Diabetic foot and foot debridement technique

Surgical foot debridement is widely practised in diabetic foot care. Although minor debridement could be done at the bedside with or without local anaesthesia, more extensive debridement would require regional or general anaesthesia in operating theatres. Delayed surgery could increase the risk of limb loss and mortality. The International Working Group of the Diabetic Foot (IWGDF) or the Infectious Diseases Society of America classifications could be used to assist management of the diabetic foot sepsis. A detailed knowledge of the anatomy of the foot is required to achieve the best outcome. Complications of diabetes and any amputation further disrupts the biomechanics of the diabetic foot and increases the risk of transfer ulceration. Foot biomechanics should be considered while debridement and reconstructive techniques employed, although adequate debridement should not be compromised.     

Diabetic foot infections: stepwise medical and surgical management

Foot complications are common among diabetic patients; foot ulcers are among the more serious consequences. These ulcers frequently become infected, with potentially disastrous progression to deeper spaces and tissues. If not treated promptly and appropriately, diabetic foot infections can become incurable or even lead to septic gangrene, which may require foot amputation. Diagnosing infection in a diabetic foot ulcer is based on clinical signs and symptoms of inflammation. Properly culturing an infected lesion can disclose the pathogens and provide their antibiotic susceptibilities. Specimens for culture should be obtained after wound debridement to avoid contamination and optimise identification of pathogens. Staphylococcus aureus is the most common isolate in these infections; the increasing incidence of methicillin-resistant S. aureus over the past two decades has further complicated antibiotic treatment. While chronic infections are often polymicrobial, many acute infections in patients not previously treated with antibiotics are caused by a single pathogen, usually a gram-positive coccus. We offer a stepwise approach to treating diabetic foot infections. Most patients must first be medically stabilised and any metabolic aberrations should be addressed. Antibiotic therapy is not required for uninfected wounds but should be carefully selected for all infected lesions. Initial therapy is usually empirical but may be modified according to the culture and sensitivity results and the patient's clinical response. Surgical intervention is usually required in cases of retained purulence or advancing infection despite optimal medical therapy. Possible additional indications for surgical procedures include incision and drainage of an abscess, debridement of necrotic material, removal of any foreign bodies, arterial revascularisation and, when needed, amputation. Most foot ulcers occur on the plantar surface of the foot, thus requiring a plantar incision for any drainage procedure.     

Diabetic foot infection treatment and care

Foot infections in diabetic patients are a common, complex and costly problem. They are potentially adverse with progression to deeper spaces and tissues and are associated with severe complications. The management of diabetic foot infection (DFI) requires a prompt and systematic approach to achieve more successful outcomes and to ultimately avoid amputations. This study reviews a multi‐step treatment for DFIs. Between September 2010 and September 2012, a total of about 37 patients were consulted for DFI. The treatment algorithm included four steps, that is, several types of debridement according to the type of wound, the application of negative pressure therapy (NPT), other advanced dressings, a targeted antibiotic therapy local or systemic as the case may, and, if necessary, reconstructive surgery. This treatment protocol showed excellent outcomes, allowing us to avoid amputation in most difficult cases. Only about 8% of patients require amputation. This treatment protocol and a multidisciplinary approach with a specialised team produced excellent results in the treatment of DFI and in the management of diabetic foot in general, allowing us to improve the quality of life of diabetic patients and also to ensure cost savings.     

