Treatment of diabetic (neuropathic) foot ulcers with two-stage debridement and closure

We reviewed 33 patients with 37 wounds treated between November of 1991 and December of 1995 in the Wound Care Center. A two-stage debridement and closure technique for neuropathic foot ulcers was performed. Patients selected included those with obvious osteomyelitis and those who had failed nonsurgical treatment. The approach included initial surgical excision of the ulcer with biopsy, bone resection with biopsy, and deep culture. The second-stage procedure 4 to 8 days later included debridement of the wound and delayed closure. Intravenous antibiotic treatment using a central line was given postoperatively in patients with documented osteomyelitis for at least 6 weeks and in patients with infected soft tissues only for about 4 weeks. All patients remained nonweightbearing for 4 weeks; this was felt necessary to prevent separation of the wound edges. Four wounds in four patients failed to heal, and two of these went on to amputation. Satisfactory healing occurred in 29 of 33 patients and in 33 of 37 wounds. The authors conclude that two-stage surgical debridement and closure is an acceptable treatment in selected nonhealing diabetic (neuropathic) foot ulcers.

Detection of osteomyelitis in the neuropathic foot: nuclear medicine, MRI and conventional radiography

The diagnostic efficacy of (1) combined three-phase bone scintigraphy and In-111 labeled WBC scintigraphy (Bone/WBC), (2) MRI, and (3) conventional radiography in detecting osteomyelitis of the neuropathic foot was compared. Conventional radiography was comparable to MRI for detection of osteomyelitis. MRI best depicted the presence of osteomyelitis in the forefoot. Particularly in the setting of Charcot joints, Bone/WBC was more specific than conventional radiography or MRI.

Surgical treatment of neuroarthropathic foot deformity

Twenty-seven feet with neuroarthropathic fracture resulting in significant deformity were treated with surgical reconstruction. The average age of the patients was 57 years with 21 patients having diabetes mellitus an average of 24 years. Five patterns of midfoot collapse were identified. The most common patterns involved abduction and dorsal displacement of the forefoot with equinus of the hindfoot. Preoperative evaluation included a medical assessment, adequate control of blood sugar, and a comprehensive vascular evaluation. Five patients presented for surgical consultation with open plantar ulcers. Four were healed with total contact casting alone whereas one patient required an exostectomy to heal the ulcer before surgery. After reconstruction, all feet had improvement in their weightbearing posture. For feet with midfoot involvement, the average anteroposterior talo-first metatarsal angle increased 5 degrees, and the average lateral talo-first metatarsal angle decreased 6.5 degrees. There was no significant loss of correction at long term follow-up. The average time in a cast postoperatively was 5.7 months, and the time to unrestricted weightbearing was 7 months. All patients were able to wear over-the-counter footwear postoperatively. Significant complications included six nonunions and two feet with extension of the neuroarthropathic process. One nonunion required revision surgery, and the feet with extension of their neuroarthropathic fractures required conversion of a triple arthrodesis to a pantalar fusion and the addition of a triple arthrodesis after a successful midfoot fusion. No infections or amputations occurred as a result of the surgery. Function increased and pain decreased as a result of successful arthrodesis. Surgical reconstruction of midfoot, hindfoot, and ankle neuroarthropathic deformity is a viable alternative to amputation for patients who fail nonoperative care. Proper preoperative evaluation and assessment will result in a rate of complications comparable to foot surgery in nondiabetic patients.

99mTc-nanocolloid scintigraphy for assessing osteomyelitis in diabetic neuropathic feet

Distinguishing osteomyelitis from neuropathic osteoarthropathy in diabetic feet is a common and difficult clinical problem with no highly accurate discriminatory investigation. This study assesses the novel use of marrow scintigraphy and compares it with magnetic resonance imaging (MRI) for the diagnosis of osteomyelitis in neuropathic osteoarthropathic diabetic feet. Nine diabetic patients with chronic foot ulcers were prospectively assessed independently using 99mTc-nanocolloid scintigraphy and MRI. Those patients showing features of osteomyelitis underwent percutaneous bone biopsy or surgical ray excision for histological confirmation. Other patients were followed up clinically for a minimum of 6 months to exclude osteomyelitis. Marrow scintigraphy, in agreement with MRI, demonstrated all four cases of biopsy proven osteomyelitis and excluded three cases with neuropathic osteoarthropathy alone. One case of suspected osteomyelitis of the ankle on marrow scintigraphy, but not MRI, was not confirmed clinically. One case of suspected osteomyelitis on both imaging modalities was shown on biopsy to demonstrate changes of avascular necrosis but not osteomyelitis. In this study 99mTc-nanocolloid scintigraphy shows a sensitivity of 100% and specificity of 60%. An important false positive result is seen with avascular necrosis, both on marrow scintigraphy and on MRI. Although larger studies are needed to evaluate this technique, 99mTc-nanocolloid marrow scintigraphy may be an alternative to MRI for assessing diabetic feet for osteomyelitis.

The use and abuse of wound care materials in the treatment of diabetic ulcerations

With the ever-increasing availability of wound care materials for use in diabetic foot ulcerations, a thorough understanding of the indications and applications of these materials is important for wound-management success. The coupling of a lack of understanding of the interaction of wound care materials and the dynamic nature of wound-healing physiology may lead to a protracted healing course that may constitute an abuse of an otherwise useful adjunct to wound healing protocols. This article provides an overview of wound care products, their indications, and possible complications of inappropriate use.

Systemic and nutritional considerations in diabetic wound healing

Metabolic and nutritional aspects of wound healing are discussed in this article, as well as the effects of both acute and chronic hyperglycemia, hyperinsulinemia, end-organ complications of diabetes, and impaired nutritional status of wound healing. Specific recommendations regarding the perioperative management of patients with diabetes mellitus are set forth, and the importance of achieving tight glucose control and overall improved metabolic control are emphasized.

