My Orthopedic Surgery

Antimicrobial therapy for diabetic foot infections A practical approach Kevin W. Shea, MD VOL 106 / NO 1 / JULY 1999 / POSTGRADUATE MEDICINE CME learning objectives To identify factors that influence antibiotic selection in the treatment of diabetic foot infections To understand the microbiology of the infected diabetic foot To establish an effective antimicrobial regimen for empirical treatment of diabetic foot infections

From Applied Radiology Radiological Case of the Month Calcaneal Bone Osteomyelitis Posted 08/04/2004 Walter Silbert, MD; Maroun Karam, MD Case Summary A 51-year-old white man with a medical history significant for Type I diabetes mellitus and peripheral vascular disease necessitating multiple prior distal amputations presented with increasing right foot pain. He reported no recent trauma or corticosteroid therapy. Physical examination revealed prior transmetatarsal amputation and a large nonhealing ulcer that penetrated deeply to the lateral aspect of the ankle. In addition, erythema, warmth, and edema of the leg and foot were noted, leading to a strong clinical suspicion of osteomyelitis

Radiology case 468-821 Clinical presentation: Middle aged insulin dependent diabetic with right ankle swelling and deformity. There is marked soft tissue swelling with fragmentation of the bones, joint destruction, but no reduction in bone density.

Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis from Wounds 2002 NG Yadlapalli, MD, Anand Vaishnav, MD, and Peter Sheehan, MD Abstract Osteomyelitis of the diabetic foot remains a difficult clinical infection, often resulting in disability and amputation. Standard management consists of thorough removal of all infected bone in conjunction with antimicrobial therapy. This may have an untoward effect on foot mechanics and may increase risk of future ulcer events. In order to evaluate the efficacy of a more conservative approach, we retrospectively assessed the outcomes patients managed by an interdisciplinary team of comprehensive inpatient and outpatient care. Over a three-year period, 160 patients were identified by a discharge database with osteomyelitis; of these, 58 had outpatient follow-up records for at least 12 months. The treatment regimen consisted of conservative debridement or surgery, four to six weeks of empiric intravenous antibiotics, and biomechanical offloading of pressure impediments to wound healing. Initial procedures were debridement (34 patients), excision of bone (13 patients), toe or ray amputation (8 patients), and major amputation (3 patients). The mean duration of antibiotic therapy was 40.3 days. At twelve-months follow up, twelve patients (20.7%) failed treatment, with nine patients having persistent ulcers, and three patients requiring amputation. The remaining 46 patients healed (79.3%). Three patients had ulcer recurrence and 21 patients had new ulcer episodes in the follow-up observation period. In conclusion, an approach to osteomyelitis in the diabetic foot that is based on conservative surgical intervention, long-term empiric antibiotics, and interdisciplinary wound care and offloading may be a safe and effective alternative to amputation in selected patients.

Diabetics develop a number of problems with their feet
Infections
Stiff deformities
Peripheral neuropathy
Peripheral vascular disease
Ulceration
Charcot neuropathic arthropathy
The causes of these are linked together.

Diabetic foot ulcers (DFUs) precede 85% of nontraumatic lower extremity amputations (LEAs). Approximately 3-4% of individuals with diabetes currently have foot ulcers or deep infections. Among persons with diabetes, 15% develop foot ulcers during their lifetime. Their risk of LEA increases by a factor of 8 once an ulcer develops. At 2 years following transtibial amputation, 36% of these patients are known to have died.
Synonyms and related keywords: Charcot foot, diabetic foot ulcer, DFU, DFUs, peripheral neuropathy, ischemic peripheral vascular disease, foot infection, Charcot osteoarthropathy, Charcot arthropathy, hypertrophic osteoarthropathy, lower extremity amputation, LEA, LEAs, foot amputation
Author: Michael S Pinzur, MD 2007

Lisa Banks Presentation to New York College of Podiatric Medicine Surgical Club

Outpatient percutaneous flexor tenotomies for management of diabetic claw toe deformities with ulcers: a preliminary report E. Tamir, A-M McLaren, A. Gadgil, T.R. Daniels Can J Surg, Vol. 51, No. 1, February 2008
Conclusion: A percutaneous flexor tenotomy with osteoclasis of the proximal interphalangeal joint performed in an outpatient clinic is a safe and effective method to off-load the tip of the toe so that that ulcer healing can occur. The presence of osteomyelitis is not a contraindication for this technique; however, an increased healing time can be expected.