The use of a dermal substitute to preserve maximal foot length in diabetic foot wounds with tendon and bone exposure following urgent surgical debridement for acute infection

In this study, we evaluated the utility of a dermal substitute for preserving maximal foot length after urgent surgical debridement. Patients referred to our Diabetic Foot Center with foot lesions were assessed for sensory–motor neuropathy, infection and critical limb ischaemia. The presence of acute foot infection indicated the need for immediate surgical debridement. The degree of amputation, if necessary, was based on the amount of apparently non infected vital tissue. When vital tendon/bone tissue remained exposed, the lesion was covered with a dermal substitute. From January to December 2008, 393 patients underwent surgical treatment for diabetic foot syndrome; 30 patients underwent immediate surgical debridement resulting in exposed tendon and/or bone tissues. An average of 4·4 ± 2·1 days following surgical debridement, all 30 patients underwent dermal regeneration template grafting to cover‐exposed healthy tendon and bone tissues, instead of achieving primary wound closure with a proximal amputation. After 21 days, a skin graft was performed. Complete wound healing occurred in 26 patients (86·7%). In these patients, the amputation level was significantly more distal (P < 0·003) with respect to that potentially required for immediate wound closure. The average healing time was 74·1 ± 28·9 days. Four patients underwent a more proximal amputation. No patients underwent major amputation. The use of the dermal substitute for treating exposed tendon and bone tissues allowed timely wound healing and preserved maximal foot length. Continued follow‐up will allow assessment of long‐term relapse and complication rates. Such treatment could constitute part of the comprehensive management of diabetic wounds.     

糖尿病足的外科一站式治疗

目的 探讨糖尿病足外科一站式治疗的临床价值.方法 175例(206条肢体)糖尿病足患者,根据患肢的不同情况,灵活组合应用球囊扩张和(或)支架成形术、局部清创术、持续负压引流术、特殊敷料换药、人工血管旁路术、自体静脉旁路术、杂交手术、截肢(趾)术、单纯保守治疗等各种治疗措施.结果 腔内治疗和旁路术治疗的糖尿病足患者术后1...     

Foot complications in patients with diabetes

Foot complications are a common cause of hospital admission of patients with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the final presenting complication. Recognition of the patient at risk may prevent the development of foot complications initially, but if they occur urgent treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries.     

Foot complications in patients with diabetes

Foot complications are a common cause of hospital admission of patients with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the final presenting complication. Recognition of the patient at risk may prevent the development of foot complications initially, but if they occur urgent treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries.     

Foot complications in patients with diabetes

Foot complications are a common cause of hospital admission of people with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the pathology precipitating presentation. Recognition of the patient at risk may prevent the development of foot complications, but if they do occur urgent treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputations in some European countries.     

Foot complications in patients with diabetes

Foot complications are a common cause of hospital admission of people with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the pathology precipitating presentation. Recognition of the patient at risk may prevent the development of foot complications, but if they do occur urgent treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputations in some European countries.     

Foot complications in patients with diabetes

Foot complications are a common cause of hospital admission of patients with diabetes and a frequent cause of amputation. Neuropathy and arterial disease make the foot particularly vulnerable, but infection is often the final presenting complication. Recognition of the patient at risk may prevent the development of foot complications initially, but if they occur rapid treatment is required to prevent limb loss. The infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours. Once the foot is made safe revascularization should be undertaken in those with significant arterial disease. Adoption of a coordinated approach to managing diabetic foot complications has resulted in reduction in major amputation in some European countries.     

Foot complications in people with diabetes

Foot complications are the most common cause of hospital admission of people with diabetes and a frequent cause of amputation. Neuropathy and peripheral arterial disease make the foot particularly vulnerable to ulceration, but infection is often the pathology precipitating presentation. Recognition of the patient at risk of ulceration may allow interventions to prevent the development of foot complications. When complications do occur, urgent treatment is required to prevent limb loss; the infected foot in a patient with diabetes is a surgical emergency. In addition to antibiotics, debridement and surgical drainage of infection should be considered within the first 24 hours after presentation. Once the foot is made safe, revascularization should be undertaken in those with significant arterial disease. Adoption of a multidisciplinary team approach to managing diabetic foot complications has resulted in reduction in major amputations in some European countries.     