Vascular evaluation of the problem diabetic foot

Ischemia plays a pivotal role in the management of the problem diabetic foot. Prompt revascularization offers the patient with diabetes with lower-extremity ischemia the best hope for limb salvage and normal ambulation. The true vascular status of the diabetic foot may be difficult to assess by clinical examination. Because of the dangers of missing correctable vascular disease, noninvasive vascular testing plays an important role in the evaluation of the problem diabetic foot. The laboratory should have documented reliability, and its results must be interpreted in the context of the patient's clinical progress. The most common laboratory error is overestimating the blood supply to the foot because of technical problems with mural calcification. Algorithms for the use of the vascular laboratory for common foot problems are presented. The vascular laboratory, although helpful, is no substitute for clinical judgement. When ischemia is suspected or when response to conservative care is poor, early vascular surgical consultation is prudent.

Tissue concentrations after a single-dose, orally administered ofloxacin in patients with diabetic foot infections

We studied the penetration of orally administered ofloxacin at the site of diabetes-related foot infections in patients with a planned debridement of the lesion. A total of nine patients received 800 mg of oral ofloxacin 120 to 150 minutes before surgery. During surgery, vital margin tissue and a serum sample were obtained. Serum and tissue concentrations of ofloxacin were measured. From seven patients sufficient amounts of tissue were obtained. Mean serum concentration was 7.0+/-3.5 mg/liter; mean tissue concentrations was 11.5+/-8.4 mg/kg. Mean serum and tissue concentrations exceed the minimal inhibitory concentration90 (MIC90) of commonly involved pathogens. This indicates that orally administered ofloxacin can be an effective treatment for infected diabetic foot lesions.

Prevalence of osteomyelitis in non-healing diabetic foot ulcers: usefulness of radiologic and scintigraphic findings

The study was conducted in order to assess the prevalence of osteomyelitis and the predictive value of radiographic (xR) and combined Tc 99-bone and leukocyte scanning (CS) findings in diabetic foot ulcers that met criteria for hospital admission (FUH). Out of 150 episodes of ulceration managed in an outpatient basis, 33 (in 28 NIDDM patients) requiring admission were evaluated. In all cases plain xR and CS were carried out. Seventeen episodes (51.5%) had a good outcome (healed or improving, at the time of the last follow up). Osteomyelitis was found in 21 episodes and 14 (66.6%) of them required an amputation. In 13 cases where xR showed characteristic radiologic changes of osteomyelitis (11 of them had a positive CS) 11 (84.6%) underwent an amputation. However, when osteomyelitis was diagnosed only by a positive CS, only 3/8 (37.5%) required a toe amputation. Severe peripheral vasculopathy was present in 44% of cases who required amputation and only in 17.6% of those who did not. We conclude that in FU underlying osteomyelitis is frequent and associated to a higher amputation rate than when no bone infection is identified (66.6 vs 17%), even when corrected for vascular status (OR 11, CI 95% 1.65-74.2), with a worse outcome when xR changes are already present.

[The "short Achilles tendon" syndrome: a new entity of the diabetic foot]

The "short Achilles tendon" syndrome, characterised by limited dorsiflexion of the tibiotarsal joint, is not well-known but could be a disposing factor for trophic disorders and plantar ulcer related to hypersupport in the diabetic subject. We report two cases of multicomplicated diabetic patients treated during several months for plantar ulcer superinfected with underlying osteoarthrits, whose course became rapidly favourable after tenotomy of the Achilles tendon. This simple surgical act can be performed in ambulatory conditions under local anaesthesia. Functional disability is negligible. The benefit of this treatment as part of the curative or preventive therapeutic arsenal for care of the diabetic foot remains to be evaluated.

Long-term aftercare and prevention of further amputation

This article discusses the recently instituted PACT (Prevention Amputation Care and Treatment) program now being used at the Cleveland Veterans Affairs Medical Center. This program is a multidisciplinary interventional prevention strategy that includes both physical and psychosocial components, addressing the long-term after-care for patients postamputation and preventive interventions for those at risk.

Toe amputations and ray resections

Loss of a part of the lower extremity is an unfortunate complication of diabetes. Indications and general principles of amputation have been established. Distal limb salvage procedures include forefoot amputation alternatives, digital amputations, and ray resections. A variety of risks and complications are associated with these procedures. Postoperative management including prosthetic and accommodative therapy may enhance the successful outcomes of these procedures.

Randomised placebo-controlled trial of granulocyte-colony stimulating factor in diabetic foot infection

BACKGROUND

Diabetic foot infections cause substantial morbidity and mortality. Neutrophil superoxide generation, a crucial part of neutrophil bactericidal activity, is impaired in diabetes. Granulocyte-colony stimulating factor (G-CSF) increases the release of neutrophils from the bone marrow and improves neutrophil function. We assessed G-CSF as adjuvant therapy for the treatment of severe foot infections in diabetic patients.

METHODS

40 diabetic patients with foot infections were enrolled in a double-blind placebo-controlled study. On admission, patients were randomly assigned G-CSF (filgrastim) therapy (n = 20) or placebo (n = 20) for 7 days. Both groups received similar antibiotic and insulin treatment. Neutrophils from the peripheral blood of these participants and from healthy controls were stimulated with opsonised zymosan, and superoxide production was measured by a spectrophotometric assay (reduction of ferricytochrome C).

