Foot lesions in patients with diabetes mellitus

Diagnostic value of procalcitonin, erythrocyte sedimentation rate (ESR), quantitative C-reactive protein (CRP) and clinical findings associated with osteomyelitis in patients with diabetic foot

BACKGROUND

The diagnosis of osteomyelitis is a key step of diabetic foot management. Procalcitonin (PCT) is a novel infection marker. This study aimed to investigate the diagnostic value of procalcitonin and other conventional infection markers and clinical findings in diagnosis of osteomyelitis in diabetic foot patients.

METHODS AND MATERIALS

This diagnostic value study was carried out on ninety patients with diabetic infected foot ulcers admitted in Kashan Beheshti Hospital, 2016. After obtaining consent, 10 cc blood sample was taken for measuring serum PCT, CBC, ESR, CRP and FBS. Clinical characteristics of the wounds were noted. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis. All statistical analyses were done with the use of SPSS-16.

RESULTS

PCT levels were 0.13 ± 0.02 ng/mili patients with osteomyelitis (n= 45) and 0.04 ± 0.02 ng/ml in patients without osteomyelitis (n= 45). PCT, Erythrocyte sedimentation rate and C-reactive protein was found significantly higher in patients with osteomyelitis (p< 0.001). The ROC curve was calculated for PCT. The area under the ROC curve for infection identification was 1 (p< 0.001). The best cut-off value for PCT was 0.085 ng/ml. Sensitivity, specificity, and positive and negative predictive values were 100%, 97.8%,97.8% and 100%, respectively.

CONCLUSION

In this group of patients, PCT was useful to discriminate patients with bone infection. Also, Erythrocyte sedimentation rate and C-reactive protein can be used as a marker of osteomyelitis in diabetic patients.

The Relationship Between Blood Hypoxia-Inducible Factor-1α, Fetuin-A, Fibrinogen, Homocysteine, and Amputation Level

Reduced life expectancy has resulted from an increased incidence of chronic complications in patients with diabetes. The diabetic foot is one of these complications and generally presents together with diabetic neuropathy and vascular insufficiency. Hypoxia-inducible factor-1α (HIF-1α) is important in developing the adaptation response to hypoxia and facilitates healing through regulation of keratinocyte migration and epithelium restoration in wounds. Fetuin-A is a transporter protein that is synthesized in the liver and inhibits vascular and ectopic calcifications. It has been observed that altered fetuin-A is associated with peripheral artery disease through vascular calcification and is associated with inflammation and metabolic syndrome occurrence in diabetic patients. Fibrinogen is an acute-phase reactant and has a major role in homeostasis, tissue repair, and wound healing. Increased fibrinogen blood level is one of the factors that facilitates the hypercoagulability in diabetics. Homocysteine has atherogenic features and causes vascular toxicity by enhancing low-density lipoprotein oxidation. We evaluated the association of serum HIF-1α, fetuin-A, fibrinogen, and homocysteine levels with amputation in 31 patients diagnosed with diabetes mellitus. According to our evaluation, a negative correlation was determined between fetuin-A and amputation level (P = .012, r = -0.450), which was statistically significant. Unfortunately, there was no significant correlation between HIF-1α, fibrinogen, homocysteine, and amputation level (P > .05). As a result, it was suggested that vascular calcification due to fetuin-A deficiency may be important in the diabetic foot pathogenesis and that fetuin-A levels may be a predictor for amputation level.

Assessment of tissular integrity in patients with diabetic foot

ABSTRACT Objective: Evaluate the impairment of tissue integrity in patients with diabetic foot and verify its association with time of diagnosis of the disease. Methods: Cross-sectional study conducted with 134 patients in an outpatient clinic located in the Northeast region of Brazil. A semi-structured questionnaire was used for data collection, which was subjected to descriptive analysis and the Mann-Whitney U non-parametric test. Results: Indicators with the lowest average score were: skin temperature, sweating, skin lesions, right and left pedal pulses, right and left tibial pulses. Patients less than ten years old had worse scores on thickness, elasticity, right tibial pulse and tissue integrity. Those with a diagnosis time of more than ten years had a greater impairment of sensation and right pulse. Conclusion: All indicators showed some impairment of tissue integrity, and the time of diagnosis of the disease was associated with six of these.