Diabetic foot disease:From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities

The burden of diabetic foot disease(DFD) is expected to increase in the future. The incidence of DFD is still rising due to the high prevalence of DFD predisposing factors. DFD is multifactorial in nature; however most of the diabetic foot amputations are preceded by foot ulceration. Diabetic peripheral neuropathy(DPN) is a major risk factor for foot ulceration. DPN leads to loss of protective sensation resulting in continuous unconscious traumas. Patient education and detection of high risk foot are essential for the prevention of foot ulceration and amputation. Proper assessment of the diabetic foot ulceration and appropriate management ensure better prognosis. Management is based on revascularization procedures, wound debridement, treatment of infection and ulcer offloading. Management and type of dressing applied are tailored according to the type of wound and the foot condition. The scope of this review paper is to describe the diabetic foot syndrome starting from the evaluation of the foot at risk for ulceration, up to the new treatment modalities.     

Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society

Foot infection is the most common reason for hospital admission of diabetic patients in the United States. Foot ulceration leads to deep infection, sepsis, and lower extremity amputation. Prophylactic foot care has been shown to decrease patient morbidity, decrease the utilization of expensive resources, and decrease the risk for amputation and premature death. The Diabetes Committee of the American Orthopaedic Foot and Ankle Society has developed guidelines for the implementation of this type of prophylactic foot care. The screening examination includes evaluation for peripheral neuropathy, skin integrity, ulcers or wounds, deformity, vascular insufficiency, and footwear. Foot-specific patient education includes instruction on self-examination and foot care practices. Individualized foot-specific patient education is indicated for patients with peripheral neuropathy. Treatment is outlined based on risk level, which is determined by the presence of peripheral neuropathy, deformity, and ulcer history. Treatment combines patient education, orthoses, footwear, and a timetable for ongoing skin and nail care. Ulcer care includes paring of calluses, debridement of infected or nonviable tissue, dressings, and off-loading. Specialty assistance may be required from a vascular surgeon, orthopaedic surgeon, podiatrist, endocrinologist/diabetologist, infectious disease consultant, radiologist, and pedorthist.     

New insights in diabetic foot infection

Foot ulcers are common in diabetic patients,have a cumulative lifetime incidence rate as high as 25%and frequently become infected.The spread of infection to soft tissue and bone is a major causal factor for lowerlimb amputation.For this reason,early diagnosis and appropriate treatment are essential,including treatment which is both local(of the foot)and systemic(metabolic),and this requires coordination by a multidisciplinary team.Optimal treatment also often involves extensive surgical debridement and management of the wound base,effective antibiotic therapy,consideration for revascularization and correction of metabolic abnormalities such as hyperglycemia.This article focuses on diagnosis and management of diabetic foot infections in the light of recently published data in order to help clinicians in identification,assessment and antibiotic therapy of diabetic foot infections.     

The role of procalcitonin as a marker of diabetic foot ulcer infection

Foot ulcers are frequent in diabetic patients and are responsible for 85% of amputations, especially in the presence of infection. The diagnosis of diabetic foot ulcer infection is essentially based on clinical evaluation, but laboratory parameters such as erythrocyte sedimentation rate (ESR), white blood count (WBC), C‐reactive protein (CRP) and, more recently, procalcitonin (PCT) could aid the diagnosis, especially when clinical signs are misleading. Fifteen diabetic patients with infected foot ulcers were admitted to our department and were compared with an additional group of patients with non‐infected diabetic foot ulcers (NIDFUs). Blood samples were collected from all patients in order to evaluate laboratory markers. In the current study, the diagnostic accuracy of PCT serum levels was evaluated in comparison with other inflammatory markers such as CRP, ESR and WBC as an indicator to make the distinction between infected diabetic foot ulcers (IDFUs) and NIDFUs. CRP, WBC, ESR and especially PCT measurements represent effective biomarkers in the diagnosis of foot infections in diabetic patients particularly when clinical signs are misleading.     