FINDINGS

G-CSF therapy was associated with earlier eradication of pathogens from the infected ulcer (median 4 [range 2-10] vs 8 [2-79] days in the placebo group; p = 0.02), quicker resolution of cellulitis (7 [5-20] vs 12 [5-93] days; p = 0.03), shorter hospital stay (10 [7-31] vs 17.5 [9-100] days; p = 0.02), and a shorter duration of intravenous antibiotic treatment (8.5 [5-30] vs 14.5 [8-63] days; p = 0.02). No G-CSF-treated patient needed surgery, whereas two placebo recipients underwent to amputation and two had extensive debridement under anaesthesia. After 7 days' treatment, neutrophil superoxide production was significantly higher in the G-CSF group than in the placebo group (16.1 [4.2-24.2] vs 7.3 [2.1-11.5] nmol per 10(6) neutrophils in 30 min; p < 0.0001). G-CSF therapy was generally well tolerated.

INTERPRETATION

G-CSF treatment was associated with improved clinical outcome of foot infection in diabetic patients. This improvement may be related to an increase in neutrophil superoxide production.

A verrucous lesion on skin grafted after necrotizing fasciitis in a diabetic patient successfully treated with combined topical 5-FU and tacalcitol

Many complications of diabetes mellitus involve the feet. These include infections, neuropathy, vasculopathy, and poor wound healing. Neuropathy causes chronic pressure or friction on an area of sensory loss and occasionally causes verrucous skin lesions. We describe a diabetic patient, complicated by necrotizing fasciitis, who developed a verrucous skin lesion on a skin graft site. The verrucous skin lesion was treated successfully with combined topical 5-fluorouracil and vitamin D3 application.

An overview of foot disease associated with diabetes mellitus

The pathologic mechanisms by which diabetes creates alterations in the neural, vascular, and immunologic systems are complex. Thanks to increased knowledge, clinicians can intercede and prevent disease and disability. Appropriate glycemic control for all patients with diabetes can prevent neuropathy and vascular changes. Early detection and appropriate intervention for patients at risk for ulceration must be a part of every nurse's practice. Education of the patient or significant other must be included as part of instruction provided to those with diabetes. In contrast to the devastating results of the pathology of diabetes, these interventions seem "painfully" simple.

Clinical Observations: Use of an EVA boot in a patient with a foot ulcer

This study reports on the successful use of a protective boot in a patient with diabetic foot disease

[Diabetic foot--an attempt at defining the risk factors for amputation]

The study included 65 patients--42 males and 23 females aged 67 +/- 17 with the diabetic foot syndrome. They were divided into 2 groups: those who underwent amputation (25 patients) and 40 who were treated conservatively. Amputations were preceded most frequently by ulceration (17 cases), phlegmona (5 cases) or dry necrosis (3 cases). The high percentage of amputations in the studied patients could be explained, at least in part, by poor general condition and advanced local changes. In the group of patients, who underwent amputation--in relation to those treated conservatively a decrease in filtration function was found (46.0 +/- 24.3 vs 89.5 +/- 26.2) and a higher percentage in the prevalence of microalbuminuria or proteinuria (80% vs 45%) as well as a higher percentage of cigarettes smokers in this group (72% vs 40%). The majority of the studied patients was characterized by poor education, lack of self-control of glycaemia, no efficient metabolic control of diabetes, measured by glycated haemoglobin and the presence of neuropathy and retinopathy. In addition, in 4 patients among the whole studied group (including 1 patient who underwent amputation), diabetes was newly diagnosed. These results indicate the necessity of improving education, early diagnosis of insulin independent diabetes, more frequent foot examinations and the elimination of amputation risk factors. Prophylaxis of diabetes foot associated with the proper treatment of diabetes is a necessary condition for decreasing of the amputation rate according to St. Vincent Declaration.

Factors associated with methicillin resistance in diabetic foot infections

Methicillin-resistant staphylococcal infections often present a challenge to physicians treating patients with pedal wounds. Most methicillin-resistant Staphylococcus aureus infections have been thought of as nosocomial in origin. Several studies have identified specific modes of transmission via hospital reservoirs such as the anterior nares of the patient, inanimate objects within close proximity of the patient, and direct contamination from health care providers. Exposure of patients to these reservoirs through hospitalization has been shown to increase the patient's risk of obtaining a methicillin-resistant S. aureus infection. Diabetic patients with a high risk for foot complications may be in greater danger of developing a methicillin-resistant S. aureus infection in that repeated hospitalizations, lengthier hospital stays, and the presence of open wounds facilitate exposure to these reservoirs.

Minor amputations on the feet after revascularization for gangrene. A consecutive series of 95 limbs

A consecutive series of 89 patients (95 limbs) with gangrene were operated on with amputation of toes or some distal part of the foot after arterial reconstruction. 43 patients had diabetes. Healing was achieved in 81/82 feet when the reconstruction was open. Amputation below or above the knee was required in 4/5 limbs when the reconstruction failed. 8 patients died before healing. The median time to healing was 30 (17-452) days, after a single amputation, and 115 (36-466) days, when more than one procedure had been necessary. We concluded that amputations on the feet for gangrene usually heal after arterial reconstruction, in patients with diabetes as well as in those with arteriosclerosis. No weight bearing and control of infection are important during the early postoperative period.

