A deeper look at low-frequency contact ultrasonic debridement in the clinical management of patients with diabetic foot ulcers.

The current study aimed to evaluate the dispersal of solution and microbes (aerosol) in the clinical environment during treatment with Low-frequency contact ultrasonic debridement (LFCUD) with or without suction attachment in patients with diabetic foot ulcers (DFUs). We performed 20 treatments in 10 patients divided into two groups to receive the proposed LFCUD modalities. We measured the microbial load of the environment pre-treatment (sample M1), during treatment with each LFCUD modality (sample M2) and post-treatment (sample M3). The use of LFCUD debridement without a suction attachment results in significantly higher immediate contamination of the clinic environment than the suction attachment, particularly during the procedure (1.70 ± 0.98 log 10 CFU/mL versus 0.77 ± 0.85 log 10 CFU/mL, p = 0.035). When suction is not applied, there are statistically significant differences depending on whether the DFUs are neuropathic or neuroischemic, finding a greater number of microorganisms with high loads in neuropathic DFUs. We found a statistically significant positive correlation between wound area (r = 0.450, p = 0.047) and TBI (r = 0.651, p = 0.006) with the bacterial load during the LFCUD. Based on our results, we recommend using the personal protective equipment required to protect staff members and patients during treatment with LFCUD and using a suction attachment where clinically possible to reduce clinic environmental pollution, especially in neuropathic DFUs and those with larger areas.

Diabetic foot off loading and ulcer remission: Exploring surgical off-loading.

INTRODUCTION: Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration. METHODS: We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations. RESULTS: Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements. CONCLUSIONS AND IMPLICATIONS: Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.

Complications associated with the approach to metatarsal head resection in diabetic foot osteomyelitis.

The aim of this study was to evaluate the recovery time and the development of complications in the dorsal and plantar approach to metatarsal head resections (MHR) in patients with diabetic foot ulcers complicated by osteomyelitis. A retrospective study was carried out involving 108 patients who underwent MHRs for the treatment of diabetic foot osteomyelitis. Two cohorts were defined: dorsal approach with incision closed with sutures and plantar approach with ulcer healed using conservative treatment. The main outcomes were the weeks until healing and complications related to the approaches. Fifty-three patients (49.1%) underwent a plantar approach and 55 (50.9%) a dorsal approach. Both approaches rendered similar healing times. However, the patients undergoing a dorsal approach developed more post-surgical complications than patients treated through a plantar approach. The dorsal approach intervention was performed on smaller and shallower ulcers; however, more complications developed at follow up using this approach than through a plantar approach for MHR complicated with osteomyelitis.

Validation of an algorithm to predict reulceration in amputation patients with diabetes.

The aim of this article was to assess the ability to predict reulceration in people with diabetes and a history of minor amputation according to the formula proposed by Miller et al. A retrospective study was performed on 156 consecutive records of patients with a recent history of simple or multiple forefoot amputation. The sample was divided according to Miller's formula into patients at low risk of reulceration and those at high risk; those were further divided into two subgroups according to whether or not the first segment of the forefoot had been amputated. Forty-eight (47·1%) individuals suffered forefoot reulceration, showing a median reulceration-free survival time of 8 months [interquartile range (IR) 3·6-14·8]. Nephropathy (P = 0.005) and Miller's formula (P = 0.028) were risk factors for reulceration-free survival time in the univariate analysis. The pattern relating to the first segment amputated [hazard ratio (HR) 2·853; P = 0·004; 95% confidence interval (CI) 1·391-5·849] and nephropathy (HR 2·468; P = 0.004; 95% CI 1.328-4.587) showed a significant hazard ratio in the multivariate Cox model. Participants with first segment amputation and one other amputation showed an association with the probability of reulceration in comparison with any other specific type of minor amputation.

Conservative Surgery of Diabetic Forefoot Osteomyelitis: How Can I Operate on This Patient Without Amputation?

