Surgical management of the acute severely infected diabetic foot - The 'infected diabetic foot attack'. An instructional review

Diabetic foot attack: Managing severe sepsis in the diabetic patient

Diabetic foot attack (DFA) is the most severe presentation of diabetic foot disease, with the patient commonly displaying severe sepsis, which can be limb or life threatening. DFA can be classified into two main categories: Typical and atypical. A typical DFA is secondary to a severe infection in the foot, often initiated by minor breaches in skin integrity that allow pathogens to enter and proliferate. This form often progresses rapidly due to the underlying diabetic pathophysiology of neuropathy, microvascular disease, and hyperglycemia, which facilitate infection spread and tissue necrosis. This form of DFA can present as one of a number of severe infective pathologies including pyomyositis, necrotizing fasciitis, and myonecrosis, all of which can lead to systemic sepsis and multi-organ failure. An atypical DFA, however, is not primarily infection-driven. It can occur secondary to either ischemia or Charcot arthropathy. Management of the typical DFA involves prompt diagnosis, aggressive infection control, and a multidisciplinary approach. Treatment can be guided by the current International Working Group on the Diabetic Foot/Infectious Diseases Society of America guidelines on diabetic foot infections, and the combined British Orthopaedic Foot and Ankle Society-Vascular Society guidelines. This article highlights the importance of early recognition, comprehensive management strategies, and the need for further research to establish standardized protocols and improve clinical outcomes for patients with DFA.

Autologous adipose-derived tissue stromal vascular fraction and intralesional epidermal growth factor combined application in patients with diabetic foot

OBJECTIVE

The aim of this study was to evaluate the effect on wound healing of intralesional epidermal growth factor (iEGF) (Heberprot-p; Hasbiotech, Cuba) and autologous adipose-derived tissue stromal vascular fraction (AD-tSVF) applied in the closure of tissue defects.

METHOD

The patients included in the study were separated into three approximately equal groups: Group 1 with iEGF+AD-tSVF applied; Group 2 with iEGF only applied; and Group 3 with conventional wound care products applied. Granulation tissue was taken from the wound bed before the application of iEGF and AD-tSVF and at intervals thereafter for flow cytometry analysis.

RESULTS

Group 1 included 11 patients; Group 2 included 10 patients; and Group 3 included 10 patients. The time to re-epithelialisation was determined as 187.60±68.78 days in Group 3 patients compared with Group 1 (72.27±10.33 days) and Group 2 (70.50±18.02 days) (p<0.001). Following the application of iEGF to the wound bed, an increase was observed in M2 macrophage (CD209+), and M1 macrophage (CD38+) levels. The (CD34+) stem cells obtained from the granulation tissue after the application of AD-tSVF were determined to still be statistically significantly increased in the wound bed on the 21st day.

CONCLUSION

The results of this study demonstrated that the application of iEGF and iEGF+ AD-tSVF significantly shortened the wound healing period compared with conventional methods. AD-tSVF stands as an effective option, especially in the patient group with halted or delayed wound healing despite the application of iEGF. Moreover, the significant increase (p<0.001) in the level of M2 macrophages (CD209+), M1 macrophages (CD38+) and stem cells (CD34+) provided by this treatment modality showed that it contributed to wound healing at the cellular level.

Imaging of porphyrin-specific fluorescence in pathogenic bacteria in vitro using a wearable, hands-free system

Fluorescence imaging is an effective method for detecting porphyrin production in bacteria, leveraging the natural fluorescence properties of porphyrins. Here we use a simple, lightweight, hands-free device for rapid, non-invasive assessments in clinical settings, microbial research, and diagnostic applications. Specifically in this study, we examined 15 bacterial and 2 fungal strains commonly associated with skin, oral, and/or multi-site infections at wound sites for their ability to autofluoresce based on their porphyrin production. We utilized Remel Porphyrin Test Agar and blood agar plates to monitor red fluorescence over several days of growth under aerobic or anaerobic conditions using the wearable REVEAL FC imaging system with a 405 nm violet excitation headlight paired with eyewear carrying 430 nm emission lenses. Fourteen of the fifteen bacteria produced red fluorescence when grown on Porphyrin Test Agar and nine of the fifteen bacteria also displayed red fluorescence on blood agar plates, consistent with their ability to synthesize porphyrins. Taken together, our results elucidate the sensitivity, effectiveness, and convenience of using wearable technology to detect pathogens that produce porphyrin-specific fluorescence. Consequently, the REVEAL system has immense potential to help diagnose wound infections, direct clinical procedures, and guide treatment options in real-time using fluorescence imaging all while minimizing the risk of contamination.

Definitive single-stage surgery for treating diabetic foot osteomyelitis: a protocolized pathway including antibiotic bone graft substitute use

BACKGROUND

Diabetic foot ulcers (DFUs) are a challenging complication of diabetes mellitus, often leading to poor clinical outcomes and significant socioeconomic burdens. We evaluated the effectiveness of a definitive single-stage protocolized surgical management pathway, including the use of local antibiotic bone graft substitute, for the treatment of infected DFUs with associated osteomyelitis.

