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Rogero RG, Swamy S, Bettin CC. The Differentiation Between Infection and Acute Charcot. Orthop Clin North Am 2024; 55:299-309. [PMID: 38403375 DOI: 10.1016/j.ocl.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.
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Affiliation(s)
- Ryan G Rogero
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA
| | - Samhita Swamy
- University of Tennessee Health Science Center College of Medicine, 847 E Parkway S, Memphis, TN 38104, USA
| | - Clayton C Bettin
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite #510, Memphis, TN 38104, USA.
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2
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis 2023:ciad527. [PMID: 37779457 DOI: 10.1093/cid/ciad527] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/23/2023] [Indexed: 10/03/2023] Open
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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3
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Woo I, Cho SJ, Park CH. State-of-the-art update for diagnosing diabetic foot osteomyelitis: a narrative review. JOURNAL OF YEUNGNAM MEDICAL SCIENCE 2023; 40:321-327. [PMID: 37822082 PMCID: PMC10626300 DOI: 10.12701/jyms.2023.00976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/27/2023] [Accepted: 09/27/2023] [Indexed: 10/13/2023]
Abstract
Recently, the International Working Group on the Diabetic Foot and the Infectious Diseases Society of America divided diabetic foot disease into diabetic foot infection (DFI) and diabetic foot osteomyelitis (DFO). DFI is usually diagnosed clinically, while numerous methods exist to diagnose DFO. In this narrative review, the authors aim to summarize the updated data on the diagnosis of DFO. An extensive literature search using "diabetic foot [MeSH]" and "osteomyelitis [MeSH]" or "diagnosis" was performed using PubMed and Google Scholar in July 2023. The possibility of DFO is based on inflammatory clinical signs, including the probe-to-bone (PTB) test. Elevated inflammatory biochemical markers, especially erythrocyte sedimentation rate, are beneficial. Distinguishing abnormal findings of plain radiographs is also a first-line approach. Moreover, sophisticated modalities, including magnetic resonance imaging and nuclear medicine imaging, are helpful if doubt remains after a first-line diagnosis. Transcutaneous bone biopsy, which does not pass through the wound, is necessary to avoid contaminating the sample. This review focuses on the current diagnostic techniques for DFOs with an emphasis on the updates. To obtain the correct therapeutic results, selecting a proper option is necessary. Based on these numerous diagnosis modalities and indications, the proper choice of diagnostic tool can have favorable treatment outcomes.
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Affiliation(s)
- Inha Woo
- Department of Orthopaedic Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Seung Jae Cho
- Department of Orthopaedic Surgery, Yeungnam University Hospital, Daegu, Korea
| | - Chul Hyun Park
- Department of Orthopaedic Surgery, Yeungnam University College of Medicine, Daegu, Korea
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4
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Calvo-Wright MDM, Álvaro-Afonso FJ, López-Moral M, García-Álvarez Y, García-Morales E, Lázaro-Martínez JL. Is the Combination of Plain X-ray and Probe-to-Bone Test Useful for Diagnosing Diabetic Foot Osteomyelitis? A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5369. [PMID: 37629412 PMCID: PMC10455253 DOI: 10.3390/jcm12165369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
A systematic review and meta-analysis was conducted to assess the diagnostic accuracy of the combination of plain X-ray and probe-to-bone (PTB) test for diagnosing diabetic foot osteomyelitis (DFO). This systematic review has been registered in PROSPERO (a prospective international register of systematic reviews; identification code CRD42023436757). A literature search was conducted for each test separately along with a third search for their combination. A total of 18 articles were found and divided into three groups for separate analysis and comparison. All selected studies were evaluated using STROBE guidelines to assess the quality of reporting for observational studies. Meta-DiSc software was used to analyze the collected data. Concerning the diagnostic accuracy variables for each case, the pooled sensitivity (SEN) was higher for the combination of PTB and plain X-ray [0.94 (PTB + X-ray) vs. 0.91 (PTB) vs. 0.76 (X-ray)], as was the diagnostic odds ratio (DOR) (82.212 (PTB + X-ray) vs. 57.444 (PTB) vs. 4.897 (X-ray)). The specificity (SPE) and positive likelihood ratio (LR+) were equally satisfactory for the diagnostic combination but somewhat lower than for PTB alone (SPE: 0.83 (PTB + X-ray) vs. 0.86 (PTB) vs. 0.76 (X-ray); LR+: 5.684 (PTB + X-ray) vs. 6.344 (PTB) vs. 1.969 (X-ray)). The combination of PTB and plain X-ray showed high diagnostic accuracy comparable to that of MRI and histopathology diagnosis (the gold standard), so it could be considered useful for the diagnosis of DFO. In addition, this diagnostic combination is accessible and inexpensive but requires training and experience to correctly interpret the results. Therefore, recommendations for this technique should be included in the context of specialized units with a high prevalence of DFO.
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Affiliation(s)
| | - Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia and Podología, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.d.M.C.-W.); (M.L.-M.); (Y.G.-Á.); (E.G.-M.); (J.L.L.-M.)
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5
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Kabir A, Sarkar A, Barui A. Acute and Chronic Wound Management: Assessment, Therapy and Monitoring Strategies. Regen Med 2023. [DOI: 10.1007/978-981-19-6008-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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6
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Haghverdian JC, Noori N, Hsu AR. Clinical Pathway for the Management of Diabetic Foot Infections in the Emergency Department. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114221148166. [PMID: 36644108 PMCID: PMC9834778 DOI: 10.1177/24730114221148166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
| | - Naudereh Noori
- Department of Orthopaedic Surgery,
University of California-Irvine, Orange, CA, USA
| | - Andrew R. Hsu
- Department of Orthopaedic Surgery,
University of California-Irvine, Orange, CA, USA
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7
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Beyond the Wound Edge: Periwound and Regional Skin Integrity. Adv Skin Wound Care 2022; 35:527. [PMID: 36125449 DOI: 10.1097/01.asw.0000872324.54156.d8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Raspovic KM, Johnson MJ, Wukich DK. A Stepwise Approach to Nonoperative and Operative Management of the Diabetic Foot Ulceration. Phys Med Rehabil Clin N Am 2022; 33:833-844. [DOI: 10.1016/j.pmr.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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9
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Winkler E, Schöni M, Krähenbühl N, Uçkay I, Waibel FWA. Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes. Foot Ankle Int 2022; 43:957-967. [PMID: 35582923 PMCID: PMC9260474 DOI: 10.1177/10711007221088552] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited. METHODS In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome "major amputation" defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed. RESULTS Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors. CONCLUSION In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO. LEVEL OF EVIDENCE Level IV, retrospective cohort study.
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Affiliation(s)
- Elin Winkler
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland,Elin Winkler, MD, Department of
Orthopedics, Balgrist University Hospital, Forchstrasse 340, Zürich, 8008,
Switzerland.
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Nicola Krähenbühl
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and
Applied Research and Infectiology, Balgrist University Hospital, Zurich,
Switzerland
| | - Felix W. A. Waibel
- Department of Orthopedics, Balgrist
University Hospital, University of Zurich, Zurich, Switzerland
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10
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Navarro-Jiménez G, Fuentes-Santos C, Moreno-Núñez L, Alfayate-García J, Campelo-Gutierrez C, Sanz-Márquez S, Pérez-Fernández E, Velasco-Arribas M, Hervás-Gómez R, Martín-Segarra O, Losa-García JE. Experience in the use of dalbavancin in diabetic foot infection. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2022; 40:296-301. [PMID: 35490091 DOI: 10.1016/j.eimce.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To describe the clinical experience with dalbavancin in the treatment of diabetic foot infection in a multidisciplinary unit of a second level hospital. METHODS A retrospective, descriptive study was made with all patients with diabetic foot infection treated with dalbavancin in the Diabetic Foot Unit of Hospital Universitario Fundación Alcorcón, covering the period from September 2016 to December 2019. Demographic parameters and comorbidities, characteristics of the infection and treatment with dalbavancin were recorded. The cure rate is estimated at 90 days after finishing the treatment. RESULTS A total of 23 patients with diabetic foot infection (osteomyelitis) started treatment with dalbavancin, 19 were men and the mean age was 65 years. The microorganisms most frequently isolated for the indication of treatment with dalbavancin were Staphylococcus aureus (11) and Corynebacterium striatum (7). Dalbavancin was used as a second choice therapy in 22 cases, in 11 due to toxicity from other antibiotics. The median duration of treatment was 5 (4-7) weeks; the most frequent dose of dalbavancin (8 patients) was 1000 mg followed by 500 mg weekly for 5 weeks. 3 patients presented mild side effects (nausea and gastrointestinal discomfort). At 90 days after completion of dalbavancin therapy, 87% (20) of the patients were cured (95% CI: 65.2%-94.52%). CONCLUSION Patients with osteomyelitis due to gram-positive microorganisms who received as part of the multidisciplinary antibiotic treatment with dalbavancin, had a high rate of cure with adequate tolerance and few side effects. Dalbavancin offers a safe alternative in treating deep diabetic foot infection.