The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic

The aim of this longitudinal study was to report on the clinical characteristics and treatment course of acute Charcot's arthropathy at a tertiary care diabetic foot clinic. Fifty-five diabetic subjects, with a mean age of 58.6 +/- 8.5 years, were studied. All patients were treated with serial total contact casting until quiescence. Following casting and before transfer to prescription footwear, patients were eased into unprotected weightbearing via a removable cast walker. This cohort was followed for their entire treatment course and for a mean 92.6 +/- 33.7 weeks following return to shoes. Pain was the most frequent presenting complaint in these otherwise insensate patients (76%). The mean duration of casting was 18.5 +/- 10.6 weeks. Patients returned to footwear in a mean 28.3 +/- 14.5 weeks. Nine per cent of the population had bilateral arthropathy. These subjects were casted significantly longer than the unilateral group (p < 0.02). Surgery was performed on 25% of patients, with approximately two-thirds of these procedures involving plantar exostectomies and one-third fusions of affected joints. Patients receiving surgery remained casted significantly longer than non-surgical patients (p < 0.05). Additionally, men were casted longer than women (p < 0.008). Acute Charcot's arthropathy requires prompt, uncompromising reduction in weightbearing stress. Our data show that the ambulatory total contact cast is very effective for this. Regardless of the specific treatment method instituted, it is imperative that appropriate and aggressive treatment be undertaken immediately following diagnosis to help prevent progression to a profoundly debilitating, limb-threatening deformity.

The acutely infected diabetic foot is not adequately evaluated in an inpatient setting

OBJECTIVE

To evaluate the standard of evaluation and treatment of the infected diabetic foot ulceration at a 551-bed university teaching institution.

DESIGN

A retrospective review of a 4-year consecutive sample (1991-1994).

POPULATION

Two hundred fifty-five patients who were admitted to a hospital for care of an infected diabetic foot ulceration. Patients were subdivided into the following 4 dichotomous variables: (1) whether the patient underwent a lower-extremity amputation, (2) whether the patient was admitted once or multiple times, (3) whether the patient underwent intraoperative debridement, and (4) whether the patient was admitted to medical or surgical services.

RESULTS

All groups that were evaluated had undergone a less than adequate foot examination. Of the admitted patients, 31.4% did not have their pedal pulses documented; 59.7% of the admitted patients were not evaluated for the presence or absence of protective sensation. Nearly 90% of the wounds were not evaluated for involvement of underlying structures, and foot radiographs were not performed in 32.9% of the patients. There were more blood cultures ordered (62.0%) than wound cultures (51.4%).

CONCLUSION

The results of this study highlight the need for a systematic, detailed lower-extremity examination for every diabetic patient who is admitted to a hospital, particularly those who are admitted with a primary diagnosis that involves a foot complication.

Amputation and reamputation of the diabetic foot

The authors compare the level of foot amputation by age, prevalence of arterial disease as a precipitating factor, gender, and ethnicity in persons with diabetes mellitus. Medical records were abstracted for each hospitalization for a lower extremity amputation from January 1 to December 31, 1993, in six metropolitan statistical areas in south Texas. Amputation level was defined by ICD-9-CM codes and were categorized as foot, leg, and thigh amputations. Foot-level amputations were further subcategorized as hallux or first ray, middle, fifth, multiple digit or ray, and midfoot amputations. Only the highest amputation level for each individual was used in the analysis. Of 1,043 subjects undergoing a lower extremity amputation in south Texas in the year 1993, 477 received their amputation at the level of the foot. African-Americans requiring a foot-level amputation were at significantly higher risk to undergo a midfoot-level amputation than was the rest of the population. Nearly 40% of all subjects undergoing a foot-level amputation had a previous history of amputation. However, nearly 40% of subjects undergoing foot amputations had not been diagnosed either before or during admission with peripheral arterial occlusive disease, suggesting a causal pathway dependent primarily on neuropathy. This implies that better screening of diabetic patients with appropriate risk-directed treatment at the primary care level may significantly impact the large number of preventable diabetes-related lower extremity amputations.

Conservative management of osteomyelitis in the feet of diabetic patients

Experience of conservative management of osteomyelitis in a specialized, multidisciplinary, diabetic foot clinic was reviewed. The records of all patients attending the clinic over a 10-year period were examined retrospectively, and 22 patients with overt osteomyelitis were identified. Median age was 66 (31-87) years. In 12 cases the bone infection was a complication of a pre-existing ulcer; the most prevalent organism cultured from swabs was Staphylococcus aureus. The main site of infection was the first toe. The total duration of antibiotic treatment was 12 weeks (median, range 5-72), and clindamycin was the most commonly used oral agent. Four patients did not respond to initial conservative therapy and proceeded to amputation, while 1 patient responded clinically but had a recurrence of osteomyelitis at the same site 6 years later. In the remaining 17 patients resolution of osteomyelitis was achieved with conservative management over a median period of follow-up of 27 (range 5-73) months. The success of conservative therapy with prolonged courses of oral antibiotics challenges conventional advice that excision of infected bone is essential in the management of osteomyelitis affecting the foot in diabetes.

Technetium-99-labeled leukocytes in diagnosing diabetic osteomyelitis in the foot

Hexamethylpropylamineoxine (HMPAO)-labeled leukocytes were studied to examine the scintigraphic significance of the procedure in diagnosing bone infection in patients with chronic nonhealing foot ulcerations. Fifty-two patients were scanned with Technetium-99-labeled white blood cells and scintigraphic results were compared with histological analysis, bone culture, and radiographic findings. Twenty-one patients demonstrated positive uptake with imaging and focal accumulation of leukocytes at the area of suspected infection. Sensitivity, specificity, and accuracy were calculated and found to be 86%, 90%, and 88%, respectively. Thirty-one members of the population were also scanned with Tc-99 methylene diphosphate (MDP) triphasic scintigraphy. Sensitivity equaled 91% and specificity was found to be significantly lower (40%) when compared with the leukocyte-labeled scans. Technetium-99 (HMPAO) leukocyte scintigraphs demonstrated a significantly higher specificity and accuracy rate when compared with Technetium-99 (MDP) triphasic scans.

Predialysis glycemic control is an independent predictor of clinical outcome in type II diabetics on continuous ambulatory peritoneal dialysis

OBJECTIVE

To evaluate the correlation between predialysis glycemic control and clinical outcomes for type II diabetic patients on continuous ambulatory peritoneal dialysis (CAPD).