Surgery is necessary in many cases of diabetic foot osteomyelitis. The decision to undertake surgery should be based on the clinical presentation of diabetic foot osteomyelitis. Surgery is required when the bone is protruding through the ulcer, there is extensive bone destruction seen on x-ray or progressive bone damage on sequential x-ray while undergoing antibiotic treatment, the soft tissue envelope is destroyed, and there is gangrene or spreading soft tissue infection. Several issues should be taken into account when considering surgery for treating diabetic foot osteomyelitis. It is necessary to have a surgeon available with diabetic foot expertise. Regarding location of diabetic foot osteomyelitis, it is important to consider whether isolated bone or a joint is involved. In cases in which osteomyelitis is associated with a bone deformity, surgery should be able to correct this. The surgeon should always reflect about whether extensive/radical surgery could destabilize the foot. The forefoot is the most frequent location of diabetic foot osteomyelitis and is associated with better prognosis than midfoot and hindfoot osteomyelitis. Many surgical procedures can be performed in patients with diabetes and forefoot ulcers complicated by osteomyelitis while avoiding amputations. Performing conservative surgeries without amputations of any part of the foot is not always feasible in cases in which the infection has destroyed the soft tissue envelope. Attempting conservative surgery in such cases risks infected tissues remaining in the wound bed leading to failure. The election of different surgical options depends on the expertise of the surgeons selected for the multidisciplinary teams. It is the aim of this article to provide a sample of surgical techniques in order to remove the bone infection from the forefoot while avoiding amputations.

The influence of the length of the first metatarsal on the risk of reulceration in the feet of patients with diabetes.

Our aim was to identify the optimal diagnostic cutoff point on the scale of protrusion measurements of the first metatarsal (M1) to predict the probability of reulceration after metatarsal head resection in patients with diabetes mellitus. We conducted a prospective study of patients with diabetes who underwent resection of at least 1 metatarsal head in our department. After surgery, we measured the difference in length (protrusion) between the M1 and the longest of the 4 lesser metatarsals by radiographic view. The patients were divided into those in whom the M1 was the longest of the 5 metatarsals (group 1) and patients in whom at least one of the lesser metatarsals was longer than the M1 (group 2). They were followed-up for 12 months and were assessed for reulceration. Ninety-one patients were included in the present study: 43 (47%) in group 1 and 48 (53%) in group 2. In group 1, the longer the protrusion of M1 was, the higher the probability for reulceration (P < .001, 95% confidence interval = 0.813-0.997). In group 2, the shorter the protrusion of M1, the higher the probability for reulceration (P = .002, 95% confidence interval = 0.628-0.905). The optimal cutoff point for group 1 was 11 mm (sensitivity = 84.6%, specificity = 86.7%) for the probability of reulceration. In group 2, it was -7 mm (sensitivity = 81.8%, specificity = 65.4%). These results suggest that M1 protrusion is an optimum prognostic indicator for reulceration and could be recommended for detecting patients at risk of reulceration after surgery.

Diabetic foot units in Spain: knowing the facts using a questionnaire.

OBJECTIVE: To ascertain the number of diabetic foot units (DFUs) in Spain, the specialists working in them, and the population covered by them. MATERIAL AND METHODS: The Spanish Group on the Diabetic Foot (SGDF) prepared and agreed a questionnaire based on the recommendations of the 2011 International Consensus on the Diabetic Foot (ICDF). From October to December 2012, the questionnaire was sent to members of three scientific societies formed by professionals involved in the care of patients with diabetes mellitus. Population coverage of the responding centers and DFUs was estimated using the 2012 population census. RESULTS: Seventy five questionnaires were received, 64 of them from general hospitals, which accounted for 13% of the general hospitals of the National Health System. It was calculated that they provided coverage to 43% of the population. Thirty four centers answered that they had a DFU. Specialized diabetic foot care was only provided to 25% of the population. The number of different professionals working at diabetic foot units was 6.3±2.7. Classification of DFUs based on their complexity was as follows: 5 basic units (14.7%), 20 intermediate units (58.8%), and 9 excellence units (26.5%). CONCLUSIONS: The number of DFUs reported in this study in Spain is low, and allow for foot care of only one out of every four patients with diabetes. Spanish health system needs to improve diabetic foot care by creating new DFUs and improving the existing ones.

Factors associated with calcification in the pedal arteries in patients with diabetes and neuropathy admitted for foot disease and its clinical significance.

