Interobserver and intraobserver reproducibility of plain X-rays in the diagnosis of diabetic foot osteomyelitis.

The purpose of this study was to analyze the interobserver and intraobserver variability in plain radiography in the diagnosis of diabetic foot osteomyelitis. A prospective observational study was performed from October 1, 2009, to July 31, 2011, on patients with diabetic foot ulcers, with clinically suspected osteomyelitis who were admitted to the Diabetic Foot Unit of the Complutense University of Madrid. Two professional groups examined 123 plain X-rays, each group comprising 3 different levels of clinical experience. To analyze intraobserver variability, 2 months later plain X-rays were reanalyzed by one of the clinical groups. When using only plain radiography for the diagnosis of osteomyelitis in the diabetic foot, low concordance rates were observed for clinicians with a similar level of experience: experienced clinicians (K(11AB) = .35, P < .001), moderately experienced clinicians (K(22AB) = .39, P < .001), and inexperienced clinicians (K(33AB) = .40, P < .001). Intraobserver agreement was highest in experienced clinicians (K(11A) = .75, P < .001), followed by moderately experienced clinicians (K(22A) = .61, P < .001) and inexperienced clinicians (K(33A) = .57, P < .001). Plain radiography for the diagnosis of diabetic foot osteomyelitis is operator dependent and shows low association strength, even among experienced clinicians, when interpreted in isolation without knowing the clinical characteristics of the lesion.

Validating the probe-to-bone test and other tests for diagnosing chronic osteomyelitis in the diabetic foot.

OBJECTIVE: To compare the diagnostic characteristics of tests used for a prompt diagnosis of chronic osteomyelitis in the diabetic foot, using bone histology as the criterion standard. The tests assessed were probe-to-bone (PTB), clinical signs of infection, radiography signs of osteomyelitis, and ulcer specimen culture. RESEARCH DESIGN AND METHODS: A prospective study was performed on patients with foot ulcers referred to our diabetic foot clinic. Ulcer infection was diagnosed by recording clinical signs of infection and taking specimens for culture. The presumptive diagnosis of osteomyelitis was based on these results and the findings of a plain X-ray and PTB test. All patients with a clinical suspicion of bone infection were subjected to surgical treatment of the affected bone. During surgery, bone specimens were obtained for a histological diagnosis of osteomyelitis. RESULTS: Over 2.5 years, 210 foot lesions were consecutively examined and 132 of these wounds with clinical suspicion of infection selected as the study sample. Of these, 105 (79.5%) lesions were diagnosed as osteomyelitis. Among the tests compared, the best results were yielded by the PTB test including an efficiency of 94%, sensitivity of 98%, specificity of 78%, positive predictive value of 95%, and negative predictive value of 91% (P < 0.001, κ 0.803); the positive likelihood ratio was 4.41, and the negative likelihood ratio was 0.02 (95% CI). CONCLUSIONS: In our outpatient population with a high prevalence of osteomyelitis, the PTB test was of greatest diagnostic value, especially for neuropathic ulcers, and proved to be efficient for detecting osteomyelitis in the diabetic foot.

Necrotizing soft-tissue infections in the feet of patients with diabetes: outcome of surgical treatment and factors associated with limb loss and mortality.

The aim of this study was to analyze the outcomes of treatment of necrotizing soft-tissue infections (NSTIs) in the feet of diabetic patients and to determine factors associated with limb salvage and mortality. A retrospective study of a consecutive series of 145 diabetic patients suffering from NSTIs treated in the Diabetic Foot Unit, La Paloma Hospital was done. NSTIs were classified as necrotizing cellulitis if it involved the subcutaneous tissue and the skin, as necrotizing fasciitis if it involved the deep fascia, and as myonecrosis in those cases where muscular necrosis was present. In the necrotizing cellulitis group (n = 109), 8 (7.3%) major amputations were performed. In the necrotizing fasciitis group (n = 25), 13 (52%) major amputations were undertaken. In the myonecrosis group (n = 11), 6 (54.5%) major amputations were performed. Predictive variables related to limb loss were fasciitis (OR = 20, 95% CI = 3.2-122.1) and myonecrosis (OR = 53.2, 95% CI = 5.1-552.4). Predictive variables of mortality were age >75 years (OR = 10.3, 95% CI = 1.9-53.6) and creatinine values >132.6 micromol/L (OR = 5.8, 95% CI = 1.1-30.2). NSTIs of the foot are an important cause of morbidity and mortality in diabetic patients.When fascia and/or muscle are involved, there are significant risks of major amputation.