Cause-Specific Risk Factors of Death in Individuals with Diabetes: A Competing Risks Modeling

BACKGROUND

Diabetes is on the rise worldwide.

OBJECTIVES

This study aimed to evaluate the risk factors of various causes of death in people with type 2 diabetes (T2D).

METHODS

In this cohort study on 2638 people with T2D, we applied cause-specific and sub-distribution hazards models to assess the impact of various factors on the risk of death. Moreover, we plotted a cumulative incidence curve to summarize cumulative failure rates over time.

RESULTS

About 75% of individuals with T2D died from cardiovascular disease (CVD) and cerebrovascular accidents (CVA). Death from CVD was associated with the increased risk of hypertension (hazard ratio (HR) = 1.83, 95% CI: 1.37 - 2.46), hypercholesterolemia (HR = 1.58, 95% CI: 1.17 - 2.14), and diabetes duration. The risk of death from CVA was related to hypertension (HR = 2.76, 95% CI: 1.67 - 4.55) and hyperglycemia (HR = 4.34, 95% CI: 1.75 - 10.79). The CVA risk in patients with diabetes duration of 10 - 20 years was higher than the risk in patients with diabetes duration > 20 years (diabetes duration of ≤ 10 years as the reference category). Diabetes duration of longer than 20 years was associated with a higher risk of death from cancer (HR = 2.65, 95% CI: 1.05 - 6.68). The risk of death from foot infection and diabetic nephropathy increased in patients with longer diabetes duration after adjustment for sex, age, and body mass index.

CONCLUSIONS

Regardless of the cause, death rates in people with T2D increase over time and risk factors have different impacts on death from each cause. This should be acknowledged in risk management in individuals with T2D.

Illness invalidation from spouse and family is associated with depression in diabetic patients with first superficial diabetic foot ulcers

OBJECTIVES

(1) To assess the prevalence of depressive disorders in a sample of diabetic patients with their first superficial diabetic foot ulcer. (2) To evaluate the association between illness invalidation from spouse, family, and depressive disorders in those patients.

METHODS

Depressive disorders and severity were diagnosed by the Structured Clinical Interview for DSM-IV Axis Ι disorders, clinical version, and the spouse and family scales of the Illness Invalidation Inventory, respectively (3*I). Physical functioning was also assessed using the Physical Component of The Short Form 36 item health-related quality of life questionnaire.

RESULTS

The prevalence of depressive disorders was 27.50% (22/80). There was a significant decrease in physical health component summary mean score and a significant increase in ulcer size, Center for Epidemiologic Studies-Depression Scale, spouse discounting, spouse lack of understanding, and family discounting mean scores in the depressed group compared to the non-depressed group. Higher levels of spouse discounting, spouse understanding, and family discounting were significant predictors of diagnosis of depressive disorders and were strongly associated with increased severity of depressive symptoms in diabetic patients with first superficial diabetic foot ulcers. Poor physical functioning was associated with increased depressive symptom severity.

CONCLUSION

This study demonstrated that illness invalidation from spouse and family is associated with diagnosis of depressive disorders and increased severity of depressive symptoms in diabetic patients with first superficial diabetic foot ulcers.

Can Ratio of Neutrophil-to-Lymphocyte Count and Erythrocyte Sedimentation Rate in Diabetic Foot Infecti on Predict Osteomyelitis and/or Amputation?

The aim of this study was to search for any relations between the neutrophil-to-lymphocyte ratio (NLR) and the development of osteomyelitis and the need for amputation in patients with diabetic foot infection (DFI). All data included DFI patients who were hospitalized in our Infectious Diseases Clinic between 2012 and 2015 and who were classified according to International Classification Disease Code System. 75 patients were analyzed in the study. The DFI patients were stratified into 3 groups of whom had amputation procedure, whom had only debridement/drainage procedure and whom had any surgery procedure. Sidac post hoc analysis was used to perform the effects of NLR, C-reactive protein, erythrocyte sedimentation rate and glycosylated hemoglobin on the surgery procedure status. The DFI patients were also stratified into two another separate group for another analysis to search for the effect of NLR values on the development of osteomyelitis. The mean value of NLR in the amputated patients’ group (15.7±10.3 was significantly higher than those with debridement procedure (9.9±5.6) and those without any surgery (6.0±2.8) (P=0.001). NLR values were also found significantly higher in patients with osteomyelitis in the second analysis (P=0.004). In this study, the NLR was found to have a predictive value on the development of osteomyelitis and on the progression to amputation in patients with DFI.