DESIGN

Sixty type II diabetic patients on CAPD were classified into 2 groups according to the status of glycemic control. In group G (good glycemic control), more than 50% of blood glucose determinations were within 3.3-11 mmol/L and the glycosylated hemoglobin (HbA1C) level was within 5-10% at all times. In group P (poor glycemic control), fewer than 50% of blood glucose determinations were within 3.3-11 mmol/L or HbA1C level was above 10% at least once during the follow-up duration. In addition to glycemic control status, predialysis serum albumin, cholesterol levels, residual renal function, peritoneal membrane function, and the modes of glycemic control were also recorded.

SETTING

Dialysis Unit, Department of Nephrology of a single university hospital.

PATIENTS

From February 1988 to October 1995, 60 type II diabetic patients receiving CAPD for at least 3 months were enrolled.

MAIN OUTCOME MEASURES

Morbidities before and during the dialysis period, patient survival, and causes of mortality.

RESULTS

The patients with good glycemic control had significantly better survival than patients with poor glycemic control (p < 0.01). There was no significant difference in predialysis morbidity between the two groups. No significant differences were observed in patient survival between the patients with serum albumin greater than 30 g/L and those with less than 30 g/L (p = 0.77), with cholesterol levels greater or less than 5.18 mmol/L (p = 0.73), and with different peritoneal membrane solute transport characteristics evaluated by peritoneal equilibration test (p = 0.12). Furthermore, there was no significant difference in survival whether the patients controlled blood sugar by diet or with insulin (p = 0.33). Cardiovascular disease and infection were the major causes of death in both groups. Although good glycemic control predicts better survival, it does not change the pattern of mortality in diabetics maintained on CAPD.

CONCLUSIONS

Glycemic control before starting dialysis is a predictor of survival for type II diabetics on CAPD. Patients with poor glycemic control predialysis are associated with increased morbidity and shortened survival.

Wound management in the diabetic foot

The multiple opinions expressed in this Grand Rounds section make it clear that management of the diabetic patient with a foot wound is complex at best. Several significant points are repeated many times. The need for a detailed history and physical exam, accurate assessment of neurologic, vascular, metabolic status, and addressing the etiologic factor involved are all essential. All authors point to multispecialty integrated treatment protocols to produce the greatest success. Little mention is made of the use of topical agents to accelerate healing. This is due to the lack of unbiased studies, and the many available reports that demonstrate rapid healing when a complete and objective protocol is followed. The aims of this Grand Rounds are to stimulate interest in this important subject, and to provide the practitioner with a scaffold with which to build their own wound care management protocols.

The natural history of acute Charcot's arthropathy in a diabetic foot specialty clinic

The aim of this longitudinal study was to report on the clinical characteristics and treatment course of acute Charcot's arthropathy at a tertiary care diabetic foot clinic. Fifty-five diabetic subjects, with a mean age of 58.6 +/- 8.5 years, were studied. All patients were treated with serial total contact casting until quiescence. Following casting and before transfer to prescription footwear, patients were eased into unprotected weightbearing via a removable cast walker. This cohort was followed for their entire treatment course and for a mean 92.6 +/- 33.7 weeks following return to shoes. Pain was the most frequent presenting complaint in these otherwise insensate patients (76%). The mean duration of casting was 18.5 +/- 10.6 weeks. Patients returned to footwear in a mean 28.3 +/- 14.5 weeks. Nine per cent of the population had bilateral arthropathy. These subjects were casted significantly longer than the unilateral group (p < 0.02). Surgery was performed on 25 % of patients, with approximately two-thirds of these procedures involving plantar exostectomies and one-third fusions of affected joints. Patients receiving surgery remained casted significantly longer than non-surgical patients (p < 0.05). Additionally, men were casted longer than women (p < 0.008). Acute Charcot's arthropathy requires prompt, uncompromising reduction in weightbearing stress. Our data show that the ambulatory total contact cast is very effective for this. Regardless of the specific treatment method instituted, it is imperative that appropriate and aggressive treatment be undertaken immediately following diagnosis to help prevent progression to a profoundly debilitating, limb-threatening deformity.

Management of the diabetic patient: causes of leg ulceration

The diabetic patient is at risk of developing numerous complications, including foot ulceration. The ulcer may contain a neuropathic and ischaemic element. Regular preventive checks can assist in early detection of foot problems. Failing eye sight and absence of sensation often result in patients relying on the healthcare professional detecting abnormalities on their behalf. The long-term effects of foot ulceration in the diabetic patient are immobility, septicaemia and amputation. Treatment options exist for the neuropathic and ischaemic foot but they vary in complexity. Accurate assessment and early recognition of the clinical signs of neuropathy and ischaemic ulceration will ensure early detection and optimum treatment interventions for the diabetic patient.

Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults

We reviewed the hospital course of 77 diabetic and 69 nondiabetic subjects who had incision, drainage, and exploration of infected puncture wounds of the foot. Diabetics were 5 times more likely to have multiple operations and 46 times more likely to have a lower extremity amputation than nondiabetics. The interval from injury to surgery was significantly longer in diabetics than nondiabetics. Total lymphocyte count and hemoglobin, hematocrit, and albumin values were significantly lower in diabetics than in nondiabetics. Diabetic amputees had higher prevalences of nonpalpable pulses, nephropathy, neuropathy, and osteomyelitis as compared with diabetic nonamputees. The neuropathic diabetic foot is not protected by pain. When combined with other comorbid factors, this may increase morbidity associated with puncture wounds of the foot.