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Affiliation(s)
- Gema Navarro-Jiménez
- Servicio de Medicina interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain.
| | | | - Leonor Moreno-Núñez
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Jesús Alfayate-García
- Servicio de Cirugía Vascular, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | | | - Sira Sanz-Márquez
- Servicio de Farmacia, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Elia Pérez-Fernández
- Unidad de Investigación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - María Velasco-Arribas
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Rafael Hervás-Gómez
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Oriol Martín-Segarra
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Juan Emilio Losa-García
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
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11
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Álvaro-Afonso FJ, García-Morales E, López-Moral M, Alou-Cervera L, Molines-Barroso R, Lázaro-Martínez JL. Comparative Clinical Outcomes of Patients with Diabetic Foot Infection Caused by Methicillin-Resistant Staphylococcus Aureus (MRSA) or Methicillin-Sensitive Staphylococcus Aureus (MSSA). INT J LOW EXTR WOUND 2022:15347346221094994. [PMID: 35414276 DOI: 10.1177/15347346221094994] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few studies have addressed the interaction of specific pathogens with clinical outcomes in patients with diabetic foot infection (DFI). Our study aim was to compare the clinical outcomes among patients with DFI caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). We gathered the data of 75 consecutive patients admitted at specialized outpatients diabetic with mild or moderate DFI in which S. aureus was isolated from bone or soft tissue specimens in pure or as a part of the polymicrobial culture. Patients were divided into two groups: those with MRSA infection and those with MSSA infection. Patients with MRSA diabetic foot infections were significantly associated with male gender (86% vs. 64%, P = .029), higher SINBAD Classification Score (3.6 ± 0.99 points vs. 2.8 ± 1.06 points, P = .001), longer mean wound evolution [17.8 (3;29.5) weeks versus 9.1 (1;12) weeks, P = .008], bone involvement [18 (50%) versus 9 (23.1%), P = .015] and longer mean healing time [18.2(8;28) weeks versus 9.1 (1;12) weeks, P = .008]. In addition, male gender (OR 8.81, 95% CI 2.00-38.84) and SINBAD Classification Score (OR 2.70, 1.46-5.00) were identified as independent risk factors for MRSA DFI. Significant differences in the number of surgical procedures to resolve infection [15 (41.7%) versus 13 (33.3%), P = .456] or in the mean healing time after surgical treatment [10.5 weeks (6.7;16.5) versus 6.1 weeks (3;8.7), P = .068] were not observed among groups, suggesting that when treatment is based on early and surgical debridement, MRSA infections are not associated with worse prognosis. In conclusion MRSA DFI has importance in clinical outcomes such as time to healing. We propose that recent lines of research regarding the genetic virulence of strains of S. aureus could provide new insights into our results.
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Affiliation(s)
- Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Esther García-Morales
- Diabetic Foot Unit, 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Mateo López-Moral
- Diabetic Foot Unit, 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Luis Alou-Cervera
- Section of Microbiology, Department of Medicine, School of Medicine, 16734Universidad Complutense de Madrid, Madrid, Spain
| | - Raúl Molines-Barroso
- Diabetic Foot Unit, 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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12
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Morley R, Rothwell M, Stephenson J, McIlvenny L, Webb F, Barber A. Complex Foot Infection Treated With Surgical Debridement and Antibiotic Loaded Calcium Sulfate-A Retrospective Cohort Study of 137 Cases. J Foot Ankle Surg 2022; 61:239-247. [PMID: 34364760 DOI: 10.1053/j.jfas.2021.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 06/12/2021] [Accepted: 07/11/2021] [Indexed: 02/03/2023]
Abstract
Complex foot infections involving bone and soft tissue in patients with co-morbidities such as diabetes and peripheral arterial disease (PAD) are a cause of significant hospital admission. They are associated with substantial economic costs to health services worldwide. Historically, severe foot infection has been treated with surgical debridement and prolonged courses of systemic antibiotics. Prolonged systemic antibiotic use increases the risk of drug side effects, antimicrobial resistance and Clostridium difficile infection. The purpose of this study was to investigate whether surgical debridement and implantation of antibiotic loaded calcium sulfate is effective in the resolution of foot infection and wound healing. A retrospective cohort study of 137 consecutive cases of osteomyelitis (127) or significant soft tissue infection (10) over 62 months from 02/2013 to 04/2018 was conducted following local ethical approval. All cases of infection were treated with surgical debridement and local antibiotic-loaded calcium sulfate. The primary outcomes of infection resolution, time to healing and duration of postoperative antibiotics were measured. In 137 cases, 88.3% of infections resolved. Infection was eradicated in 22 patients without postoperative systemic antibiotics. About 82.5% of wounds healed, with an average healing time of 11.3 weeks. Healing time was significantly increased for the co-morbidities of diabetes and PAD (p =< .05) and for those requiring prolonged systemic postoperative antibiotics. Conservative surgical debridement and implantation of local antibiotic impregnated calcium sulfate is safe and effective in managing complex foot infections. We advocate early surgical intervention before deeper tissue involvement to help preserve lower limb structure and function.
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Affiliation(s)
- Robert Morley
- Consultant Podiatric Surgeon, Derbyshire Community Health Services NHS FT, Department of Podiatric Surgery, Buxton Hospital, Buxton, Derbyshire, UK.
| | - Matt Rothwell
- Specialist Registrar in Podiatric Surgery, Department of Health Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
| | - John Stephenson
- Senior Lecturer in Biomedical Statistics, Department of Health Sciences, University of Huddersfield, Queensgate, Huddersfield, UK
| | - Liza McIlvenny
- Head of Integrated therapies, Stockport NHS FT, Podiatry Department, Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport, UK
| | - Frank Webb
- Consultant Podiatric Surgeon, Derbyshire Community Health Services NHS FT, Department of Podiatric Surgery, Buxton Hospital, Buxton, Derbyshire, UK
| | - Aaron Barber
- Specialist Registrar in Podiatric Surgery, Stockport NHS FT, Podiatry Department, Stepping Hill Hospital, Poplar Grove, Hazel Grove, Stockport, UK
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13
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Bone and Joint Infections: The Role of Imaging in Tailoring Diagnosis to Improve Patients' Care. J Pers Med 2021; 11:jpm11121317. [PMID: 34945789 PMCID: PMC8709091 DOI: 10.3390/jpm11121317] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/28/2022] Open
Abstract
Imaging is needed for the diagnosis of bone and joint infections, determining the severity and extent of disease, planning biopsy, and monitoring the response to treatment. Some radiological features are pathognomonic of bone and joint infections for each modality used. However, imaging diagnosis of these infections is challenging because of several overlaps with non-infectious etiologies. Interventional radiology is generally needed to verify the diagnosis and to identify the microorganism involved in the infectious process through imaging-guided biopsy. This narrative review aims to summarize the radiological features of the commonest orthopedic infections, the indications and the limits of different modalities in the diagnostic strategy as well as to outline recent findings that may facilitate diagnosis.
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14
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You J, Liu C, Chen Y, Zhu W, Li H, Li L. A Bibliometric Analysis of the Top-Cited Articles on Diabetic Foot Ulcers. INT J LOW EXTR WOUND 2021:15347346211034388. [PMID: 34310226 DOI: 10.1177/15347346211034388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of this study was to determine the top-cited articles in the field of diabetic foot ulcer (DFU) research. A cross-sectional bibliometric analysis was conducted in January 2021 by using Boolean search terms in the Scopus and the Web of Science databases. The 50 top-cited articles that met the inclusion criteria were ranked and evaluated for several characteristics, including year of publication, country of origin, authorship, publishing journal, topic categories, publishing type, and level of evidence. The median number of citations per article in the list was 442 (interquartile range [IQR], 320-520), with a median of 21.8 citations (IQR, 16.5-34.5) per year since publication. The publication years ranged from 1986 to 2017, with 1998 accounting for the greatest number of studies (n = 7). The citation classics were published in 20 journals and originated from institutions in 9 countries. The majority of the studies were clinical, of which expert opinion/review with Level V evidence and clinical studies with Levels I and II evidence comprised the greater proportion in the list. This study provides useful insights into the history and development of DFU research. The top-cited list may serve as a quick reference for education curriculums and clinical practice, in addition to providing a foundation for further studies on this topic.