The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration

BACKGROUND

Diabetic foot infections are associated with substantial morbidity and mortality. Prediction of diabetic foot ulcer outcome may be helpful for optimizing management strategy. This study aimed to determine the major predictors of amputation and length of stay in diabetic patients with acute foot ulceration.

METHODS

A total of 55 type 2 diabetic patients with diabetic foot infection were enrolled. The patients were evaluated according to the Infectious Diseases Society of America and International Working Group on the Diabetic Foot criteria and also the Wagner's classification. Blood samples were taken at the start of hospitalization for the measurement of glucose, hemoglobin A1C (HbA1C), white blood cells (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Length of stay in hospital was recorded.

RESULTS

WBC and CRP were significantly higher in lower-extremity amputation (LEA) group (p = 0.001 and p = 0.008, respectively); also, ESR was higher in this group, but there was no statistical significance. Wagner grade and infection severity were significantly higher in the LEA group as compared with the non-LEA group (both p values < 0.001). Glycemic control parameters (i.e., HbA1C, plasma glucose) were not different in LEA and non-LEA groups. In correlation analyses, amputation rate was negatively correlated (r = - 0.512, p < 0.001) with length of stay. WBC, ESR, CRP, Wagner grade, and severity of infection showed positive correlation with length of stay (r = 0.493, p < 0.001; r = 0.271, p = 0.045; r = 0.299, p = 0.027; r = 0.434, p = 0.001; and r = 0.464, p < 0.001, respectively).

CONCLUSIONS

Baseline levels of acute-phase reactants, especially CRP, WBC, ESR, and increased Wagner grade, appeared to be helpful in predicting amputation and length of stay in diabetic patients with acute foot ulceration. However, duration of diabetes and glucose control seems to have no effect.

Prevention of lower-limb lesions and reduction of morbidity in diabetic patients

Objective

Methods

Results

Conclusions

The impact of religious connectedness on health-related quality of life in patients with diabetic foot ulcers

Religious connectedness is common phenomenon in Saudi Arabia and adjacent Gulf countries. An observational case control study was designed, enrolling 180 adult patients to report the association between religious connectedness and health-related quality of life (HRQL) in people with and without diabetes and foot ulcers. Sixty diabetic patients with foot ulcers (Group I) were compared with sixty diabetic patients without foot ulcer (Group II) and sixty healthy subjects (Group III) for assessment of their HRQL by using SF-36 questionnaire. The effect of religious connectedness was assessed using intrinsic/extrinsic religious connectedness scale. HRQL was found to be significantly lower in Group I compared with Group II and III as well as in group II compared with group III (P<0.001). Group I patients showed a poorer HRQL with increased severity, duration and multiplicity of foot ulcers. There was a strong positive relationship between religious connectedness and HRQL as indicated by a positive correlation between religious connectedness scale and mental, physical component summary scores (r=0.66 and 0.59 respectively and P<0.001). While quality of life is generally poor in people with diabetic foot ulcers, there exists a strong positive relationship between religious connectedness and higher HRQL. These findings may have implications on improving outcomes.

Quality of life in patients with diabetic foot ulcers: validation of the Cardiff Wound Impact Schedule in a Canadian population