METHODS

A retrospective cohort study was conducted. Medical records were extracted (from January 2017 to December 2020) to establish a database consisting of patients who underwent surgical intervention for the treatment of an infected DFU with osteomyelitis. Patients were divided into conventional (control) and protocolized (intervention) surgical groups depending on the treatment received. Clinical outcomes were assessed over a 12-month follow-up period.

RESULTS

A total of 136 consecutive patients were included (conventional = 33, protocolized = 103). The protocolized group demonstrated a statistically significant reduction in the mean number of operations performed per patient (1.2 vs. 3.5) (P < 0.001) and a shorter accumulative hospital length of stay (12.6 vs. 25.1 days) (P < 0.001) compared to the conventional group. Major amputation rates were significantly lower in the protocolized group (2% vs. 18%) (P < 0.001). Within 12 months of surgical intervention, the protocolized group exhibited an ulcer healing rate of 89%, with a low rate of recurrence (3%).

CONCLUSION

The protocolized surgical pathway, including local antibiotic bone graft substitute use, demonstrated superior outcomes compared to conventional management for the treatment of infected DFUs with osteomyelitis. Further research is needed to evaluate the cost-effectiveness and generalizability of this approach.

Comprehensive nursing model for diabetic foot ulcers: A strategy to improve prognosis and quality of life

Diabetic foot (DF) ulcer is one of the common complications of diabetic patients, with high incidence and amputation rate, which seriously affects the quality of life and health of patients. Therefore, how to effectively prevent and treat DF ulcers and reduce amputation rate has become an urgent problem in the medical field. As a comprehensive nursing model for patients with DF ulcers, comprehensive nursing intervention is designed to improve the therapeutic effect and prognosis and reduce the rate of amputation. Convenient sampling method was used to select 360 patients with DF who received routine care for DF ulcers from July 2013 to July 2023 for retrospective cohort analysis. According to the existence of exposure factors (comprehensive nursing intervention), 180 cases were divided into observation group and comparison group. The basic demographic data, amputation rate, severity of foot ulcer, neuropathy and vascular disease, and blood glucose control were compared between the 2 groups. The data was analyzed using SPSS26.0. Harman single factor test was used to check whether there was common method bias in the study data. Descriptive analysis, Spearman rank correlation analysis and multiple linear regression analysis were used to analyze the current situation of amputation rate of DF patients and the influence of comprehensive nursing intervention on the amputation rate of DF patients. The amputation rate was 2.8% in the Observation group compared to 8.3% in the Comparison group. The amputation rate of the observation group was generally higher in the age group, and the amputation rate of the observation group was higher in the middle school education level and below and the economic status of <5000 yuan. The difference was statistically significant (P < .05). Age (odds ratio [OR] = 1.96; 95% confidence interval [CI]: 0.88-4.38), education level (OR = 1.30; 95% CI: 1.69-6.46), economic status (OR = 2.28; 95% CI: 1.69-10.85) was an independent risk factor for amputation rate (P < .05). Comprehensive nursing interventions have played a positive role in reducing the rate of amputation in patients with DF.

Surgical management of the diabetic foot: The current evidence

The prevalence of diabetes mellitus and its associated complications, particularly diabetic foot pathologies, poses significant healthcare challenges and economic burdens globally. This review synthesises current evidence on the surgical management of the diabetic foot, focusing on the interplay between neuropathy, ischemia, and infection that commonly culminates in ulcers, infections, and, in severe cases, amputations. The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies, as diabetic foot complications are a leading cause of hospital admissions among diabetic patients, significantly impacting morbidity and mortality rates. This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers, infections, and skeletal pathologies such as Charcot arthropathy, emphasising the critical role of early diagnosis, comprehensive management strategies, and interdisciplinary care in mitigating adverse outcomes. In addressing surgical interventions, this review evaluates conservative surgeries, amputations, and reconstructive procedures, highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies. The integration of advanced diagnostic tools, novel surgical techniques, and postoperative care, including offloading and infection control, are discussed in the context of optimising healing and preserving limb function.

Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF

In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.

An Orthopedic Perspective on Diabetic Foot Attack - A Case Report

Introduction

Diabetic foot attack (DFA), also known as diabetic foot ulceration, is a severe and potentially limb-threatening complication of diabetes mellitus. It refers to the development of open sores or ulcers on the feet of individuals with diabetes, often leading to infections, tissue damage, and, in extreme cases, amputation. The underlying cause of DFAs is multifactorial and involves a complex interplay of various factors, including peripheral neuropathy, peripheral arterial disease, foot deformities, impaired wound healing, and poor glycemic control. This case report would be first of its kind from an orthopedic perspective.