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Affiliation(s)
- Jiaxing You
- Department of Orthopedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Chao Liu
- Department of Orthopedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yixin Chen
- Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Weifen Zhu
- Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongye Li
- Department of Orthopedics, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Lin Li
- Department of Endocrinology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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15
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Navarro-Jiménez G, Fuentes-Santos C, Moreno-Núñez L, Alfayate-García J, Campelo-Gutierrez C, Sanz-Márquez S, Pérez-Fernández E, Velasco-Arribas M, Hervás-Gómez R, Martín-Segarra O, Losa-García JE. Experience in the use of dalbavancin in diabetic foot infection. Enferm Infecc Microbiol Clin 2021; 40:S0213-005X(20)30416-X. [PMID: 33451810 DOI: 10.1016/j.eimc.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe the clinical experience with dalbavancin in the treatment of diabetic foot infection in a multidisciplinary unit of a second level hospital. METHODS A retrospective, descriptive study was made with all patients with diabetic foot infection treated with dalbavancin in the Diabetic Foot Unit of Hospital Universitario Fundación Alcorcón, covering the period from September 2016 to December 2019. Demographic parameters and comorbidities, characteristics of the infection and treatment with dalbavancin were recorded. The cure rate was estimated at 90 days after finishing the treatment. RESULTS A total of 23 patients with diabetic foot infection (osteomyelitis) started treatment with dalbavancin, 19 were men and the mean age was 65 years. The microorganisms most frequently isolated for the indication of treatment with dalbavancin were Staphylococcus aureus (11) and Corynebacterium striatum (7). Dalbavancin was used as a second choice therapy in 22 cases, in 11 due to toxicity from other antibiotics. The median duration of treatment was 5 (4-7) weeks; the most frequent dose of dalbavancin (8 patients) was 1000mg followed by 500mg weekly for 5 weeks. 3 patients presented mild side effects (nausea and gastrointestinal discomfort). At 90 days after completion of dalbavancin therapy, 87% (20) of the patients were cured (95% CI: 65.2%-94.52%). CONCLUSION Patients with osteomyelitis due to gram-positive microorganisms who received as part of the multidisciplinary antibiotic treatment with dalbavancin, had a high rate of cure with adequate tolerance and few side effects. Dalbavancin offers a safe alternative in treating deep diabetic foot infection.
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Affiliation(s)
- Gema Navarro-Jiménez
- Servicio de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | | | - Leonor Moreno-Núñez
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Jesús Alfayate-García
- Servicio de Cirugía Vascular, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | | | - Sira Sanz-Márquez
- Servicio de Farmacia, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Elia Pérez-Fernández
- Unidad de Investigación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - María Velasco-Arribas
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Rafael Hervás-Gómez
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Oriol Martín-Segarra
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Juan Emilio Losa-García
- Sección de Enfermedades Infecciosas, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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16
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Abstract
The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the literature and propose standardized terminology for imaging findings of infection on MRI, in order to improve both communication with clinical colleagues and patient care.A definition was proposed for each term; debate followed, and the committee reached consensus. Potential controversies were raised, with formulated recommendations. The committee arrived at consensus definitions for cellulitis, soft tissue abscess, and necrotizing infection, while discouraging the nonspecific term phlegmon. For bone infection, the term osteitis is not useful; the panel recommends using terms that describe the likelihood of osteomyelitis in cases where definitive signal changes are lacking. The work was presented virtually to SSR members, who had the opportunity for review and modification prior to submission for publication.
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17
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Musculoskeletal MRI of Nontraumatic Emergencies. Top Magn Reson Imaging 2020; 29:321-330. [PMID: 33264272 DOI: 10.1097/rmr.0000000000000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A wide range of nontraumatic musculoskeletal conditions may require emergent or urgent management to avoid adverse clinical outcomes. These entities include bone and soft tissue infections, tissue necrosis, impending pathologic fracture or fungating tumor, and pseudoaneurysms. In this review, the magnetic resonance imaging appearance of these various entities is presented and discussed with the aim of improving radiologist and clinician recognition of the importance of key imaging findings in each case.
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18
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Taniguchi T, Takemoto M, Kubota Y, Motegi SI, Taniguchi A, Nakagami H, Maezawa Y, Koshizaka M, Kato H, Mori S, Tsukamoto K, Kuzuya M, Yokote K. Management guideline for Werner syndrome 2020. 5. Infection associated with Werner syndrome. Geriatr Gerontol Int 2020; 21:150-152. [PMID: 33135262 DOI: 10.1111/ggi.14073] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Minoru Takemoto
- Department of Diabetes, Metabolism and Endocrinology, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Yoshitaka Kubota
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Sei-Ichiro Motegi
- Department of Dermatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akira Taniguchi
- Department of Orthopaedic Surgery, Nara Medical University, Nara, Japan
| | - Hironori Nakagami
- Department of Health Development and Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiro Maezawa
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masaya Koshizaka
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hisaya Kato
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Seijiro Mori
- Center for the Promotion of Clinical Investigation, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Kazuhisa Tsukamoto
- Department of Internal Medicine, School of Medicine, Teikyo University, Tokyo, Japan
| | - Masafumi Kuzuya
- Department of Community Healthcare & Geriatrics, Nagoya University Graduate School of Medicine, Institutes of Innovation for Future Society, Nagoya University, Nagoya, Japan
| | - Koutaro Yokote
- Department of Endocrinology, Hematology and Gerontology, Chiba University Graduate School of Medicine, Chiba, Japan
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19
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Ferreira RC. Diabetic Foot. Part 1: Ulcers and Infections. Rev Bras Ortop 2020; 55:389-396. [PMID: 32968329 PMCID: PMC7494373 DOI: 10.1055/s-0039-3402462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/13/2019] [Indexed: 12/03/2022] Open
Abstract
Diabetes is a systemic disease that has achieved epidemic proportions in modern society. Ulcers and infections are common complications in the feet of patients with advanced stages of the disease, and are the main cause of amputation of the lower limb. Peripheral neuropathy is the primary cause of loss of the protective sensation of the feet and frequently leads to plantar pressure ulcers and osteoarticular disruption, which in turn develops into Charcot neuropathy (CN). Common co-factors that add to the morbidity of the disease and the risk of amputation in this population are obesity, peripheral arterial disease, immune and metabolic disorders. Orthopedic surgeons must be aware that the early detection and prevention of these comorbidities, through diligent medical care and patient education, can avoid these amputations.
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Affiliation(s)
- Ricardo Cardenuto Ferreira
- Grupo de Cirurgia do Pé e Tornozelo, Departamento de Ortopedia e Traumatologia da Santa Casa de Misericórdia de São Paulo, Sâo Paulo SP, Brasil
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20
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Sax AJ, Halpern EJ, Zoga AC, Roedl JB, Belair JA, Morrison WB. Predicting osteomyelitis in patients whose initial MRI demonstrated bone marrow edema without corresponding T1 signal marrow replacement. Skeletal Radiol 2020; 49:1239-1247. [PMID: 32130445 DOI: 10.1007/s00256-020-03396-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 01/20/2020] [Accepted: 02/05/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE We endeavored to determine which characteristics of diabetic ulcers portend the strongest risk for osteomyelitis in patients whose initial T1-weighted imaging was normal. By determining which features have a greater risk for osteomyelitis, clinicians can treat patients more aggressively to reduce the sequela of inadequately treated osteomyelitis. MATERIALS AND METHODS We performed a retrospective analysis of MR imaging from 60 pedal ulcers with suspected osteomyelitis. Ulcer dimensions and depth were measured. Ratios of marrow ROI/joint fluid ROI on T2/STIR sequences were obtained. Progression to osteomyelitis on subsequent MRI was characterized by loss of normal marrow signal on T1-weighted images. Statistical analysis was performed with a two-sample t test and Cox proportional hazard model. A p value < 0.05 was used as the threshold for statistical significance. RESULTS Sixty MR exams were identified. Thirty-four progressed to osteomyelitis. Marrow ROI/joint fluid ratios averaged 65% in the osteomyelitis group, and 45% in the non-osteomyelitis group, p < 0.001. ROI ratios > 53% had a 6.5-fold increased risk of osteomyelitis, p < 0.001. Proximity to bone averaged 6 mm in the osteomyelitis group and 9 mm in the non-osteomyelitis group, p = 0.02. Ulcer size averaged 4 cm2 in the osteomyelitis group versus 2.4 cm2 in the non-osteomyelitis group, p = 0.07. Ulcers greater than 3 cm2 has a 2-fold increase in the risk of osteomyelitis, p = 0.04. CONCLUSION Increasing bone marrow ROI signal/joint fluid ratios on T2/STIR images were the strongest risk factors for developing osteomyelitis, while ulcer size and depth are weaker predictors.