The purpose of this study was to evaluate and validate the Cardiff Wound Impact Schedule (CWIS), a disease-specific quality-of-life measure, in a diabetic foot ulcer (DFU) population. Patients with DFUs have restrictions as part of their treatment and rehabilitation, which can affect health-related quality of life (HRQoL). Because of the high number of comorbidities experienced in diabetes, a disease-specific quality-of-life measure is needed to best assess the affect of a foot ulcer on HRQoL. Patients with DFUs completed the CWIS and a World Health Organization generic quality-of-life questionnaire. Validity was assessed by comparing domains of the questionnaires. Patients were categorised using the University of Texas wound classification system. Mean CWIS scores were compared between categories to assess the questionnaire's ability to differentiate wound severity. Patients with open ulcers scored significantly lower on the CWIS than those with healed ulcers. Correlations between questionnaire domains were as follows: Social Life with Social Functioning (r = 0·641, P < 0·001); Well-Being with General Health (r = 0·533, P < 0·01); Physical Symptoms and Daily Living with Physical Functioning (r = 0·631, P < 0·01) and Health-Related Quality of Life with Vitality (r = 0·425, P < 0·01). However, there was no significant difference in mean CWIS scores between categories of wound severity. We have demonstrated the ability of the CWIS in assessing HRQoL in a DFU population and its ability to differentiate between healed and non healed states.

Global burden of disease attributable to diabetes mellitus in Brazil

Type II diabetes mellitus accounts for 90% of all cases of diabetes, and its inclusion in health evaluation has shown that its complications have a considerable impact on the population's quality of life. The current article presents the results of the Global Burden of Disease Study in Brazil for the year 1998, with an emphasis on diabetes mellitus and its complications. The indicator used was disability-adjusted life years (DALY), using a discount rate of 3%. In Brazil, ischemic heart disease, stroke, and diabetes accounted for 14.7% of total lost DALYs. Brazil showed a higher proportion of years lived with disability (YLDs) among total DALYs for diabetes as compared to other countries. Retinopathy and neuropathy were the complications that contributed most to YLDs. According to forecasts, diabetes mellitus will have an increasing impact on years of life lost due to premature death and disability in the world, shifting from the 11th to 7th cause of death by 2030. It is thus urgent to implement effective measures for prevention, early diagnosis, counseling, and adequate follow-up of patients with diabetes mellitus.

Current concepts in imaging diabetic pedal osteomyelitis

Diabetic pedal osteomyelitis is primarily a manifestation of vascular insufficiency with resultant tissue ischemia, neuropathy, and infection. Nearly all cases of pedal osteomyelitis arise from a contiguous ulcer and soft tissue infection. MR imaging is the modality of choice to assess for the presence of osteomyelitis and associated soft tissue complications, to guide patient management, and to aid in limited limb resection.

Update on tissue-engineered biological dressings

Tissue-engineered biological dressings offer promise in the treatment of burns, chronic ulcers, donor site and other surgical wounds, and a variety of blistering and desquamating dermatologic conditions. For example, the prevalence of diabetic foot ulcers ranges from 4.4% to 10.5% of diabetics, resulting in 82,000 lower extremity amputations annually; venous leg ulcers affect 0.18% to 1.35% of the population; and pressure ulcers are found in 5.0% to 8.8% of institutionalized patients and 14.8% of patients in acute care facilities. Despite the large number of potential beneficiaries, cellular tissue-engineered products have suffered setbacks in recent years and have garnered considerably lower market share than commercial promoters anticipated. The mechanism of action of these products is not universally agreed upon, but delivery of growth factors and extracellular matrix components to the wound is thought to be important; graft "take" is not usually considered to occur. These "engineered" products do not specifically match a treatment modality to an underlying pathology. Clinical effect is often modest, and sometimes not justi- fiable from a cost-benefit perspective. Nevertheless, clinical reports in the literature of uses of tissueengineered biological dressings continue to mount, indicating that these products are finding niche applications where clinical utility is high and the cost can be defended. Despite commercial setbacks, the first-approved products, Dermagraft, Apligraf, and Cultured Epidermal Autograft (Epicel) are still being marketed, and new ones, such as OrCel, continue to be developed. The major indications for these products are summarized and a brief review of the available clinical literature is offered.