Relationships between measures of function, strength and walking speed in patients with diabetes and transmetatarsal amputation

OBJECTIVE

To determine the correlation between strength and functional measures, and the intercorrelation between the functional measures themselves, in a group of subjects with diabetes mellitus (DM) and transmetatarsal amputation (TMA).

DESIGN

Correlational study.

SETTING

The subjects were tested in the Applied Kinesiology Laboratory of the Program in Physical Therapy at Washington University School of Medicine, St Louis, MO, USA.

SUBJECTS

Thirty subjects with DM and TMA (mean age 61.7 +/- 11.3 years) were studied.

MAIN OUTCOME MEASURES

Function was measured using the Functional Reach Test (FR), the Physical Performance Test (PPT), the Sickness Impact Profile (SIP), and walking speed (WS) for 15.24 m. Strength measurements were taken using a hand-held dynamometer.

RESULTS

Highest correlations were found between hip extension strength and PPT: r = 0.69, FR: r = 0.45, and WS: r = 0.76, between knee extension strength and PPT: r = 0.48, and WS: r = 0.51, between hip flexion strength and PPT: r = 0.51, FR: r = 0.47, and WS: r = 0.59, between knee flexion strength and PPT: r = 0.57, and WS: r = 0.63, and between dorsiflexion strength and PPT: r = 0.49, and WS: r = 0.63. The following intercorrelations between functional measures were significant; PPT and FR: r = 0.66, PPT and SIP: r = -0.54, PPT and WS: r = 0.77, FR and WS: r = 0.54, SIP and WS: r = -0.47.

CONCLUSIONS

The relationship between measures of hip and knee muscle strength and function provides some evidence that rehabilitation should focus on strengthening hip and knee extensors and flexors to improve function. The relationships between walking speed and strength, PPT, FR and SIP suggest that the simple measure of walking speed is a useful functional test in the clinic.

Distal arterial occlusive disease in diabetes is related to medial arterial calcification

In diabetes mellitus, peripheral arterial occlusive disease predominantly affects the lower leg (tibial and peroneal vessel disease). Our study suggests that this feature is related to the presence of forefoot medial arterial calcification.

Diabetic foot complications

A case study describing the difficulties encountered by a joint vascular and diabetic foot-care team in the management of a patient with a late presentation

Soft tissue infections and the diabetic foot

Soft tissue infections are classified as local or spreading. Spreading soft tissue infections are potentially life-threatening conditions, requiring prompt diagnosis and treatment. The information presented is based on a literature review and the authors' clinical experience. Diagnosis of soft tissue infections is aimed at determining the level of infection (skin, fascia, muscle) and whether necrosis is present. The bacteriology of these infections is varied and is of secondary importance. Treatment of skin infections that have no dead tissue is with antibiotics alone. Infections at the fascial or muscle level and those with necrosis at any level require surgical debridement and adjuvant antibiotics. The feet of diabetic patients are prone to plantar forefoot ulcers associated with tissue destruction and infection. The vast majority are caused by mechanical factors. If local immune defenses are adequate, bacterial colonization occurs without infection. Most diabetic foot ulcers will respond to relief of pressure, which may require total contact casting. Antibiotics and debridement are required in infected or deep ulcers, or when the ulcer does not respond to total contact casting.

The acutely infected diabetic foot is not adequately evaluated in an inpatient setting

OBJECTIVE

To evaluate the standard of evaluation and treatment of the infected diabetic foot ulceration at a 551-bed university teaching institution.

DESIGN

A retrospective review of a 4-year consecutive sample (1991-1994).

POPULATION

Two hundred fifty-five patients who were admitted to a hospital for care of an infected diabetic foot ulceration. Patients were subdivided into the following 4 dichotomous variables: (1) whether the patient underwent a lower-extremity amputation, (2) whether the patient was admitted once or multiple times, (3) whether the patient underwent intraoperative debridement, and (4) whether the patient was admitted to medical or surgical services.

RESULTS

All groups that were evaluated had undergone a less than adequate foot examination. Of the admitted patients, 31.4% did not have their pedal pulses documented; 59.7% of the admitted patients were not evaluated for the presence or absence of protective sensation. Nearly 90% of the wounds were not evaluated for involvement of underlying structures, and foot radiographs were not performed in 32.9% of the patients. There were more blood cultures ordered (62.0%) than wound cultures (51.4%).

CONCLUSION

The results of this study highlight the need for a systematic, detailed lower-extremity examination for every diabetic patient who is admitted to a hospital, particularly those who are admitted with a primary diagnosis that involves a foot complication.

Treatment of osteomyelitis in the diabetic foot. Contribution of conservative surgery

OBJECTIVE

To compare the duration of healing of foot ulcers with osteomyelitis in diabetic patients treated by medical treatment versus medical treatment associated with conservative orthopedic surgery.

RESEARCH DESIGN AND METHODS

We entered into the study 67 diabetic patients who had a foot ulcer with osteomyelitis without ischemia requiring a peripheral arterial reconstruction. Thirty-two diabetic patients were included in a first historic group from 1986 to 1993, treated by antibiotic therapy, offloading, and wound care. Thirty-two patients were included from September 1993 to March 1995, treated by the same medical treatment and conservative orthopedic surgery.

RESULTS

The healing rate was 57% in the group treated by the medical treatment alone versus 78% in the surgical group (P < 0.008). The duration of healing was 462 +/- 98 days versus 181 +/- 30 days (P < 0.008).

CONCLUSIONS

Conservative surgery contributes to an increase in the healing rate of foot ulcers with osteomyelitis compared with a medical treatment alone.

Is prophylactic diabetic foot surgery dangerous?