2019《国际糖尿病足工作组糖尿病足预防和治疗指南》解读

由国际糖尿病足工作组(IWGDF)主办的第8届世界ISDF(国际糖尿病足研讨会)大会于2019年5月22日-25日在荷兰海牙召开,此次大会颁布了2019《IWGDF糖尿病足预防和治疗指南》。该指南对2015版进行了更新,涉及以下6个章节:预防糖尿病患者足部溃疡,糖尿病患者足部溃疡减压,足部溃疡和糖尿病患者周围动脉疾病的诊断、预后和管理,糖尿病患者足部感染的诊断和治疗,促进糖尿病患者足部溃疡愈合的干预措施及糖尿病足溃疡的分类。该文对该指南进行相关解读,以期为国内糖尿病足研究者提供最前沿信息。     

Surgical management of the acute severely infected diabetic foot – The ‘infected diabetic foot attack’. An instructional review

Diabetic Foot Infection (DFI), in its severest form the acute infected ‘diabetic foot attack’, is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This “diabetic foot attack” is characterised by acutely spreading infection and substantial soft tissue necrosis.In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, ‘time is tissue’, referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.     

Diabetic foot ulcers: A devastating complication of diabetes mellitus continues non-stop in spite of new medical treatment modalities

Diabetic foot ulcer is a devastating complication of diabetes mellitus and significant cause of mortality and morbidity all over the world and can be complex and costly. The development of foot ulcer in a diabetic patient has been estimated to be 19%-34% through their lifetime. The pathophysiology of diabetic foot ulcer consist of neuropathy, trauma and, in many patients, additional peripheral arterial disease. In particular, diabetic neuropathy leads to foot deformity, callus formation, and insensitivity to trauma or pressure. The standard algorithms in diabetic foot ulcer management include assessing the ulcer grade classification, surgical debridement, dressing to facilitate wound healing, off-loading, vascular assessment (status and presence of a chance for interventional vascular correction), and infection and glycemic control. Although especially surgical procedures are sometimes inevitable, they are poor predictive factors for the prognosis of diabetic foot ulcer. Different novel treatment modalities such as nonsurgical debridement agents, oxygen therapies, and negative pressure wound therapy, topical drugs, cellular bioproducts, human growth factors, energy-based therapies, and systematic therapies have been available for patients with diabetic foot ulcer. However, it is uncertain whether they are effective in terms of promoting wound healing related with a limited number of randomized controlled trials. This review aims at evaluating diabetic foot ulcer with regard to all aspects. We will also focus on conventional and novel adjunctive therapy in diabetic foot management.     

The association between foot posture,single leg balance and running biomechanics of the foot

ObjectivesA mal-aligned foot posture (high-arched and flat feet) and poor single leg balance ability have been separately associated with foot injuries during running. Therefore, clinicians assess these routinely. However, the extent to which foot posture and single-leg balance ability affect actual foot biomechanics during running is not known. This study aims to investigate the association of foot posture, single-leg balance ability, and foot biomechanics during running.MethodThis is a cross sectional study of sixty-nine participants who had their foot postures and single-leg balance ability assessed. The Foot Posture Index and Balance Error Scoring System were used. Their foot kinetics was measured as they ran on an instrumented treadmill and foot kinematics was processed using a 3D motion capture system. Multiple-regression was used to analyse the variance of foot biomechanics explained by foot posture and single-leg balance ability.ResultsFoot posture and single-leg balance ability were found to account significantly for the variance in rearfoot eversion (24%) and forefoot dorsiflexion (7%). Two regression equations were derived, where rearfoot eversion and forefoot dorsiflexion during running may be predicted.ConclusionFoot posture and single-leg balance ability can predict rearfoot eversion and forefoot dorsiflexion only during running. Based on the regression equations, individuals with the same foot posture but different single-leg balance ability may exhibit different foot kinematics. However, the angular differences are small. The equations may be useful for clinicians working in places where running gait analysis equipment are not readily accessible. Further studies with larger sample sizes are required to validate these equations. In addition, further studies are necessary to investigate the effect of these two variables under different running conditions e.g. with footwear and with orthoses.