Caracterização de pessoas com diabetes em unidades de atenção primária e secundária em relação a fatores desencadeantes do pé diabético

OBJETIVO: estudo descritivo que caracterizou pessoas com diabetes da rede básica de saúde em relação aos fatores desencadeantes do pé diabético, considerando variáveis socio-demográficas, história clínica e risco para complicações nos pés. MÉTODOS: obtiveram-se dados mediante entrevista e avaliação dos pés. Na análise foi considerada avaliação dermatológica, estrutural, circulatória e neurológica e classificados conforme proposta de Sims e colaboradores. RESULTADOS: a idade média foi 58,5±8,5 anos; tempo da doença 8,7±6,7 anos, com ensino fundamental incompleto. Nos antecedentes clínicos 73% referiram hipertensão arterial e 22% dislipidemia. A glicemia média foi 159±79 mg/dl e HbA1c 7,8±2%. Na avaliação dos pés 73% apresentaram higiene/corte de unhas impróprios, 63% pele ressecada/descamativa, 52% unhas alteradas, 49% calos/rachaduras e 33% pé plano. Na classificação de risco identificou-se 7,9% com insensibilidade plantar e 6,9% com insensibilidade plantar e deformidade nos pés. CONCLUSÕES: estas alterações poderiam ser prevenidas com intervenções básicas e educação para cuidados com os pés.

Comparison of different screening tests for detecting diabetic foot neuropathy

INTRODUCTION

Regarding the major role of sensory neuropathy in diabetic foot ulcers, the use of an appropriate screening test for early detection of this neuropathy has a crucial role in the management of diabetic foot disorders. As there were no previous studies that performed all screening tests in the same group of patients, we performed all tests in a single group of diabetic patients and compared them to find out the possible differences between the results.

METHODS

A total of 142 diabetic outpatients at Shariati Teaching Hospital were chosen by systematic randomized selection. Different screening tests for detecting neuropathy in diabetic foot such as symptom and sign scores, Michigan Neuropathy Disability Score (MNDS), and testing by a monofilament were performed for each patient.

RESULTS

According to the neuropathy symptom score, 54.9% of the patients were neuropathic, their score was higher than 5, and by neuropathy sign score, 10.1% were neuropathic with a score higher than 6. Regarding MNDS, 42.7% of the subjects were neuropathic, with a score higher than 3. Finally, 23.9% were unable to sense at least one point in the monofilament examination.

CONCLUSIONS

There were obvious differences between the results of different methods in our study. However, there were significant correlations between them, except between sign and symptom score methods. For determining the most reliable screening test, further studies are needed to compare these methods with a gold standard test and reveal the specificity and sensitivity of these tests.

Quality of life and clinical correlates in patients with diabetic foot ulcers

OBJECTIVE

To compare the Health Related Quality of Life (HRQL) of French diabetic patients with and without foot ulcers and to determine the factors influencing disease-specific HRQL for those with foot ulcers.

METHODS

355 diabetic patients, including 239 with foot ulcers (group 1) and 116 without foot ulcers (group 2) were studied in a cross-sectional setting. Socio-demographic and clinical variables were recorded and HRQL was evaluated using a generic HRQL questionnaire (SF-36) for all subjects. For group 1, the severity of foot ulcers was assessed according to Wagner's classification, and disease-specific HRQL assessed using the Diabetes Foot Ulcer Scale (DFS).

RESULTS

HRQL was found to be significantly lower (P = 0.0001) in group 1 than in group 2 for all domains of the SF-36. Independent inverse relationships were found between good HRQL in the DFS domain of Leisure and Wagner grade (OR = 0.136 [0.029-0.467]) as well as the number of foot ulcers (OR = 0.365 [0.191-0.678]). Age was significantly associated with several DFS domains including Daily Activities, Physical Health and Dependence.

CONCLUSION

Our findings suggest that the number and severity of foot ulcers are associated with patient HRQL, especially in terms of leisure activity disruption and constraints due to treatment. These findings have implications for the evaluation, planning and management of patient care in diabetic foot disease.

Pé diabético: estratégias para prevenção

Aproximadamente 50% das amputações não-traumáticas em membros inferiores ocorrem entre pessoas com diabetes. As amputações são precedidas por úlceras, caracterizadas por lesões cutâneas, com perda do epitélio, que podem estender-se até a derme ou chegar a tecidos profundos. As úlceras, geralmente, são acompanhadas de insensibilidade por neuropatia periférica crônica e associadas a pequenos traumas que se originam do uso de calçados inapropriados, dermatoses comuns ou manipulações incorretas dos pés. O objetivo deste estudo é descrever as principais estratégias para avaliar fatores de risco que conduzem ao desenvolvimento de complicações nos membros inferiores entre pessoas com diabetes, bem como considerá-las uma responsabilidade da equipe de assistência primária. É um trabalho de revisão da literatura, com ênfase na avaliação dos pés como medida preventiva fundamental, para identificar, precocemente, as alterações neurológica e vascular periféricas e disfunções biomecânicas. Destaca-se a avaliação dos calçados como fator externo.

