The management of the infected diabetic foot

Diabetes is a chronic disease with a worldwide increasing trend. Foot complications, closely related to neuropathy and obstructive peripheral vascular disease, are responsible for more than 1 million of leg amputations every year. Foot infection can dramatically increase the risk of amputation. Although many ulcer classification systems have been proposed to stratify the severity of the infectious process, the definition of a specific therapeutic approach still remains an unsolved problem. A Diabetic Foot Triage and an Integrated Surgical Protocol are proposed to identify a diagnostic flowchart and a step-by-step surgical protocol that can be applied in the treatment of diabetic foot infection. Considering the rapid climbing of multidrug resistant strains it is very important to rationalize the use of antibiotics utilizing them only for the treatment of true infected ulcers. PAD is widely considered the most important factor conditioning the outcome of a diabetic foot ulcer. Currently no randomized control trials are reported in the international literature directly comparing open versus endovascular revascularisation in diabetic patients with CLI. Insufficient data are available to demonstrate whether open bypass surgery or endovascular interventions are more effective in these patients. A decisional flow chart in choosing the best revascularization strategy in diabetic patients with CLI is proposed. Goals and technical aspects of emergency and elective surgical procedures in diabetic foot are analysed to evaluate critical aspects and to suggest proper surgical choices.

Multicentre observational study of the natural history of left-sided acute diverticulitis

BACKGROUND

The natural history of acute diverticulitis (AD) is still unclear. This study investigated the recurrence rate, and the risks of emergency surgery, associated stoma and death following initial medical or surgical treatment of AD.

METHODS

The Italian Study Group on Complicated Diverticulosis conducted a 4-year multicentre retrospective and prospective database analysis of patients admitted to hospital for medical or surgical treatment of AD and then followed for a minimum of 9 years. The persistence of symptoms, recurrent episodes of AD, new hospital admissions, medical or surgical treatment, and their outcome were recorded during follow-up.

RESULTS

Of 1046 patients enrolled at 17 centres, 743 were eligible for the study (407 recruited retrospectively and 336 prospectively); 242 patients (32·6 per cent) underwent emergency surgery at accrual. After a mean follow-up of 10·7 years, rates of recurrence (17·2 versus 5·8 per cent; P < 0·001) and emergency surgery (6·9 versus 1·3 per cent; P = 0·021) were higher for medically treated patients than for those treated surgically. Among patients who had initial medical treatment, age less than 40 years and a history of at least three episodes of AD were associated with an increased risk of AD recurrence. There was no association between any of the investigated parameters and subsequent emergency surgery. The risk of stoma formation was below 1 per cent and disease-related mortality was zero in this group. The disease-related mortality rate was 0·6 per cent among patients who had surgical treatment.

CONCLUSION

Long-term risks of recurrent AD or emergency surgery were limited and colectomy did not fully protect against recurrence.

Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of a removable cast walker compared with that of a nonremovable fiberglass off-bearing cast in the treatment of diabetic plantar foot ulcer.

RESEARCH DESIGN AND METHODS

Forty-five adult diabetic patients with nonischemic, noninfected neuropathic plantar ulcer were randomly assigned for treatment with a nonremovable fiberglass off-bearing cast (total contact cast [TCC] group) or walker cast (Stabil-D group). Treatment duration was 90 days. Percent reduction in ulcer surface area and total healing rates were evaluated after treatment.

RESULTS

A total of 48 patients were screened; however, 2 patients in the TCC group and 1 patient in the Stabil-D group did not complete the study and were considered dropouts. There were no significant differences in demographic and clinic characteristics of the 45 patients completing the study. Ulcer surface decreased from 1.41 to 0.21 cm(2) (P < 0.001) in the TCC group and from 2.18 to 0.45 cm(2) (P < 0.001) in the Stabil-D group, with no significant differences between groups (P = 0.722). Seventeen patients (73.9%) in the TCC group and 16 patients (72.7%) in the Stabil-D group achieved healing (P = 0.794). Average healing time was 35.3 +/- 3.1 and 39.7 +/- 4.2 days in the TCC and Stabil-D group, respectively (P = 0.708).

CONCLUSIONS

The Stabil-D cast walker, although removable, was equivalent in efficacy to the TCC in terms of ulcer size reduction and total healing rate. The easier use of Stabil-D may help increase the use of off-loading devices in the management of plantar neuropathic diabetic foot ulcers.