The aim of this study was to determine the factors associated with calcification in the pedal arteries (CPAs) in a population of patients with diabetes admitted for acute foot disease and to find whether the presence of CPAs had any influence on the short-term outcomes. Electronic charts were retrospectively reviewed for patients admitted to our department for acute diabetic foot problems between January 1, 2008, and December 31, 2012. Digital images of the plain x-rays, which were performed on patients during this period, were reviewed. Patients were classified into 2 groups: those with absence (group 1) and presence of CPAs (group 2). One hundred and sixty-five patients were included in the present study. Ninety-eight (59.4%) patients had CPAs in the plain x-rays. The predictive variables related to the presence of CPAs were duration of diabetes >20 years (odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.0-4.3), retinopathy (OR = 2.2, 95% CI = 1.0-4.6), albuminuria (OR = 3.3, 95% CI = 1.5-7.4), and peripheral arterial disease (OR = 4.2, 95% CI = 2.0-8.7). Fifty-six patients underwent amputation (33.9%): 13 (19.4%) in group 1 and 43 (43.9%) in group 2 (P < .01). Thirty-four patients (20.6) required reoperation: 6 (9%) in group 1 and 28 (28.6%) in group 2 (P < .01). In conclusion, the predictive variables related to the presence of CPAs in a series of patients admitted for foot disease were duration of diabetes >20 years, retinopathy, albuminuria, and peripheral arterial disease. Differences in the outcomes were related to the association of CPAs with peripheral arterial disease.

Gram-negative diabetic foot osteomyelitis: risk factors and clinical presentation.

Osteomyelitis frequently complicates infections in the feet of patients with diabetes. Gram-positive cocci, especially Staphylococcus aureus, are the most commonly isolated pathogens, but gram-negative bacteria also cause some cases of diabetic foot osteomyelitis (DFO). These gram-negatives require different antibiotic regimens than those commonly directed at gram-positives. There are, however, few data on factors related to their presence and how they influence the clinical picture. We conducted a retrospective study to determine the variables associated with the isolation of gram-negative bacteria from bone samples in cases of DFO and the clinical presentation of these infections. Among 341 cases of DFO, 150 had a gram-negative isolate (alone or combined with a gram-positive isolate) comprising 44.0% of all patients and 50.8% of those with a positive bone culture. Compared with gram-positive infections, wounds with gram-negative organisms more often had a fetid odor, necrotic tissue, signs of soft tissue infection accompanying osteomyelitis, and clinically severe infection. By multivariate analysis, the predictive variables related to an increased likelihood of isolating gram-negatives from bone samples were glycated hemoglobin <7% (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.1-3.5) and a wound caused by traumatic injury (OR = 2.0, 95% CI = 1.0-3.9). Overall, patients whose bone samples contained gram-negatives had a statistically significantly higher prevalence of leukocytosis and higher white blood cell counts than those without gram-negatives. In conclusion, gram-negative organisms were isolated in nearly half of our cases of DFO and were associated with more severe infections, higher white blood cell counts, lower glycated hemoglobin levels, and wounds of traumatic etiology.

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.

Controversies regarding radiological changes and variables predicting amputation in a surgical series of diabetic foot osteomyelitis.

BACKGROUND: To investigate if radiological changes have any influence on the outcomes of surgical treatment of diabetic foot osteomyelitis. METHODS: Data of patients included in a prospective cohort who underwent surgical treatment for definitive osteomyelitis were analyzed. Cases were classified according to radiological changes as "early osteomyelitis" when no radiological changes were found or in cases showing periosteal elevation and/or subcortical demineralization and/or cortical disruption. Cases showing sequestra and/or gross bone destruction were classified as "advanced osteomyelitis". RESULTS: Early osteomyelitis was defined according to radiological findings in 37 cases (45.7%) and advanced in 44 (54.3%). Advanced osteomyelitis was not associated with the risk of undergoing amputation. CONCLUSIONS: The bone changes seen in simple X-rays in cases of osteomyelitis do not have any prognostic value when surgical treatment is undertaken. The outcomes are more related to soft tissue involvement than bone destruction seen in simple X-rays.

Limb salvage for spreading midfoot osteomyelitis following diabetic foot surgery.

Osteomyelitis is a challenging problem when it appears in the feet of patients with diabetes. Although the most frequent port of entry for bacteria is an ulcer, surgical wounds also permit entry of bacteria into the foot. This surgical complication may become limb-threatening, and treatment is a challenge. Here we present two cases of patients with neuropathic feet and palpable distal pulses, who were previously treated with surgery, and who presented with spreading bone infection in the midfoot. Pictures and radiological studies are shown. In both cases, bone infection caused severe destruction of the architecture of the midfoot, and the limbs of both patients were threatened. Midfoot osteomyelitis is associated with a higher rate of major amputations than osteomyelitis of the forefoot. Furthermore, meticillin-resistant Staphylococcus aureus was isolated in one of the cases. Our successful limb salvage approach was based on three steps: 1) removing the infected bone; 2) culture-guided antibiotic treatment; and 3) stabilizing the infected foot by means of total contact casting with openings resulting in a stable foot. To the best of our knowledge, there are no reports of the use of a total contact cast to stabilize an unstable and infected foot. Eight years (Case 1) and four years (Case 2) after complete healing, there were no recurrences of infection.