Health-related quality of life of patients with diabetes and foot ulcers

Thirty-four patients with diabetes who attended a university diabetic foot clinic for treatment of a foot ulcer completed the American Academy of Orthopaedic Surgeons Musculoskeletal Outcomes Measure. The purpose of the study was to measure the impact of foot ulcers in patients with diabetes on the physical, mental, emotional, and social aspects of patients' lives. Thirty had at least a high school education. Only six were employed at the time. Nineteen were retired or disabled due to poor health. Sixteen were obese, 10 were considered overweight, and eight had a BMI within the acceptable range. Subjects had an average of four to five bodily systems affected by comorbid illness for which they were receiving treatment, some of which limited their activities. Approximately 85% of the study population required some type of ambulatory assist device or were unable to ambulate independently. The study population was significantly limited in performing all physical activities, especially those requiring use of the foot and ankle, and viewed their own health as being significantly worse than that of the general population. All stated that their foot/ankle disease interfered with their lives. Pain was not a significant component of their disability. The results of this study confirm the hypothesis that foot ulcers in patients with diabetes have a negative impact on quality of life in affected individuals.

O conhecimento dos familiares acerca da problemática do portador de diabetes mellitus

Considerando a família como fonte de apoio ao doente, realizou-se este estudo visando analisar a problemática do portador de diabetes na visão dos familiares, em Unidade Ambulatorial de um hospital universitário do interior do Brasil. Os dados foram coletados de 24 familiares por meio de entrevista semi-estruturada. Para apresentação e análise dos dados, utilizou-se estatística descritiva. Nos resultados, observou-se que os familiares conhecem as causas do diabetes parcialmente. Quanto às condições de adesão ao tratamento, 70,8% consideraram prioritário dieta adequada que, concomitantemente, foi salientada como problema. Em relação às doenças decorrentes, 23 salientaram problemas nos rins/visão. Quanto aos cuidados com os pés, destacou-se a utilização de meias de algodão e limpas. Referente às experiências dos familiares com pessoas portadoras de problemas nos pés, 83,3% responderam afirmativamente, destacando as amputações/úlceras. Dados apontam necessidade de educação aos familiares, uma vez que proporcionam suporte no controle da doença e na prevenção de complicações.

Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting

BACKGROUND

The established guidelines for a diabetes foot examination include assessing circulatory, skin, and neurological status to detect problems early and reduce the likelihood of amputation. Physician adherence to the guidelines for proper examination is less than optimal.

OBJECTIVE

Our objective was to increase compliance with the performance of a proper foot examination through a predominantly physician-directed interventional campaign.

METHODS

The study consisted of 3 parts: a retrospective chart review to estimate background compliance, an educational intervention, and prospective chart review at 3 and 6 months. A properly documented foot examination was defined as assessing at least 2 of the 3 necessary components. The educational intervention consisted of 2 lectures directed at resident physicians and a quality assurance announcement at a general internal medicine staff meeting. Clinic support staff were instructed to remove the shoes and socks of all diabetic patients when they were placed in exam rooms, and signs reminding diabetics were placed in each exam room.

RESULTS

There was a significant increase in the performance of proper foot examination over the course of the study (baseline 14.0%, 3 months 58.0%, 6 months 62.1%; P <.001). Documentation of any component of a proper foot examination also increased substantially (32.6%, 67.3%, 72.5%; P <.001). Additionally, performance of each component of a proper exam increased dramatically during the study: neurological (13.5%, 35.8%, 38.5%; P <.001), skin (23.0%, 64.2%, 69.2%; P <.001), and vascular (14.0%, 51.2%, 50.5%; P <.001).