Any treatment rendered to the deformed, insensate foot should be undertaken with the prime intentions of reducing the potential for future limb-threatening events and allowing the patient to continue as an ambulatory, productive member of society. The purpose of this article is to compare morbidity and outcomes of elective foot surgery among diabetics and nondiabetics with isolated toe deformities. We compared the prevalence of infection, wound complication, and recurrence of ulcers in 31 diabetics and 33 nondiabetics. All of these patients received a single proximal interphalangeal joint arthroplasty with a mean follow-up of 3 years (range 12 to 61 months). The diabetic group was divided into two subgroups: 1) insensate with deformity, but no history of ulceration, and 2) insensate with deformity and a previous history of ulceration. Diabetics with a history of ulceration were more likely to experience a postoperative infection (14.3%) than neuropathic diabetic patients with no history of ulceration (0%) and nondiabetic subjects (0%) (p = 0.04, Cl = 3.1 to 8.6). There was not a significant difference in prevalence of dehiscence among diabetic and nondiabetic groups (16.1% versus 9.1%, respectively, Cl = 0.4 to 8.8). The long-term outcomes after prophylactic surgery at a site of previous ulceration were uniformly good, with 96.3% of patients remaining ulcer-free a mean of 3 years postoperatively.

Management of diabetic foot infections, including the use of home intravenous antibiotic therapy

Osteomyelitis and soft-tissue foot infections continue to be the source of major amputations in the diabetic patient. Many of these amputations can be prevented with a prompt, aggressive, and integrated approach. Foot alterations should be appropriately investigated for osteomyelitis and culture-driven antimicrobial therapy combined with aggressive surgical intervention, including revascularization when necessary, should be pursued. This approach increases the chances for limb salvage. Early discharge from the hospital with HIVAT offers a safe and effective alternative to a prolonged hospital stay with significant cost savings in appropriately selected patients.

Update on the diagnosis and management of osteomyelitis

Osteomyelitis can be classified by duration, pathogenesis, location, extent, and host status. Bone infections are currently classified by the Waldvogel or the Cierny-Mader classification. Because the Waldvogel classification is an etiologic system and the Cierny-Mader classification is descriptive, both classifications can be simultaneously used. The Cierny-Mader classification is based on the anatomy of the bone infection and the physiology of the host. Cierny-Mader staging allows stratification of long bone osteomyelitis and the development of comprehensive treatment guidelines for each stage. Current trends in long bone osteomyelitis therapy emphasize early diagnosis and aggressive treatment. Radiographs and bone cultures are the mainstays of diagnosis. Imaging with radionuclide scans, computerized tomography, and magnetic resonance imaging are used when the diagnosis of osteomyelitis is equivocal or to help guage the extent bone and soft tissue infection. Surgical treatment involves débridement of necrotic bone and tissue, obtaining appropriate cultures, managing dead space, and, when necessary, obtaining bone stability. Medical therapy includes improving any host deficiencies, initial antibiotic selection, and antibiotic modification based on culture results. Antibiotic delivery has expanded to include effective oral agents and local therapy with antibiotics mixed in polymethylmethacrylate. Cierny-Mader staging was developed to describe long bone osteomyelitis. This staging system has to be modified to describe diabetic foot osteomyelitis and vertebral osteomyelitis. Osteomyelitis in patients with diabetes mellitus involves the bones of the feet or ankles. The vascular and neurologic status of the patient must be carefully accessed. Patients may be managed with local débridement surgery or ablative surgery plus 2 to 4 weeks of antibiotic therapy depending on whether all of the osteomyelitis is surgically removed. If the patient does not wish surgery or is not a surgical candidate, suppressive antibiotic therapy can be used. Vertebral osteomyelitis is usually hematogenous in origin. The diagnosis is made by bone cultures, histology, and radiographs. Magnetic resonance imaging and technetium scans are useful in making the diagnosis and in gauging the extent of the bone and soft tissue infection. Therapy requires parenteral antibiotic therapy and may include early surgery and stabilization. The choice of an antibiotic therapy is guided by the bone biopsy or débridement culture results.

The prevalence of neuropathic foot ulceration in Sri Lankan diabetic patients

OBJECTIVE

To determine the prevalence of diabetic neuropathy and neuropathic ulceration among patients with non-insulin dependent diabetes (NIDDM) attending a Sri Lankan diabetic clinic.

SETTING

The diabetic clinic of the General Hospital Colombo (Sri Lanka National Hospital).

RESEARCH DESIGN AND METHOD

Five hundred randomly selected diabetic patients (mean age 47.4 SD 17.59 years, 275 were males, mean duration of diabetes 5.29, SD 6.44 years) were screened for diabetic neuropathy using a neuropathy symptom score (NSS) neurological disability score (NDS) and pressure preception threshold using Semmes Weinstein monofilaments.

RESULTS

Patients with neuropathy were older (mean 55.69 years SD 14.16) than those who did not (mean 47.1 years, SD 15.05 p = 0.001) and had diabetes for a longer period (mean 7.5, SD 8 years vs 4.8 SD 5.66, p = 0.002). 123 (30.6%, 95% CI 28-32%) patients had neuropathy according to the criteria used. 51(10.2%, 95% CI 8.2-12.2%) had a foot ulcer, a history of foot ulceration or a lower extremity amputation due to neuropathic ulceration. 26(5.1%, 95% CI 3.2-7%) patients had neuropathic foot ulcers at presentation and a further 14 (2.8%, 95% CI 1.4-4.2%) had developed an ulcer within one year of diagnosis of diabetes. 24 (4.8%, 95% CI 3-6.8%) had a history of lower extremity amputation.

CONCLUSION

Neuropathic ulceration is a significant cause of morbidity in patients with NIDDM. One third of all NIDDM patients attending the clinic had a risk of foot ulceration. Preventive foot care programmes should be implemented at all diabetic clinics in Sri Lanka.