Surgical treatment of limb- and life-threatening infections in the feet of patients with diabetes and at least one palpable pedal pulse: successes and lessons learnt.

Outcomes of surgically treated limb- and life-threatening infections in patients with diabetes and a well-vascularized foot based only on the palpation of foot pulses are not well known. The authors retrospectively studied a series of 173 patients with diabetes and limb- (moderate) or life- (severe) threatening infections with at least one palpable pedal pulse who were admitted to their department for the treatment of infected diabetic foot from January 1, 1998, to December 31, 2009. A total of 141 patients (81.5%) presented with limb-threatening/moderate infections and 32 (18.5%) with life-threatening/severe infections. In all, 49 patients (28.3%) presented with soft tissue infections only, 90 (52%) with osteomyelitis and 34 (19.7%) with a combined infection. Amputation was needed in 74 patients (42.7%), of whom 6 needed a major amputation (3.5% of overall). A total of 99 (57.2%) patients were treated by conservative surgery. Four patients (2.3%) died during the postoperative period (30 days). Limb salvage was achieved in 167 (96.5%) of the patients who were followed up until healing. Healing of the wounds by secondary intention was achieved in a median of 72 days. Clinical results permit the observation that a high rate of limb salvage can be achieved after the surgical treatment of limb- and life-threatening infections in patients with at least one palpable pedal pulse.

Never amputate a patient with diabetes without consulting with a specialized unit.

This study presents a case report of a patient who underwent a severe infection following revascularization because dry necrosis became infected. A major amputation had been indicated because the infection did not respond to antibiotics and advanced wound care with topical negative pressure wound therapy with silver. The patient did not accept the major amputation and attended the authors' specialized unit. Persistent osteomyelitis was diagnosed with a simple X-ray, a cheap tool. Local surgery, antibiotics, appropriate wound care, and split-skin grafting achieved limb salvage in 12 weeks in this patient who had been scheduled for major amputation. Major amputation in patients with an infected foot can sometimes be avoided by correct diagnosis of infection and managing appropriately with specialized support.

In-hospital complications and mortality following major lower extremity amputations in a series of predominantly diabetic patients.

The purpose of this study was to analyze the outcomes of major lower extremity amputations (MLEAs) in a series, including diabetic patients, with the aim to study whether diabetes mellitus is a risk factor of in-hospital mortality and perioperative complications. A retrospective analysis of 283 MLEAs (221 of these patients were diabetic and 62 were nondiabetic) performed between January 1, 1998, and December 31, 2008, at the General Surgery Department and Diabetic Foot Unit of La Paloma Hospital in Las Palmas de Gran Canaria (Canary Islands) was done. The significant risk factors of mortality were >" xbd="324" xhg="301" ybd="1481" yhg="1446"/>75 years of age (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 1.4-11.7), postoperative cardiac complications (OR = 12.3, 95% CI = 3.7-40.2) and postoperative respiratory complications (OR = 3.8, 95% CI = 1.0-13.3). No statistically significant risk factors were found related to the presence of systemic and wound-related complications. In diabetic patients, the significant risk factors of mortality were postoperative cardiological complications (OR = 13.6, 95% CI = 3.1-59.6), postoperative respiratory complications (OR = 5.9, 95% CI = 1.0-35.5), and first episode of amputation (OR = 5.9, 95% CI = 1.4-24.3). There were no statistically significant differences in the outcome of major amputations between diabetic and nondiabetic patients. Hospital stay was significantly longer in diabetic patients (P < .01) though when the patients with diabetic foot infections were excluded, this difference was not found.

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.

Epidemiology of diabetes-related lower extremity amputations in Gran Canaria, Canary Islands (Spain).

We have studied the rate of lower extremity amputations (LEAs) in the south of Gran Canaria. The incidence rate was 319.7 per 100,000 (95% CI, 258.6-380.8) per year in the diabetic subjects. The incidence of both diabetic and non-diabetic LEAs is the highest reported in Spain.