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Affiliation(s)
- Alessandra J Sax
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA.
| | - Ethan J Halpern
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - Adam C Zoga
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - Johannes B Roedl
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - Jeffrey A Belair
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
| | - William B Morrison
- Department of Radiology, Thomas Jefferson University Hospital, 10th Floor, 132 S. 10th Street, Philadelphia, PA, 19107, USA
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21
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An orthopaedist’s review of diabetic foot wounds and osteomyelitis. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Lee CS, Divi SN, Dirschl DR, Hynes KK. Financial Impact of Magnetic Resonance Imaging in the Surgical Treatment of Foot and Ankle Osteomyelitis. J Foot Ankle Surg 2020; 59:69-74. [PMID: 31882152 DOI: 10.1053/j.jfas.2019.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/23/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023]
Abstract
Magnetic resonance imaging (MRI) is generally considered the most sensitive imaging for diagnosis of osteomyelitis; however, it is associated with significant cost and is at times ordered as initial screening imaging when a less resource-intensive test would suffice. The purpose of this retrospective cohort study was to examine the differences between patients with osteomyelitis of the foot and ankle, and their subsequent treatment course, who underwent MRI compared with those who did not. Financial impact of MRI as it relates to clinical decision-making was also calculated. Patients treated for a diagnosis of osteomyelitis of the foot and ankle from 2009 to 2015 were retrospectively identified. Demographics, imaging modalities, and operative procedures for each patient were collected. An "impact MRI" was defined as one that led to a subsequent operative procedure within the same admission. The impact cost of an MRI was estimated using the equation: (average MRI cost) × (total MRIs/impact MRIs). A total of 144 patients underwent 220 MRIs, and 399 patients did not have MRIs. The operative rate between the 2 groups was similar (70.8% versus 70.4%, p = .93). Multiple linear regression showed that MRI was not a significant predictor of operation (p = .50). However, we found a significant correlation between MRI use and operative intervention for patients with increased comorbidities. From 2011 to 2015, there was a significant increase in impact cost, while controlling for average MRI cost ($8172 to $15,292, p ≤ .05). Over the study period, the impact cost of an MRI significantly increased from 1.8 to 5.0 times the average cost.
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Affiliation(s)
- Cody S Lee
- Medical Student, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Srikanth N Divi
- Orthopaedic Resident, Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Douglas R Dirschl
- Chairman, Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL
| | - Kelly K Hynes
- Assistant Professor, Department of Orthopaedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, IL.
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23
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Abstract
We present an approach to managing complex deformities in Charcot neuroarthropathy that typically present around the midfoot. This approach follows a stepwise progression from prevention, early detection, nonoperative through to operative management. It centers on multidisciplinary care with input from diabetologists, orthotists, plaster technicians, physiotherapists, orthopedic, vascular, and/or plastic surgeons. We discuss the timing of surgery with regard to Eichenholtz stage of disease and trends toward early surgical intervention. We review traditional and new surgical concepts. We evaluate the role of limited interventions. We aim to provide a template for deciding where future research priorities should be directed.
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Affiliation(s)
- Ashtin Doorgakant
- Foot and Ankle Unit, Northern General Hospital, Foot and Ankle Offices, Selby Wing, Herries Road, Sheffield S5 7AU, UK.
| | - Mark B Davies
- Northern General Hospital, Foot and Ankle Unit, Herries Road, Sheffield, S5 7AU, UK
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24
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Lauri C, Glaudemans AW, Campagna G, Keidar Z, Muchnik Kurash M, Georga S, Arsos G, Noriega-Álvarez E, Argento G, Kwee TC, Slart RH, Signore A. Comparison of White Blood Cell Scintigraphy, FDG PET/CT and MRI in Suspected Diabetic Foot Infection: Results of a Large Retrospective Multicenter Study. J Clin Med 2020; 9:jcm9061645. [PMID: 32486304 PMCID: PMC7356770 DOI: 10.3390/jcm9061645] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/16/2022] Open
Abstract
Diabetic foot infections (DFIs) represent one of the most frequent and disabling morbidities of longstanding diabetes; therefore, early diagnosis is mandatory. The aim of this multicenter retrospective study was to compare the diagnostic accuracy of white blood cell scintigraphy (WBC), 18F-fluorodeoxyglucose positron emission tomography/computed tomography ((18F) FDG PET/CT), and Magnetic Resonance Imaging (MRI) in patients with suspected DFI. Images and clinical data from 251 patients enrolled by five centers were collected in order to calculate the sensitivity, specificity, and accuracy of WBC, FDG, and MRI in diagnosing osteomyelitis (OM), soft-tissue infection (STI), and Charcot osteoarthropathy. In OM, WBC acquired following the European Society of Nuclear Medicine (EANM) guidelines was more specific and accurate than MRI (91.9% vs. 70.7%, p < 0.0001 and 86.2% vs. 67.1%, p = 0.003, respectively). In STI, both FDG and WBC achieved a significantly higher specificity than MRI (97.9% and 95.7% vs. 83.6%, p = 0.04 and p = 0.018, respectively). In Charcot, both MRI and WBC demonstrated a significantly higher specificity and accuracy than FDG (88.2% and 89.3% vs. 62.5%, p = 0.0009; 80.3% and 87.9% vs. 62.1%, p < 0.02, respectively). Moreover, in Charcot, WBC was more specific than MRI (89.3% vs. 88.2% p < 0.0001). Given the limitations of a retrospective study, WBC using EANM guidelines was shown to be the most reliable imaging modality to differentiate between OM, STI, and Charcot in patients with suspected DFI.
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Affiliation(s)
- Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Andor W.J.M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Giuseppe Campagna
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, 3109601 Haifa, Israel; (Z.K.); (M.M.K.)
| | - Marina Muchnik Kurash
- Department of Nuclear Medicine, Rambam Health Care Campus, 3109601 Haifa, Israel; (Z.K.); (M.M.K.)
| | - Stamata Georga
- 3rd Department of Nuclear Medicine, Aristotle University Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (S.G.); (G.A.)
| | - Georgios Arsos
- 3rd Department of Nuclear Medicine, Aristotle University Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (S.G.); (G.A.)
| | - Edel Noriega-Álvarez
- Department of Nuclear Medicine, University Hospital of Ciudad Real, 13005 Ciudad Real, Spain;
| | - Giuseppe Argento
- Radiology Unit, Sant’Andrea University Hospital, 00189 Rome, Italy;
| | - Thomas C. Kwee
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Riemer H.J.A. Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, 7500 Enschede, The Netherlands
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
- Correspondence: ; Tel.: +39-06-3377-6191
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25
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Hot topics in diabetic foot infection. Int J Antimicrob Agents 2020; 55:105942. [PMID: 32194153 DOI: 10.1016/j.ijantimicag.2020.105942] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 01/12/2023]
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26
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Aicale R, Cipollaro L, Esposito S, Maffulli N. An evidence based narrative review on treatment of diabetic foot osteomyelitis. Surgeon 2020; 18:311-320. [PMID: 32081665 DOI: 10.1016/j.surge.2020.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 12/18/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The diagnosis of diabetic food infection is usually clinical, and its severity is related to location and depth of the lesion, and the presence of necrosis or gangrene. Osteomyelitis of the foot and ankle can be extremely debilitating, and, in the preantibiotic era acute staphylococcal osteomyelitis carried a mortality rate of 50%. The microbiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial. Indeed, gram-negative and gram-positive bacilli can be identified using molecular techniques applied to bone biopsies compared to conventional techniques. The aim of the present study is to report a complete overview regarding medical and surgical management of diabetic foot osteomyelitis (DFO) in combination or alone. MATERIALS AND METHODS We performed a search in PubMed and Scopus electronic databases (up to January 2019) of articles assessing the epidemiology, diagnostic strategy and pharmacological treatment of diabetic foot infection. In the search strategy, we used various combinations of the following key terms: infection, orthopaedic, diabetic foot, management, DFO. RESULTS This article discusses the definition, epidemiology, microbiological assessment, clinical evaluation, pharmacological and surgical management and a comparison between them, of DFO. After the initial literature search and removal of duplicate records, a total of 756 potentially relevant citations were identified. After a further screening and according to the inclusion criteria, a total of 65 articles were included in the present review. CONCLUSION The association of antibiotic and surgical therapy seems to be more effective compared to each one alone. The lack of comparison studies and randomized controlled trials makes it difficult to give information about the efficacy of the different management therapies.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy.
| | - Lucio Cipollaro
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy.
| | - Silvano Esposito
- Department of Infectious Diseases, School of Medicine and Surgery, University of Salerno, Salerno, Italy.