Case Report

A 55-year-old white British gentleman, a chronic uncontrolled Type 2 diabetic, was referred by the medical team on a busy on-call night. He presented with a sudden onset pain, swelling, and difficulty in weight bearing on his left foot. He had a non-healing plantar ulcer for over a year. His inflammatory markers were abnormally high and magnetic resonance imaging of his leg and foot showed massive collection in his foot with gas extending along the posterior compartment. Diagnosis of a severe DFA was made, and urgent debridement and washout were carried out. Despite aggressive debridement, patient progressively deteriorated warranting an admission into intensive care unit. After subsequent debridement and local antibiotic therapy, he recovered and was discharged with clinic follow-up.

Conclusion

Effective management strategies for DFAs encompass a multidisciplinary approach. Preventive measures play a key role in reducing the incidence of DFAs. Regular foot examinations, self-care education, proper glycemic control, and foot hygiene are essential components of preventive strategies. Patient education regarding self-monitoring, appropriate footwear, and early recognition of foot-related complications is crucial to empower individuals with diabetes to take proactive measures.

Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon

Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.

Characteristics and management of patients undergoing emergency surgery for diabetic foot attack

BACKGROUND

Diabetic foot attack (DFA) is considered one of the worst manifestations of diabetic foot. It is necessary to act quickly to prevent amputation and save the patient's life. The aim of this study is to reveal the characteristic features of DFAs and be a guide to healthcare professionals to manage and refer these patients.

METHODS

Sixty-five patients with DFAs were analyzed retrospectively. Demographics were collected. All patients' ınfectious dis-eases Society of America/International Working Group on the Diabetic Foot (IDSA/IWDGF) stages, site ıschemia neuropathy, bacterial ınfection and depth (SINBAD) and laboratory risk ındicator for necrotizing fasciitis (LRINEC) scores were calculated. According to these measurements, patients were categorized and statistical results were obtained.

RESULTS

We found that patients who underwent emergency surgery due to DFA applied to an average of two hospitals before applying to our facility and the median acceptance time since the beginning of the first complaint was 9 days. All patients were IDSA/IWDGF stages three and four. Most of the patients had SINBAD scores between four and six. 60% of the patients were at high risk for necrotizing fasciitis according to the LRINEC score. 58.2% of patients had periferic arterial stenosis and the amputation rate was 69.2%. 21.3% of the patients were followed in the intensive care unit, and our patients' mortality rate was 4.2%.

CONCLUSION

DFA is an emergency surgical condition that requires high clinical suspicion. If not diagnosed and treated with emergency surgery, it has a high mortality and amputation rate. High white blood cell count in patients, local and systemic signs of inflammation, presence of subcutaneous emphysema in the lower extremities on a direct X-ray radiography, and high blood sugar should be considered as warning signs for DFA. Emergency surgical intervention should be performed on these patients, and if the patient is not in a suitable center for emergency surgery, they should be rapidly referred to a center with experienced clinicians.

Treatment of Infected Nonunions With Bone Defects Using Autologous Bone Graft and Absorbable Antibiotic-Loaded Calcium Sulfate-Hydroxyapatite Paste

BACKGROUND

Revision surgery in the presence of infection carries high risks. We describe our results using a new technique to treat these challenging problems. We treated infected nonunions with cavitary voids with adjuvant antibiotic loaded calcium sulfate-hydroxyapatite paste composite and autologous bone graft (ABG) layer technique coupled with stable fixation.

METHODS

Thirty consecutive patients who underwent revision foot and ankle surgery for an infected nonunion were prospectively studied. Following multidisciplinary team workup, surgical debridement and biopsies were undertaken. Bone voids were measured and classified according to containment and size. ABG was mixed and layered with an adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste followed by surgical reconstruction including arthrodesis and fixation. Empirical and pathogen-specific antibiotics were instituted until intraoperative sample-specific antibiotics were identified and used. Patients were prospectively followed up for a minimum of 1 year.

RESULTS

The male-female ratio was 16:14, mean age was 51.3 years, and 23.3% smoked at definitive surgery. Void volume was <1 cm³ (n=9), 1-2 cm³ (n = 13), and >2 cm³ (n=8). No patients either were lost to follow-up or had a further infective episode at a mean of 38.3 months; 86.7% united with fusion on imaging. Four patients had radiographic evidence of nonunion; 3 were asymptomatic and 1 required revision surgery (void >2 cm³). Independent ambulation was achieved at an average of 12 weeks, at 1 year mean American Orthopaedic Foot & Ankle Society score was 77.7 (SD 9.59), and the Manchester-Oxford Foot Questionnaire reached an effect size >0.5 in all domains at 1 year following surgery. The union rate was independent of smoking status and vitamin D deficiency (P = .94).

CONCLUSION

Layered autologous bone grafting with adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste has been shown to be effective and safe in revision arthrodesis, with low comorbidities in void gaps without infection recurrence.