Efficacy and safety of neutral pH superoxidised solution in severe diabetic foot infections.

The use of antiseptics in wound care is often controversial and there is definitely a need for a non toxic, highly disinfective agent. This study assessed the efficacy of a neutral pH superoxidised aqueous solution (NpHSS) for infection control, odour reduction and surrounding skin and tissue damage on infected diabetic foot ulcerations. From November 2003 to March 2004, 45 patients with type 2 diabetes were randomised into a single-blind clinical trial comparing NpHSS (intervention group; n = 21) versus conventional disinfectant (control group; n = 16). All patients received comprehensive care including surgical debridement as appropriate, moist wound care, intensive glucose control and broad spectrum antibiotics. Treatment groups were matched in terms of sex, age (61.9 +/- 11.9 versus 67.8 +/- 11.6), years of diabetes duration (16.4 +/- 8.1 versus 17 +/- 10.2), obesity, HgAlc (7.1 +/- 2 versus 6.7 +/- 1.8), initial fasting glycaemia (163 +/- 59 versus 152 +/- 65.8 mg/dl), ulcer duration/week (13.7 +/- 24 versus 15.1 +/- 16.3), B/A Index (0.9 +/- 0.5 versus 1.14 +/- 0.7), depth and extent of infection/periwound cellulitis (groups B and C of the Tampico Hospital Classification) as well as aetiology (P = 0.647). Odour reduction was achieved in all NpHSS patients (100% versus 25%; P < 0.01) and surrounding cellulitis diminished (P < 0.001) in 17 patients (80.9% versus 43.7%). Nineteen patients in the NpHSS group showed advancement to granulating tissue stage (90.4% versus 62.5%; P = 0.05) with significantly less tissue toxicity (94% versus 31.2%; P < 0.01). A non toxic, NpHSS, as part of a comprehensive care regimen, may be more efficacious in infection control, odour and erythema reduction than conventional disinfectants in treatment of diabetic foot infections.

[Randomized comparative trial of a collagen/oxidized regenerated cellulose dressing in the treatment of neuropathic diabetic foot ulcers]. / Estudio aleatorizado y comparativo de un apósito de colágeno y celulosa oxidada regenerada en el tratamiento de úlceras neuropáticas de pie diabético.

INTRODUCTION: Diabetic foot is a complication of diabetes mellitus that manifests with the development of ulcers that frequently precede amputation. Several studies have verified that the environment of the diabetic neuropathic foot ulcer contains a high concentration of metalloproteinases. The aim of the present study was to evaluate the efficacy of a protease-modulating dressing in the treatment of neuropathic diabetic foot ulcers. MATERIAL AND METHOD: A randomized controlled trial was conducted in 40 patients with a 6-week or longer history of neuropathic diabetic foot ulcer. The patients were randomized to two groups: group 1 (n = 20) received treatment with the protease-modulating dressing while the control group (group 2; n = 20) received the treatment specified in the standardized protocol for good wound care. The patients were then followed-up for 6 weeks. RESULTS: After 6 weeks, healing was achieved in 12 patients (63% of n = 19) in group 1 under treatment with the protease-modulating dressing versus three patients (15% of n = 19) in the control group (p < 0.03). The mean time to healing was 23.3 +/- 9.9 days in group 1 and 40.6 +/- 1.15 days in group 2 (p < 0.01). CONCLUSIONS: The results confirm the hypothesis that the use of protease-modulating dressings in patients with neuropathic diabetic foot ulcers leads to better tissue regeneration than good wound care.