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, Faculty of Medicine and Surgery, University of Salerno, 84084 Baronissi, Italy; Clinica Ortopedica, Ospedale San Giovanni di Dio e Ruggi D'Aragona, 84131, Salerno, Italy; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, UK; Keele University, School of Medicine, Institute of Science and Technology in Medicine, Guy Hilton Research Centre, Thornburrow Drive, Hartshill, Stoke-on-Trent, ST4 7QB, UK.
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27
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Abstract
Calcaneal osteomyelitis can be a debilitating disease if proper treatment protocols are not initiated. This literature review details the epidemiology, clinical, diagnostic, and prognostic factors, and medical management in those who developed this disease.
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28
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Gupta S, Loh KJ, Pedtke A. Sensing and actuation technologies for smart socket prostheses. Biomed Eng Lett 2019; 10:103-118. [PMID: 32175132 DOI: 10.1007/s13534-019-00137-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/17/2019] [Accepted: 10/26/2019] [Indexed: 01/20/2023] Open
Abstract
The socket is the most critical part of every lower-limb prosthetic system, since it serves as the interfacial component that connects the residual limb with the artificial system. However, many amputees abandon their socket prostheses due to the high-level of discomfort caused by the poor interaction between the socket and residual limb. In general, socket prosthesis performance is determined by three main factors, namely, residual limb-socket interfacial stress, volume fluctuation of the residual limb, and temperature. This review paper summarizes the various sensing and actuation solutions that have been proposed for improving socket performance and for realizing next-generation socket prostheses. The working principles of different sensors and how they have been tested or used for monitoring the socket interface are discussed. Furthermore, various actuation methods that have been proposed for actively modifying and improving the socket interface are also reviewed. Through the continued development and integration of these sensing and actuation technologies, the long-term vision is to realize smart socket prostheses. Such smart socket systems will not only function as a socket prosthesis but will also be able to sense parameters that cause amputee discomfort and self-adjust to optimize its fit, function, and performance.
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Affiliation(s)
- Sumit Gupta
- 1Department of Structural Engineering, University of California-San Diego, La Jolla, CA 92093-0085 USA
| | - Kenneth J Loh
- 1Department of Structural Engineering, University of California-San Diego, La Jolla, CA 92093-0085 USA
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29
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Walker EA, Beaman FD, Wessell DE, Cassidy RC, Czuczman GJ, Demertzis JL, Lenchik L, Motamedi K, Pierce JL, Sharma A, Ying-Kou Yung E, Kransdorf MJ. ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients With Diabetes Mellitus. J Am Coll Radiol 2019; 16:S440-S450. [DOI: 10.1016/j.jacr.2019.05.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 12/16/2022]
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30
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Leone A, Vitiello C, Gullì C, Sikora AK, Macagnino S, Colosimo C. Bone and soft tissue infections in patients with diabetic foot. Radiol Med 2019; 125:177-187. [DOI: 10.1007/s11547-019-01096-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/09/2019] [Indexed: 11/24/2022]
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Heidari N, Oh I, Li Y, Vris A, Kwok I, Charalambous A, Rogero R. What Is the Best Method to Differentiate Acute Charcot Foot From Acute Infection? Foot Ankle Int 2019; 40:39S-42S. [PMID: 31322932 DOI: 10.1177/1071100719859892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Differentiation between acute Charcot neuroarthropathy (CN) and acute infection/osteomyelitis is complex and requires multiple (>1) diagnostic criteria. These criteria include an emphasis on the presence of neuropathy, history, and physical examination. The absence of skin wounds and resolution of swelling/erythema with elevation makes the likelihood of infection very low. In unclear cases, laboratory testing, histologic examination and culturing of bone specimens, scintigraphy, and imaging, especially magnetic resonance imaging (MRI), may be of benefit. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Nima Heidari
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Irvin Oh
- 2 Department of Orthopaedics and Rehabilitation University of Rochester, Rochester, NY, USA
| | - Yueyang Li
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Alexandros Vris
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Iris Kwok
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Alexander Charalambous
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ryan Rogero
- 3 Rothman Orthopaedic Institute, Philadelphia, PA, USA
- 4 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Lavery LA, Crisologo PA, La Fontaine J, Bhavan K, Oz OK, Davis KE. Are We Misdiagnosing Diabetic Foot Osteomyelitis? Is the Gold Standard Gold? J Foot Ankle Surg 2019; 58:713-716. [PMID: 31256899 PMCID: PMC6624071 DOI: 10.1053/j.jfas.2018.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Indexed: 02/03/2023]
Abstract
To compare the incidence of osteomyelitis based on different operational definitions using the gold standard of bone biopsy, we prospectively enrolled 35 consecutive patients who met the criteria of ≥21 years of age and a moderate or severe infection based on the Infectious Diseases Society of America classification. Bone samples were obtained from all patients by percutaneous bone biopsy or intraoperative culture if the patient required surgery. Bone samples were analyzed for conventional culture, histology, and 16S ribosomal RNA genetic sequencing. We evaluated 5 definitions for osteomyelitis: 1) traditional culture, 2) histology, 3) genetic sequencing, 4) traditional culture and histology, and 5) genetic sequencing and histology. There was variability in the incidence of osteomyelitis based on the diagnostic criteria. Traditional cultures identified more cases of osteomyelitis than histology (68.6% versus 45.7%, p = .06, odds ratio [OR] 2.59, 95% confidence interval [CI] 0.98 to 6.87), but the difference was not significant. In every case that histology reported osteomyelitis, bone culture was positive using traditional culture or genetic sequencing. The 16S ribosomal RNA testing identified significantly more cases of osteomyelitis compared with histology (82.9% versus 45.7%, p = .002, OR 5.74, 95% CI 1.91 to 17.28) and compared with traditional cultures but not significantly (82.9% versus 68.6%, p = .17, OR 2.22, 95% CI 0.71 to 6.87). When both histology and traditional culture (68.6%) or histology and genetic sequencing cultures (82.9%) were used to define osteomyelitis, the incidence of osteomyelitis did not change. There is variability in the incidence of osteomyelitis based on how the gold standard of bone biopsy is defined in diabetic foot infections.
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Affiliation(s)
- Lawrence A. Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - P. Andrew Crisologo
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kavitha Bhavan
- Department of Internal Medicine, Infectious Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Orhan K. Oz
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Kathryn E. Davis
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Avani F, Damoogh S, Mottaghitalab F, Karkhaneh A, Farokhi M. Vancomycin loaded halloysite nanotubes embedded in silk fibroin hydrogel applicable for bone tissue engineering. INT J POLYM MATER PO 2019. [DOI: 10.1080/00914037.2019.1616201] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Farzaneh Avani
- Biomedical Engineering Faculty, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran
| | - Sheyda Damoogh
- National Cell Bank of Iran, Pasteur Institute of Iran, Tehran, Iran
| | - Fatemeh Mottaghitalab
- Nanotechnology Research Centre, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Akbar Karkhaneh
- Biomedical Engineering Faculty, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran
| | - Mehdi Farokhi
- National Cell Bank of Iran, Pasteur Institute of Iran, Tehran, Iran
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Brucato MP, Wachtler MF, Nasser EM. Osteomyelitis of the Calcaneus With Pathologic Fracture. J Foot Ankle Surg 2019; 58:591-595. [PMID: 30685422 DOI: 10.1053/j.jfas.2018.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Indexed: 02/03/2023]
Abstract
Pathologic fractures of the calcaneus secondary to osteomyelitis (OM) have rarely been reported in the literature. This case series describes 5 patients who were treated in our institution for chronic OM of the calcaneus and subsequently suffered a fracture of the involved calcaneus in the absence of trauma. All 5 patients had a history of insulin-dependent diabetes mellitus and were treated with a range of surgical treatments including open reduction and internal fixation, external fixation, and excision of the fracture fragment. Three (60%) of the patients required a below-the-knee amputation of the ipsilateral limb, 1 (20%) expired, and 1 (20%) experienced healing of the fracture and the associated heel wound. Pathologic fracture of the calcaneus secondary to OM is a recognized entity, although case descriptions have rarely been reported for this challenging condition.