Reconstruction of the diabetic Charcot foot incorporating bone grafts

Literature is sparse concerning the topic of Charcot foot reconstruction incorporating various types of bone grafts and internal fixation. No concrete, methodical approach has yet been established to dictate under what conditions bone grafting would be applicable in Charcot joints. It is the intent of the authors to convey, through limited experience, an approach to the surgical reconstruction of the diabetic Charcot foot using bone grafting and internal fixation as it applies to the Sanders and Mrdjenovich patterns 2 and 3. Three case studies are presented with emphasis on the biomechanical examination, computerized tomography, radiographic appearance, patterns of bone and joint destruction, and types of bone grafts using internal fixation.

Efficacy of sulbactam-ampicillin for the treatment of severe diabetic foot infections

Diabetic foot infections, a frequent and serious cause of morbidity in patients with diabetes mellitus, are caused by anaerobic and aerobic bacteria. Given the fact that seriously impaired host defense factors are almost always present in these patients, bactericidal agents with a broad spectrum of antimicrobial activity are required for their treatment. Seventy-four patients with diabetic foot infections were treated with parenteral sulbactam-ampicillin (1.5 g, q.i.d.). All patients were followed-up prospectively in order to determine the efficacy and safety of sulbactam-ampicillin. The mean duration (+/- SD) of treatment in patients with osteomyelitis (n = 49) and soft tissue infections (n = 25) was 41 +/- 5 and 14 +/- 3 days, respectively. Infected limbs were amputated at various levels in 14 patients (19%). Clinical cure rates were 86% and 100% in patients with osteomyelitis and with soft tissue infection, respectively. The most frequent side effect was diarrhea and observed in 10 patients (14%). The results of the present study indicate that sulbactam-ampicillin is safe and effective in the treatment of diabetic foot infections.

Role of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections

PURPOSE

The role of magnetic resonance imaging (MRI) in the diagnosis of osteomyelitis in foot infections in diabetics was investigated. The accuracy, sensitivity, and specificity of MRI, plain radiography, and nuclear scanning were determined for diagnosing osteomyelitis, and a cost comparison was made.

METHODS

Twenty-seven patients with diabetic foot infections were studied prospectively. All patients underwent MRI and plain radiography. Twenty-two patients had technetium bone scans, and 19 patients had Indium scans. Nineteen patients had all four tests performed. Patients with obvious gangrene or a fetid foot were excluded.

RESULTS

The diagnosis of osteomyelitis was established by pathologic specimen (n = 18), bone culture (n = 3), or successful response to medical management (n = 6). Osteomyelitis was confirmed in nine of the pathologic specimens. The diagnostic sensitivity, specificity, and accuracy for MRI was 88%, 100%, and 95%, respectively, for plain radiography it was 22%, 94%, and 70%, respectively, for technetium bone scanning it was 50%, 50%, and 50%, respectively, and for Indium leukocyte scanning it was 33%, 69%, and 58%, respectively. The data were analyzed statistically with the two-tailed Fisher's exact test. MRI was the only test that was statistically significant (p < 0.01).

CONCLUSIONS

MRI appeared to be the single best test for the diagnosis of osteomyelitis associated with diabetic foot infections. It had a better diagnostic accuracy than conventional modalities and appeared to be more cost-effective than the frequently used Indium scan.

Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation?

We retrospectively evaluated the charts of 112 patients with diabetic foot infection to determine if early aggressive surgical intervention improves outcome. All patients were classified into two groups on the basis of the timing of surgical intervention and appropriate antimicrobial therapy. Group I included patients who underwent no surgical intervention during the first 3 days of hospitalization but received intravenous antimicrobial therapy, and group II included patients who underwent surgical intervention promptly and received intravenous antimicrobial therapy. Group II was further divided; group IIA included patients who underwent debridement, and group IIB included patients who underwent local limited amputation. A higher rate of patients in group I than in group II (27.6% vs. 13%, respectively; P < .01) required above-ankle amputation during the same hospitalization or subsequent admission. Overall, an aggressive surgical approach against foot infection in hospitalized diabetic patients reduced the need for above-ankle amputation and the length of hospital stay by at least 6 days. Treatment of diabetic foot infection requires the combination of early surgical treatment and antimicrobial therapy.

Monitoring neuropathic ulcer healing with infrared dermal thermometry

The purpose of this study is to prospectively evaluate skin temperatures at the site of neuropathic ulceration before, during, and after wound healing using the contralateral extremity as a physiologic control and to evaluate variables that may influence skin temperature gradients. We studied 17 male and 8 female diabetics with mean age and duration of diabetes of 52.4 +/- 11.6 years and 13.8 +/- 7.8 years with grade I (Meggitt-Wagner) plantar ulcers. All patients received weekly cast changes with wound and skin temperature assessments. After healing, all patients were fitted with prescription shoe gear. Temperatures on the ulcerated foot were higher than those on the contralateral foot on initial presentation (91.1 vs. 84.2 degrees F, t = 8.9, p < 0.0001, 95% Cl 5.3 to 8.5), but the same following healing. Patients with vibration perception thresholds greater than 45 V had wider skin temperature gradients than those with lesser degrees of sensory neuropathy (8.8 +/- 4.1 vs. 4.9 +/- 2.5 degrees F, p = 0.007). Additionally, subjects with toe brachial indices below 0.60 had greater skin temperature gradients at the site of ulceration than those with higher indices (9.4 +/- 4.0 vs. 5.8 +/- 3.4 degrees F, p = 0.01). There was not a significant difference in initial skin temperature gradients by duration of wound prior to treatment, duration of wound healing, sex, maximum plantar pressure, or hemoglobin A1C level.