CONCLUSIONS

Patients with diabetes are unlikely to have foot examinations in their primary medical care. A simple, low-cost educational intervention significantly improved the adherence to foot examination guidelines for patients with diabetes.

Work-up of the diabetic foot

Diabetes is a common disease with potentially devastating complications affecting the foot and ankle. A combination of vascular disease, peripheral neuropathy, and immunopathy results in a cascade of conditions including ischemia and infarction, tendinopathy, atrophy, edema, deformity, neuropathic osteoarthropathy, callus, ulceration, and infection. MRI is useful for evaluation of these complications, and assists the clinician in medical or surgical planning.

MR image analysis of pedal osteomyelitis: distribution, patterns of spread, and frequency of associated ulceration and septic arthritis

PURPOSE

To evaluate the anatomic distribution of pedal osteomyelitis and septic arthritis in a large patient group with advanced pedal infection and to compare ulcer location with the distribution of osteomyelitis and septic arthritis.

MATERIALS AND METHODS

Contrast material-enhanced magnetic resonance (MR) imaging findings were reviewed for 161 feet in 51 women and 107 men (82% of whom had diabetes mellitus) who were suspected of having osteomyelitis and who underwent tissue diagnosis. Location of skin ulceration and presence of osteomyelitis (indicated by means of low T1-weighted signal intensity, high T2-weighted signal intensity, and contrast enhancement) and septic arthritis (indicated by synovial enhancement and adjacent cellulitis) were evaluated by two musculoskeletal radiologists.

RESULTS

In the forefoot, osteomyelitis occurred most frequently at the fifth metatarsal (n = 24), first metatarsal (n = 21), and first distal phalanx (n = 15). In the hindfoot, the calcaneus (n = 21) was involved most frequently. Osteomyelitis was directly adjacent to skin ulcers or surgical defects in all cases but one. Spread of osteomyelitis to adjacent bones in the forefoot occurred in 26 (16%) bones. Evidence of septic arthritis on MR images was present in 53 (33%) feet and involved most frequently the fifth (n = 13) and first (n = 8) metatarsophalangeal joints.

CONCLUSION

Pedal osteomyelitis results almost exclusively from contiguous infections and occurs most frequently around the fifth and first metatarsophalangeal joints. One-third of patients with advanced pedal infection show evidence of septic arthritis on MR images.

Soft-tissue reconstruction of the foot with distally based neurocutaneous flaps in diabetic patients

Soft-tissue coverage of the foot in diabetic patients is often a difficult problem to undertake. The aim of this study was to evaluate the efficiency and safety of distally based neurocutaneous flaps for foot reconstruction in diabetic patients. The authors describe their experience with a series of 10 diabetic patients in whom reconstruction of defects of the foot (range, 6 x 11-10 x 12 cm) were performed using distally based sural and saphenous neurocutaneous flaps. In 9 patients the flap survived completely and in only 1 patient was superficial marginal necrosis of the flap observed. Partial skin graft loss at the donor site occurred in 1 patient, but no additional surgical revision was needed and healing occurred by secondary intention. In these diabetic patients, defects were reconstructed successfully using neurocutaneous flaps, and good results were achieved.

Single-stage surgical treatment of noninfected diabetic foot ulcers

A retrospective study was undertaken to evaluate a single-stage approach in the treatment of noninfected, chronic, well-perfused diabetic foot wounds. This single-stage approach consisted of total excision of the ulcer with broad exposure, correction of the underlying osseous deformity, and immediate primary closure using a local random flap. Four hundred cases of pedal ulcers were analyzed by chart review. Of those, 67 cases underwent a single-stage surgical treatment and were analyzed for length of hospital stay, postoperative complications, time to heal, recurrence of the ulcer, and postprocedure ambulatory status. The age of the ulcers before surgery was 12 +/- 12 months (mean +/- SD), with a range of 1 to 60. The median perioperative hospital stay was 5 +/- 7.6 days. All patients were followed until the wounds were healed or to amputation. The median total time to heal was 30.8 +/- 40 days. Ninety-seven percent of the wounds healed. The recurrence rate of ulceration was 10.4 percent (seven of 67), over a time span of up to 6 years. All but one patient returned to previous levels of ambulation, and many patients had improved levels of ambulation. The single-stage approach eliminated the need for additional surgical procedures, with their associated costs and risks. In addition, healing times were significantly reduced, resulting in decreased hospital stays and subsequent costs and providing the patient with an expedient return to footwear so that bipedal function could be restored. Most importantly, by addressing the underlying bony pathologic findings, the recurrence rates were also drastically reduced.