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35
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Schmidt BM, McHugh JB, Patel RM, Wrobel JS. Prospective Analysis of Surgical Bone Margins After Partial Foot Amputation in Diabetic Patients Admitted With Moderate to Severe Foot Infections. Foot Ankle Spec 2019; 12:131-137. [PMID: 29644884 PMCID: PMC7185086 DOI: 10.1177/1938640018770285] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Osteomyelitis is common in diabetic foot infections and medical management can lead to poor outcomes. Surgical management involves sending histopathologic and microbiologic specimens which guides future intervention. We examined the effect of obtainment of surgical margins in patients undergoing forefoot amputations to identify patient characteristics associated with outcomes. Secondary aims included evaluating interobserver reliability of histopathologic data at both the distal-to and proximal-to surgical bone margin. METHODS Data were prospectively collected on 72 individuals and was pooled for analysis. Standardized method to retrieve intraoperative bone margins was established. A univariate analysis was performed. Negative outcomes, including major lower extremity amputation, wound dehiscence, reulceration, reamputation, or death were recorded. RESULTS Viable proximal margins were obtained in 63 out of 72 cases (87.5%). Strong interobserver reliability of histopathology was recorded. Univariate analysis demonstrated preoperative platelets, albumin, probe-to-bone testing, absolute toe pressures, smaller wound surface area were associated with obtaining viable margins. Residual osteomyelitis resulted in readmission 2.6 times more often and more postoperative complications. CONCLUSIONS Certain patients were significantly different in the viable margin group versus dirty margin group. High interobserver reliability was demonstrated. Obtainment of viable margins resulted in reduced rates of readmission and negative outcomes. LEVELS OF EVIDENCE Prognostic, Level I: Prospective.
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Affiliation(s)
- Brian M. Schmidt
- Division of Metabolism, Endrocrinology, and Diabetes, Department of Internal Medicine
| | | | - Rajiv M. Patel
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - James S. Wrobel
- Division of Metabolism, Endrocrinology, and Diabetes, Department of Internal Medicine
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AlSadrah SA. Impaired quality of life and diabetic foot disease in Saudi patients with type 2 diabetes: A cross-sectional analysis. SAGE Open Med 2019; 7:2050312119832092. [PMID: 30815259 PMCID: PMC6385329 DOI: 10.1177/2050312119832092] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/29/2019] [Indexed: 12/31/2022] Open
Abstract
Objectives: This study aimed to assess the overall health-related quality of life in type 2 diabetes mellitus patients with diabetic foot disease compared to diabetic patients without diabetic foot and to identify the clinical utility of this assessment. Methods: A total of 250 consecutive patients with type 2 diabetes mellitus (100/150 with/without diabetic foot, respectively) were interviewed. The questionnaires of the 36-item short-form survey and region-specific foot and ankle ability measure were applied. Wagner–Meggitt wound classification was used for foot-ulcer evaluation. Follow-up of patients for 3–6 weeks was done to identify the potential clinical short outcomes of diabetic foot ulcers. Results: Type 2 diabetes mellitus patients with diabetic foot exhibited poor mental and physical health consequences. Females had more prevalence of forefoot lesions, larger ulcer size, advanced Wagner grade, and higher frequency of unhealed ulcers. Receiver operating characteristic curve analysis demonstrated high value of foot and ankle ability measure and 36-item short-form questionnaires to discriminate type 2 diabetes mellitus patients with and without diabetic foot at cutoff values of 66 and 49.6, respectively. Foot and ankle ability measure questionnaire also showed high performance for differentiating the clinical outcome of foot ulcer. Total foot and ankle ability measure subscale score above the cutoff value of 65.5 could discriminate patients with complete healing and unhealed ulcer lesions at a high sensitivity and specificity. Conclusion: The current findings confirm the impact of diabetic foot disease on type 2 diabetes mellitus overall health-related quality of life reflected in 36-item short-form questionnaire and foot and ankle ability measure questionnaire which showed high discriminative values for type 2 diabetes mellitus patient sub-grouping. Their application in routine clinical health assessment with continuous medical education programs is highly recommended to achieve a better health-related quality of life.
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Affiliation(s)
- Sana A AlSadrah
- Department of Preventive Medicine, Governmental Hospital Khobar, Health Centers in Khobar, Ministry of Health, Khobar, Saudi Arabia
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37
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Meyr AJ, Seo K, Khurana JS, Choksi R, Chakraborty B. Level of Agreement With a Multi-Test Approach to the Diagnosis of Diabetic Foot Osteomyelitis. J Foot Ankle Surg 2019; 57:1137-1139. [PMID: 30181032 DOI: 10.1053/j.jfas.2018.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Indexed: 02/03/2023]
Abstract
Although bone biopsy has historically been considered the "gold standard" or "standard reference" for the diagnosis of diabetic foot osteomyelitis, some contemporary investigations have provided evidence against this as a single diagnostic test and in support of a combination of clinical, laboratory, and radiographic findings. The objective of this investigation was to measure the level of agreement between several commonly used forms of diagnostic testing for diabetic foot osteomyelitis. A retrospective chart review was performed of 50 consecutive patients admitted to a single tertiary healthcare center with the documented performance of 1) a clinical probe-to-bone test on hospital admission; 2) plain film radiographs prior to any surgical intervention; 3) magnetic resonance imaging prior to any surgical intervention; and an intraoperative excisional bone debridement performed, with samples sent for both 4) histologic analysis and 5) microbiologic analysis. A frequency count of agreement among these 5 tests was performed, and the interobserver (or inter-test) agreement was measured using the kappa statistic. We observed low levels of inter-test agreement between the 5 diagnostic tests (range 42.0%-62.0%), and levels of chance-corrected agreement were well below what would be considered appropriate for a "gold standard" or "standard reference." Levels of the kappa statistic ranged from 0.0 to 0.220, with most inter-test comparisons falling in the "poor agreement" and "slight agreement" interpretation ranges. The highest level of agreement occurred between the plain film radiographs and magnetic resonance imaging (62.0% agreement and kappa statistic of 0.220). Although it is likely that a combination of clinical, radiographic, and laboratory tests provides the best diagnostic approach for diabetic foot osteomyelitis, the data provided herein indicate that the tests themselves might have high intrinsic levels of unreliability and that the specific combination of tests that might be best used remains unclear.
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Affiliation(s)
- Andrew J Meyr
- Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | - Kyung Seo
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Temple University Hospital, Philadelphia, Pennsylvania
| | - Jasvir S Khurana
- Associate Professor, Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Rachana Choksi
- Resident, Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Baidarbhi Chakraborty
- Resident, Department of Pathology and Laboratory Medicine, Temple University Hospital, Philadelphia, Pennsylvania
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38
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Singh M, Khan K, Fisch E, Frey C, Mathias K, Jneid H, Musher DM, Barshes NR. Acute Cardiac Events in Patients With Severe Limb Infection. INT J LOW EXTR WOUND 2018; 17:261-267. [PMID: 30461325 DOI: 10.1177/1534734618810944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Recent studies have shown an association between infections, such as influenza, pneumonia, or bacteremia, and acute cardiac events. We studied the association between foot infection and myocardial infarction, arrhythmia, and/or congestive heart failure. We analyzed the records of 318 consecutive episodes of deep soft tissue infection, gangrene, and/or osteomyelitis in 274 patients referred to a vascular surgery service at a tertiary center. We identified 24 acute cardiac events in 21 of 318 (6.6%) episodes of foot infection or foot gangrene. These 24 events included 11 new myocardial infarctions (3.5%), 8 episodes of new onset or worsening congestive heart failure (2.5%), and 5 new arrhythmias (1.6%). Tachycardia and systemic inflammatory response syndrome were associated with acute cardiac events ( P < .05 for each). The 1-year survival of patients with acute cardiac events was 50.4%, significantly lower than the 91.7% 1-year survival of patients without acute cardiac events ( P < .0015). Acute cardiac complications are not uncommon among patients presenting with severe foot infection and are associated with a high 1-year mortality. Primary care physicians, cardiologists, and vascular and orthopedic surgeons must keep a high index of suspicion for the occurrence of an acute cardiac event.
