The diabetic foot

Lower extremity complications are common in patients with diabetes and include neuropathy, ulceration, infection, and peripheral arterial disease. Foot infections represent the single most common cause of hospitalization and lower extremity amputation in persons with diabetes. Foot ulceration as a result of diabetic peripheral sensory neuropathy, rigid osseous deformities and soft-tissue contractures, repetitive trauma from unprotected ambulation, and peripheral vascular disease can all lead to a limb- or life-threatening infection. Antibiotic therapy for diabetic soft-tissue and osseous infections is usually inadequate as an isolated form of therapy. The mainstay of treatment involves well-planned surgical procedures, including extensive and properly placed incisions to perform adequate drainage of abscesses and débridement of necrotic soft-tissue and osseous structures from which deep cultures are obtained for specific antibiotic coverage. Initial antibiotic therapy should provide broad-spectrum coverage, and when final culture results are available the regimen should be revised to organism-specific coverage. Detailed and timely evaluation of the vascularity of the limb is paramount, followed by timely vascular reconstruction involving various endovascular and open surgical procedures to restore pulsatile flow to the full extent of the limb.