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up

OBJECTIVE

To evaluate 1) the new ulceration, the new major amputation, and the survival rates of 115 diabetic subjects hospitalized for foot ulceration from 1990 to 1993, with an average follow-up of 6.5 years, and 2) the demographic and clinical characteristics associated with these events.

RESEARCH DESIGN AND METHODS

A total of 115 subjects, 31 women and 84 men, were monitored until 31 December 1998. All subjects were provided with therapeutic shoes and received intense education. Data concerning new ulceration, new major amputation, and reamputation events and the date and cause of death were recorded for each patient. The prognostic factors for these events were then evaluated.

RESULTS

The average follow-up was 78.3 +/- 15.3 months (range 60-106). During this time, 13 homolateral and 12 contralateral episodes of new ulceration occurred. At univariate analysis, none of the variables considered were significantly associated with the new ulceration. There were three major amputations: two of the limb previously healed and one of the contralateral limb. Of the 115 subjects, 51 (44.3%) died: 24 of the 31 women (77.4%) and 27 of the 84 men (32.1%). Ischemic cardiopathy was the most frequent cause of death (60.8%). Mortality concerned 20 of the 27 subjects (74.1%) undergoing major amputation from 1990 to 1993 and 31 of the 88 healed subjects (35.2%), with a significant difference (P < 0.0001). Multivariate analysis showed the independent role of the ankle-brachial index < or =0.5 (P = 0.005), age (P = 0.003), and female sex (P = 0.027).

CONCLUSIONS

We believe that the use of therapeutic shoes and intense educational training, including the education of the family, have contributed to the low incidence of new ulceration and major amputation in our study population. The high frequency of ischemic cardiopathy as a cause of death should, perhaps, lead to a more aggressive diagnostic and therapeutic attitude toward this pathology in diabetic subjects admitted to hospitals for foot ulceration.

Soft-tissue reconstruction for recalcitrant diabetic foot wounds

Thirty-three consecutive patients with plantar soft-tissue defects were managed by a single surgeon (EDN) with reconstruction by a medial plantar artery (MPA)-based flap. Foot defects resulted from a combination of abnormal weightbearing distribution and neuropathy secondary to diabetes mellitus in all patients. A retrospective study of diabetic patients from 1984 to 1997 with foot defects reconstructed with a MPA-based flap were reviewed. Thirty-three patients (age 55 +/- 9) with an average tissue deficit of 13 +/- 9 cm2 had MPA reconstruction of the heel (n = 8), midfoot (n = 23), and forefoot (n = 2). The mean follow-up was 19 months (range, 3 months-5 years). There were four minor complications, including marginal flap necrosis or localized infection, although all healed uneventfully. There were six major complications resulting in loss of the flap and proximal amputation. Out of seven patients, there were 12 rerotations of the previously rotated flap. Various techniques for reconstruction of plantar foot defects have been described in the literature. Utilizing glabrous skin for reconstruction of these defects is appealing for its unique shear and pressure-resisting properties. Surgical management of diabetic foot defects with the medial plantar artery flap is an effective means of soft tissue reconstruction.

Diabetic foot ulcers: current concepts

Foot ulcerations and their sequelae remain a major source of morbidity for patients with diabetes mellitus. Often leading to infection, osteomyelitis, or gangrene, these lesions have consistently been ascertained as significant risk factors for subsequent lower extremity amputation. Hence education, appropriate foot care, and early intervention have assumed important roles in programs focused on amputation prevention. Multidisciplinary cooperation has been demonstrated as the most successful approach to the management and prevention of foot lesions in patients with diabetes. This article reviews the epidemiology, current understanding of the underlying pathophysiology, and treatment rationale for diabetic foot ulcerations. Such knowledge is essential in the overall management of these complicated patients and, when incorporated into daily practice, can significantly reduce the incidence and morbidity of foot disease in diabetes.