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Affiliation(s)
| | | | - Evan Fisch
- 2 Baylor College of Medicine, Houston, TX, USA
| | | | | | - Hani Jneid
- 2 Baylor College of Medicine, Houston, TX, USA.,3 Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Daniel M Musher
- 2 Baylor College of Medicine, Houston, TX, USA.,3 Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Neal R Barshes
- 2 Baylor College of Medicine, Houston, TX, USA.,3 Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
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39
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Ramanujam CL, Han D, Zgonis T. Medical Imaging and Laboratory Analysis of Diagnostic Accuracy in 107 Consecutive Hospitalized Patients With Diabetic Foot Osteomyelitis and Partial Foot Amputations. Foot Ankle Spec 2018; 11:433-443. [PMID: 29291264 DOI: 10.1177/1938640017750255] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
UNLABELLED The primary aim of our study was to compare the preoperative diagnostic accuracy of plain radiographic findings with the accuracy of magnetic resonance imaging (MRI) findings for diabetic foot osteomyelitis in hospitalized patients who underwent first-time partial foot amputations with confirmed histopathological specimens positive for osteomyelitis. Second, it was desired to determine whether certain variables within the initial clinical presentation and preoperative laboratory findings were associated with more accurate diagnosis of diabetic foot osteomyelitis in this study population. Finally, it was desired to determine the most common bacterial organisms found in bone and soft-tissue cultures taken intraoperatively and to determine how often the same organism was found in both. After applying the inclusion and exclusion criteria to the initial 329 patients identified through chart review, the final sample size for further analysis was n =107. In this study, after adjusting for the effects of covariates such as age, erythrocyte sedimentation rate (ESR) and C-reactive protein, plain radiographs seemed to have statistically more significant power than MRI in predicting and diagnosing diabetic foot osteomyelitis. In addition, higher ESR values were confirmed to predict a higher chance of positive diagnosis for diabetic foot osteomyelitis. Furthermore, the presence of positive bacterial identification from intraoperative bone cultures did not always indicate true osteomyelitis on histopathological examination. LEVELS OF EVIDENCE Level II: Diagnostic study.
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Affiliation(s)
- Crystal L Ramanujam
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics (CLR, TZ), The University of Texas Health San Antonio.,Department of Management Science & Statistics, College of Business (DH), The University of Texas at San Antonio, Texas
| | - David Han
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics (CLR, TZ), The University of Texas Health San Antonio.,Department of Management Science & Statistics, College of Business (DH), The University of Texas at San Antonio, Texas
| | - Thomas Zgonis
- Division of Podiatric Medicine and Surgery, Department of Orthopaedics (CLR, TZ), The University of Texas Health San Antonio.,Department of Management Science & Statistics, College of Business (DH), The University of Texas at San Antonio, Texas
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40
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Taha OA, Connerton PL, Connerton IF, El-Shibiny A. Bacteriophage ZCKP1: A Potential Treatment for Klebsiella pneumoniae Isolated From Diabetic Foot Patients. Front Microbiol 2018; 9:2127. [PMID: 30254618 PMCID: PMC6141743 DOI: 10.3389/fmicb.2018.02127] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 08/20/2018] [Indexed: 11/25/2022] Open
Abstract
The recorded growth in infection by multidrug resistant bacteria necessitates prompt efforts toward developing alternatives to antibiotics, such as bacteriophage therapy. Immuno-compromised patients with diabetes mellitus are particularly prone to foot infections by multidrug resistant Klebsiella pneumoniae, which may be compounded by chronic osteomyelitis. Bacteriophage ZCKP1, isolated from freshwater in Giza, Egypt, was tested in vitro to evaluate its lytic activity against a multidrug resistant K. pneumoniae KP/01, isolated from foot wound of a diabetic patient in Egypt. Characterization of ZCKP1 phage indicated that it belonged to the Myoviridae family of bacteriophages with a ds-DNA genome size of 150.9 kb. Bacteriophage ZCKP1 lysed a range of osteomyelitis pathogenic agents including Klebsiella spp., Proteus spp. and E. coli isolates. The bacteriophage reduced the bacterial counts of host bacteria by ≥2 log10 CFU/ml at 25°C, and demonstrated the ability to reduce bacterial counts and biofilm biomass (>50%) when applied at high multiplicity of infection (50 PFU/CFU). These characteristics make ZCKP1 phage of potential therapeutic value to treat K. pneumoniae and associated bacteria present in diabetic foot patients.
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Affiliation(s)
- Omar A Taha
- Biomedical Sciences, University of Science and Technology, Zewail City of Science and Technology, Giza, Egypt
| | - Phillippa L Connerton
- Division of Food Sciences, School of Biosciences, University of Nottingham, Loughborough, United Kingdom
| | - Ian F Connerton
- Division of Food Sciences, School of Biosciences, University of Nottingham, Loughborough, United Kingdom
| | - Ayman El-Shibiny
- Biomedical Sciences, University of Science and Technology, Zewail City of Science and Technology, Giza, Egypt.,Faculty of Environmental Agricultural Sciences, Arish University, Arish, Egypt
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Abstract
PURPOSE OF REVIEW Diabetes mellitus affects approximately 30.8 million people currently living in the USA. Chronic diabetes complications, including diabetic foot complications, remain prevalent and challenging to treat. We review clinical diagnosis and challenges providers may encounter when managing diabetic foot ulcers and Charcot neuroarthropathy. RECENT FINDINGS Mechanisms controlling these diseases are being elucidated and not fully understood. Offloading is paramount to heal and manage diabetic foot ulcers and Charcot neuroarthropathy. Diabetic foot ulcers recur and the importance of routine surveillance and multidisciplinary approach is essential. Several predictors of failure in Charcot foot include a related diabetic foot ulcer, midfoot or rearfoot location of the Charcot event, and progressive bony changes on interval radiographs. Patients with diabetic foot ulcer and/or Charcot neuroarthropathy are in need of consistent and regular special multidisciplinary care. If not diagnosed early and managed effectively, morbidity and mortality significantly increase.
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Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA.
| | - Crystal M Holmes
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48106, USA
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42
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Brocco E, Ninkovic S, Marin M, Whisstock C, Bruseghin M, Boschetti G, Viti R, Forlini W, Volpe A. Diabetic foot management: multidisciplinary approach for advanced lesion rescue. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:670-684. [PMID: 29808982 DOI: 10.23736/s0021-9509.18.10606-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The diabetic foot is a complication of diabetes affecting 15% of diabetics in their lives. It is associated to diabetic neuropathy and peripheral vascular disease and its incidence has increased. The ulceration is the initial cause of a dramatic process leading, if not correctly treated, to amputations. Both neuropathy, neuro-ischemia and infections have a role in determining healing or worsening of the lesions and 85% of all amputations in diabetic patients are preceded by a foot ulceration deteriorating to a severe gangrene or infection. The different causative agents and the different clinical presentations of diabetic foot ask a multidisciplinary approach in order to address treatments to the final goals, the prevention of the amputations and the maintenance of a functional foot able with weight-bearing ability. Many professional figures, diabetologists, surgeons (both general and vascular and orthopedics), interventional radiologists, infectious diseases specialists, specialized nurses, podiatrists, orthotic technicians, are called to apply their knowledges to the diabetic patients affected by diabetic foot in a virtuous circle leading to reach the goals, with the imperative action of the multidisciplinary team. The so organized center will allow both a correct and rapid diagnosis, the use in ambulatorial environments of modern tools, or the hospitalization in multitasking wards, in which all the complications and the necessary treatments are possible, both in emergencies or in elective way, considering both revascularizations and surgery.
