A step-wise approach for surgical management of diabetic foot infections.

Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to effect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with special emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure.

Chronic, painful lower extremity wounds: postoperative pain management through the use of continuous infusion of regional anaesthesia supplied by a portable pump device.

Reducing and preventing postoperative pain are currently a topic of great interest. There are different modalities for providing analgesia that can provide an alternative or adjunct to opioid therapy. One mode of therapy involves the use of portable pain pump devices that can deliver continuous local anaesthesia directly to the site of interest. A considerable amount of attention in literature has been dedicated to using regional anaesthesia postoperatively for various surgical applications. However, to our knowledge, little or no work has been published concerning the use of infusion of regional anaesthesia in the treatment of painful lower extremity wounds. We present a case report of a 55-year-old gentleman with a complex past medical history, 2-year history of opioid dependency and a 2-week history of intractable pain associated with the combination of debilitating painful diabetic neuropathy and painful lower extremity wounds. After surgical debridement of the lower extremity wounds, substantial analgesia was achieved postoperatively through the implantation of a portable direct infusion pump device. The device supplied 2 ml/hour of 0.25% bupivacaine and resulted in a reduction in pain within the first hour of implantation. Although the device achieved maximal analgesia at 6 hours, we found that this could have been likely reduced through the use of a 5-ml bolus dose of 0.25% bupivacaine at the time of implantation. The device provided sufficient analgesia to the patient without any observed adverse effects, and showed significant potential in avoiding an increase in his requirement for other systemic analgesia including opioids.

Novel use of platelet-rich plasma to augment curative diabetic foot surgery.

Autologous platelet-rich plasma (PRP) may enhance wound healing through the formation of a platelet plug that provides both hemostasis and the secretion of biologically active proteins, including growth factors such as platelet-derived growth factor, transforming growth factor (TGF)-ß, TGF-ß2, and epidermal growth factor. The release of these growth factors into the wound may create an environment more conducive to tissue repair and could accelerate postoperative wound healing. To our knowledge, there are no reports of combining the use of PRP with curative diabetic foot surgery. This article provides a summary of the literature regarding PRP and wound healing and presents a case of a 49-year-old man with diabetes and a three-month history of a deep, nonhealing plantar hallux wound in which PRP was combined with a first metatarsophalangeal joint arthroplasty. Through the use of the PRP and bioengineered tissue to supplement curative diabetic foot surgery, the patient healed uneventfully at seven weeks.

A stepwise approach for surgical management of diabetic foot infections.

Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health-care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to affect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health-care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure.

Novel use of doxycycline in continuous-instillation negative pressure wound therapy as "wound chemotherapy".

Negative-pressure wound therapy (NPWT) is frequently employed in the treatment of complex wounds. The authors present a description of real-time streaming therapy of a variety of wound chemotherapeutic agents through NPWT. Doxycycline, which acts as a competitive inhibitor of matrix metalloproteinases and tumor necrosis factor alpha and further decreases inflammation through the reduction of nitrous oxide production, may prove helpful when delivered in this manner. To the authors' knowledge, this is the first report in the literature describing this method of delivery of doxycycline.

Novel use of insulin in continuous-instillation negative pressure wound therapy as "wound chemotherapy".

Negative pressure wound therapy (NPWT) is frequently employed in the treatment of complex wounds. A variety of wound chemotherapeutic agents such as insulin, which acts as a growth factor, may prove helpful in treatment as well. We present a case report in which insulin was used as a chemotherapeutic agent in continuous-instillation NPWT. To our knowledge, this is the first report in the literature describing this method of delivery.

An update on pharmacological interventions for diabetic foot ulcers.

Diabetic foot ulcers are the most common lower extremity complications of diabetes. Peripheral neuropathy and peripheral vascular disease are the underlying risk factors for diabetic foot ulcers, subsequently leading to infections and requiring antimicrobial therapy for the management of the disease. Each risk factor is a target for clinical intervention, with the intent to delay or prevent disease progression to amputation. The effective therapy includes interdisciplinary care, which involves optimized pharmacological interventions in concert with other treatments such as debridement strategies and specialized wound dressings. The pharmacological therapy alone cannot lead to successful therapy, and therefore, these supplementary techniques/modalities should not be overlooked. It is therefore the aim of this report to review various pharmacological interventions, specific to the diabetic foot and wound healing, along with incorporation of advanced therapies required to achieve a multifaceted treatment of diabetic foot ulcers and provide basis for superior drugs as well as drug delivery systems.