Creatinine &#40;mg&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;99 &#40;0&#46;78&#8722;1&#46;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Glomerular filtration rate &#40;ml&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79 &#40;54&#8722;99&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3541867.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Baseline patient characteristics &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;23&#41;&#46;</p>"
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      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nephropathy &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;11&#47;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ischaemic heart disease &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;3&#47;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cerebrovascular disease &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;3 &#40;1&#47;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Retinopathy &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;7 &#40;14&#47;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Peripheral arterial disease &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52&#46;2 &#40;12&#47;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Peripheral polyneuropathy &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100 &#40;23&#47;23&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab3541869.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Chronic DM complications&#46;</p>"
        ]
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      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Table "
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Previous ulcer &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preventive &#40;<span class="elsevierStyleItalic">n</span>&#8239;&#61;&#8239;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ulcer area &#40;cm&#41;<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;53 &#40;0&#46;63&#8722;2&#46;83&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Conservative treatment time &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;6&#8722;24&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">21 &#40;15&#8722;28&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Ulcer healing after surgery &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">5&#46;56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">5&#46;88&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">16&#46;67&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                      "titulo" => "IDF Diabetes Atlas&#58; Global&#44; regional and country-level diabetes prevalence estimates for 2021 and projections for 2045"
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                          "etal" => true
                          "autores" => array:6 [
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                            3 => "M&#46; Pinkepank"
                            4 => "K&#46; Ogurtsova"
                            5 => "B&#46;B&#46; Duncan"
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                            1 => "M&#46; Brosa"
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                            3 => "S&#46;A&#46; Bus"
                            4 => "R&#46;J&#46; Hinchliffe"
                            5 => "B&#46;A&#46; Lipsky"
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                          "etal" => false
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Article information

ISSN: 23870206
Original language: English

DOI:10.1016/j.medcle.2023.11.013

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