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Affiliation(s)
- Enrico Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy -
| | - Sasa Ninkovic
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Mariagrazia Marin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Christine Whisstock
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Marino Bruseghin
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Giovanni Boschetti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | - Raffaella Viti
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
| | | | - Antonio Volpe
- Department of Orthopedic Surgery, Foot and Ankle Clinic, Abano Terme Polyclinic, Abano Terme, Padua, Italy
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43
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Affiliation(s)
- Andrew Dodd
- Division of Orthopaedic Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Timothy R Daniels
- Division of Orthopaedic Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
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44
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Staphylococcal Osteomyelitis: Disease Progression, Treatment Challenges, and Future Directions. Clin Microbiol Rev 2018; 31:31/2/e00084-17. [PMID: 29444953 DOI: 10.1128/cmr.00084-17] [Citation(s) in RCA: 244] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Osteomyelitis is an inflammatory bone disease that is caused by an infecting microorganism and leads to progressive bone destruction and loss. The most common causative species are the usually commensal staphylococci, with Staphylococcus aureus and Staphylococcus epidermidis responsible for the majority of cases. Staphylococcal infections are becoming an increasing global concern, partially due to the resistance mechanisms developed by staphylococci to evade the host immune system and antibiotic treatment. In addition to the ability of staphylococci to withstand treatment, surgical intervention in an effort to remove necrotic and infected bone further exacerbates patient impairment. Despite the advances in current health care, osteomyelitis is now a major clinical challenge, with recurrent and persistent infections occurring in approximately 40% of patients. This review aims to provide information about staphylococcus-induced bone infection, covering the clinical presentation and diagnosis of osteomyelitis, pathophysiology and complications of osteomyelitis, and future avenues that are being explored to treat osteomyelitis.
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45
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Korkmaz P, Koçak H, Onbaşı K, Biçici P, Özmen A, Uyar C, Özatağ DM. The Role of Serum Procalcitonin, Interleukin-6, and Fibrinogen Levels in Differential Diagnosis of Diabetic Foot Ulcer Infection. J Diabetes Res 2018; 2018:7104352. [PMID: 29675434 PMCID: PMC5841040 DOI: 10.1155/2018/7104352] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/13/2017] [Indexed: 12/15/2022] Open
Abstract
AIMS We aimed to evaluate the roles of interleukin-6 (IL-6), PCT, and fibrinogen levels in the differential diagnosis of the patients with infected diabetic foot ulcer (IDFU) and noninfected diabetic foot ulcer (NIDFU) and to compare those with C-reactive protein (CRP), white blood cell (WBC), and erythrocyte sedimentation rate (ESR). METHODS Patients over 18 years with a diagnosis of type 2 diabetes mellitus and DFU who were followed up in our hospital between 1 January 2016 and 1 January 2017 were included in the study. In addition to this patient group, patients with diabetes but without DFU were determined as the control group. RESULTS Thirty-eight patients with IDFU, 38 patients with NIDFU, and 43 patients as the control group were included in the study. Fifty-six point three percent of the patients who participated in the study were males, and the mean age was 61.07 ± 11.04 years. WBC, ESR, CRP, IL-6, and fibrinogen levels of the cases with IDFU were determined to be significantly higher compared to the cases in NIDFU (p < 0.01). The area under the ROC curve (AUROC) value was highest for CRP (0.998; p < 0.001), and the best cut-off value for CRP was 28 m/L. The best cut-off values for fibrinogen, IL-6, ESR, and WBC were 480 mg/dL, 105.8 pg/mL, 31 mm/h, and 11.6 (103 μ/L), respectively. CONCLUSION Serum PCT levels were not found to be effective in the discrimination of IDFU and NIDFU. Serum IL-6 and fibrinogen levels seem to be two promising inflammatory markers in the discrimination of IDFU.
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Affiliation(s)
- Pınar Korkmaz
- Department of Clinical Microbiology and Infectious Diseases, Dumlupınar University Faculty of Medicine, 43020 Kutahya, Turkey
| | - Havva Koçak
- Department of Biochemistry, Dumlupınar University Faculty of Medicine, Kutahya, Turkey
| | - Kevser Onbaşı
- Department of Endocrinology and Metabolism, Dumlupınar University Faculty of Medicine, Kutahya, Turkey
| | - Polat Biçici
- Department of Plastic Surgery, Kütahya Dumlupınar Training and Research Hospital, Kutahya, Turkey
| | - Ahmet Özmen
- Department of Clinical Microbiology and Infectious Diseases, Kütahya Dumlupınar Training and Research Hospital, Kutahya, Turkey
| | - Cemile Uyar
- Department of Clinical Microbiology and Infectious Diseases, Kütahya Dumlupınar Training and Research Hospital, Kutahya, Turkey
| | - Duru Mıstanoğlu Özatağ
- Department of Clinical Microbiology and Infectious Diseases, Dumlupınar University Faculty of Medicine, 43020 Kutahya, Turkey
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Aragón-Sánchez J, Lipsky BA. Modern management of diabetic foot osteomyelitis. The when, how and why of conservative approaches. Expert Rev Anti Infect Ther 2017; 16:35-50. [PMID: 29231774 DOI: 10.1080/14787210.2018.1417037] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Diabetic foot osteomyelitis (DFO) has long been considered a complex infection that is both difficult to diagnose and treat, and is associated with a high rate of relapse and limb loss. Areas covered: DFO can usually be diagnosed by a combination of clinical evaluation, serum inflammatory markers and plain X-ray. When the results of these procedures are negative or contradictory, advanced imaging tests or bone biopsy may be necessary. Staphylococcus aureus remains the most frequent microorganism isolated from bone specimens, but infection is often polymicrobial. Antibiotic therapy, preferably with oral agents guided by results of bone culture, for a duration of no more than six weeks, appears to be as safe and effective as surgery in cases of uncomplicated forefoot DFO. Surgery (which should be limb-sparing when possible) is always required for DFO accompanied by necrotizing fasciitis, deep abscess, gangrene or in cases not responding (either clinically or radiographically) to apparently appropriate antibiotic treatment. Expert commentary: Research in the past decade has improved diagnosis and treatment of DFO, and most cases can now be managed with a 'conservative' approach, defined as treatment either exclusively with antibiotics or with surgery removing as little bone and soft tissue as necessary.
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Affiliation(s)
- Javier Aragón-Sánchez
- a Department of Surgery, Diabetic Foot Unit , La Paloma Hospital , Las Palmas de Gran Canaria , Spain
| | - Benjamin A Lipsky
- b Department of Medicine , University of Washington School of Medicine , Seattle , WA , USA.,c Green Templeton College , University of Oxford , Oxford , UK
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Abstract
INTRODUCTION Diabetic foot osteomyelitis therapeutical options are based on antibiotic therapy and surgical resection of the infected bone(s). Surgical and medical approaches of patients suffering from a diabetic foot osteomyelitis do not oppose but are complementary and need to be discussed as a tailored manner. Areas covered: The aim of the present article is to discuss data issued from the most recent guidelines of the Infectious Diseases Society of America and the International Working Group on the Diabetic Foot on the management of the diabetic foot infection and from a search in the current literature using the terms diabetic foot osteomyelitis and treatment/therapy/therapeutical in both PubMed and Medline, restricted to the last five years. Expert opinion: Surgical removal of the entire infected bone(s) has been considered in the past as the standard treatment but medical approach of these patients has now proven efficacy in selected situations. The current emergence of bacteria, especially among Gram negative rods, resistant to almost all the available antibiotics gradually augments the complexity of the management of these patients and is likely to decrease the place of the medical approach and to worsen the outcome of these infections in the next future.
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Affiliation(s)
- Eric Senneville
- a Infectious Diseases Department , Gustave Dron Hospital , Tourcoing , France.,b Orthopaedic Departement of Gustave Dron Hospital of Tourcoing and Roger Salengro Hospital of Lille , French Reference Center for Osteo-Articular Infections (CRIOAC Lille-Tourcoing) , France.,c Faculty of Medicine , Lille University 2 , Lille , France
| | - Olivier Robineau
- a Infectious Diseases Department , Gustave Dron Hospital , Tourcoing , France.,b Orthopaedic Departement of Gustave Dron Hospital of Tourcoing and Roger Salengro Hospital of Lille , French Reference Center for Osteo-Articular Infections (CRIOAC Lille-Tourcoing) , France.,c Faculty of Medicine , Lille University 2 , Lille , France
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Abstract
Charcot arthropathy of the foot and ankle is a severe complication of peripheral neuropathy and is most commonly seen in the developed world in association with diabetes mellitus. Correct diagnosis and differentiation from osteomyelitis of the foot and ankle are critical to guide treatment. It can exist concomitantly with osteomyelitis, typically in the setting of an advanced midfoot ulcer. Simple plain radiographs and contrasted MRI studies often yield inconclusive or confusing data. Correct use of imaging studies and a clinical algorithm can be effective tools to help make accurate and early diagnoses and guide clinical interventions for these conditions.
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Affiliation(s)
- John Womack
- Piedmont Orthopaedic Associates, 35 International Drive, Greenville, SC 29615, USA.
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Dhanireddy S, Neme S. Acute and Chronic Osteomyelitis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00044-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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