Esther García-Morales

Antibiotics Versus Conservative Surgery for Treating Diabetic Foot Osteomyelitis: A Randomized Comparative Trial

OBJECTIVE No prospective trials have been carried out comparing antibiotic treatment alone with primarily surgical treatment in patients with diabetes and foot osteomyelitis. The aim of the current study was to compare the outcomes of the treatment of diabetic foot osteomyelitis in patients treated exclusively with antibiotics versus patients who underwent conservative surgery, following up the patients for a period of 12 weeks after healing. RESEARCH DESIGN AND METHODS Between 1 January 2010 and 31 December 2012, a prospective randomized comparative trial (clinical trial reg. no. NCT01137903, clinicaltrials.gov) of patients with diabetes who had received a diagnosis of neuropathic foot ulcers complicated by osteomyelitis was carried out at the Diabetic Foot Unit at the Complutense University of Madrid. Patients were randomized into the following two groups: the antibiotics group (AG) and the surgical group (SG). Antibiotics were given for a period of 90 days in the AG. Patients in the SG received conservative surgery with postoperative antibiotic treatment for 10 days. RESULTS Eighteen patients (75%) achieved primary healing in the AG, and 19 (86.3%) in the SG (P = 0.33). The median time to healing was 7 weeks (quartile [Q] 1 to Q5, Q3–Q8) in the AG and 6 weeks (Q1–Q3, Q3–Q9) in the SG (P = 0.72). The conditions of four patients from the AG worsened (16.6%), and they underwent surgery. Three patients from the SG required reoperation. No difference was found between the two groups regarding minor amputations (P = 0.336). CONCLUSIONS Antibiotic therapy and surgical treatment had similar outcomes in terms of healing rates, time to healing, and short-term complications in patients with neuropathic forefoot ulcers complicated by osteomyelitis without ischemia or necrotizing soft tissue infections.

Necrotizing Soft-Tissue Infections in the Feet of Patients With Diabetes: Outcome of Surgical Treatment and Factors Associated With Limb Loss and Mortality

The aim of this study was to analyze the outcomes of treatment of necrotizing soft-tissue infections (NSTIs) in the feet of diabetic patients and to determine factors associated with limb salvage and mortality. A retrospective study of a consecutive series of 145 diabetic patients suffering from NSTIs treated in the Diabetic Foot Unit, La Paloma Hospital was done. NSTIs were classified as necrotizing cellulitis if it involved the subcutaneous tissue and the skin, as necrotizing fasciitis if it involved the deep fascia, and as myonecrosis in those cases where muscular necrosis was present. In the necrotizing cellulitis group (n = 109), 8 (7.3%) major amputations were performed. In the necrotizing fasciitis group (n = 25), 13 (52%) major amputations were undertaken. In the myonecrosis group (n = 11), 6 (54.5%) major amputations were performed. Predictive variables related to limb loss were fasciitis (OR = 20, 95% CI = 3.2-122.1) and myonecrosis (OR = 53.2, 95% CI = 5.1-552.4). Predictive variables of mortality were age >75 years (OR = 10.3, 95% CI = 1.9-53.6) and creatinine values >132.6 µmol/L (OR = 5.8, 95% CI = 1.1-30.2). NSTIs of the foot are an important cause of morbidity and mortality in diabetic patients.When fascia and/or muscle are involved, there are significant risks of major amputation.

Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series.

Diabet. Med. 29, 813–818 (2012)

Impact of Diabetic Foot Related Complications on the Health Related Quality of Life (HRQol) of Patients - A Regional Study in Spain

The diabetic foot reduces the health-related quality of life (HRQoL) in patients with diabetes mellitus. This study aims at ascertaining the impact of the etiological factors of the diabetic foot on the various aspects of HRQoL. This is a comparative study involving type 1 or type 2 (n = 421) diabetic patients divided into 2 groups. Group 1 (n = 258) includes diabetic patients without foot lesions and group 2 (n = 163) includes patients suffering from a diabetic foot ulcer. The HRQoL of the sample was assessed by using the SF-36 Health Questionnaire. The overall HRQoL score was 68.58 ± 18.24 in group 1 and 50.99 ± 18.98 in group 2 (P < .001). The diabetic foot—related etiological factors that significantly reduce these patients’ HRQoL are neuropathy, amputation history, and poor metabolic control (P < .001). Quality of life was lower in women with diabetic foot than in men. Neuropathy—regarded as the main etiological factor in the diabetic foot—also proved to be a variable that reduces the HRQoL. Paradoxically, peripheral vascular disease did not prove to have a negative impact on the quality of life.

Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series

Aims  The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin‐resistant Staphylococcus aureus (MRSA) with cases caused by methicillin‐sensitive Staphylococcus aureus (MSSA).

Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads

To analyse the risk of reulceration caused by the transfer of lesions in patients with diabetes, undergoing resection of at least one metatarsal head.

Inter-observer reproducibility of diagnosis of diabetic foot osteomyelitis based on a combination of probe-to-bone test and simple radiography

Probe-to-bone test and simple X-rays are both standard tests for the diagnosis of diabetic foot osteomyelitis. This study demonstrates the importance of considering jointly clinical information (probe-to-bone test) and diagnostic tests (simple radiography) to increase agreement among clinicians on diagnosis of diabetic foot osteomyelitis.

Histopathologic characteristics of bone infection complicating foot ulcers in diabetic patients.

BACKGROUND A universally accepted histopathologic classification of diabetic foot osteomyelitis does not currently exist. We sought to evaluate the histopathologic characteristics of bone infection found in the feet of diabetic patients and to analyze the clinical variables related to each type of bone infection. METHODS We conducted an observational prospective study of 165 diabetic patients with foot ulcers who underwent surgery for bone infection. Samples for microbiological and histopathologic analyses were collected in the operating room under sterile conditions. RESULTS We found four histopathologic types of osteomyelitis: acute osteomyelitis (n = 46; 27.9%), chronic osteomyelitis (n = 73; 44.2%), chronic acute osteomyelitis (n = 14; 8.5%), and fibrosis (n =32; 19.4%). The mean ± SD time between the initial detection of ulcer and surgery was 15.4 ± 23 weeks for acute osteomyelitis, 28.6 ± 22.4 weeks for chronic osteomyelitis, 35 ± 31.3 weeks for chronic acute osteomyelitis, and 27.5 ± 27.3 weeks for the fibrosis stage (analysis of variance: P = .03). Bacteria were isolated and identified in 40 of 46 patients (87.0%) with acute osteomyelitis, 61 of 73 (83.5%) with chronic osteomyelitis, 11 of 14 (78.6%) with chronic acute osteomyelitis, and 25 of 32 (78.1%) with fibrosis. CONCLUSIONS Histopathologic categorization of bone infections in the feet of diabetic patients should include four groups: acute, chronic, chronic acute, and fibrosis. We suggest that new studies should identify cases of fibrosis to allow comparison with the present results.

Interobserver and intraobserver reproducibility of plain X-rays in the diagnosis of diabetic foot osteomyelitis

The purpose of this study was to analyze the interobserver and intraobserver variability in plain radiography in the diagnosis of diabetic foot osteomyelitis. A prospective observational study was performed from October 1, 2009, to July 31, 2011, on patients with diabetic foot ulcers, with clinically suspected osteomyelitis who were admitted to the Diabetic Foot Unit of the Complutense University of Madrid. Two professional groups examined 123 plain X-rays, each group comprising 3 different levels of clinical experience. To analyze intraobserver variability, 2 months later plain X-rays were reanalyzed by one of the clinical groups. When using only plain radiography for the diagnosis of osteomyelitis in the diabetic foot, low concordance rates were observed for clinicians with a similar level of experience: experienced clinicians (K11AB = .35, P < .001), moderately experienced clinicians (K22AB = .39, P < .001), and inexperienced clinicians (K33AB = .40, P < .001). Intraobserver agreement was highest in experienced clinicians (K11A = .75, P < .001), followed by moderately experienced clinicians (K22A = .61, P < .001) and inexperienced clinicians (K33A = .57, P < .001). Plain radiography for the diagnosis of diabetic foot osteomyelitis is operator dependent and shows low association strength, even among experienced clinicians, when interpreted in isolation without knowing the clinical characteristics of the lesion.

Surgical Treatment of Limb- and Life-Threatening Infections in the Feet of Patients With Diabetes and at Least One Palpable Pedal Pulse Successes and Lessons Learnt

Outcomes of surgically treated limb- and life-threatening infections in patients with diabetes and a well-vascularized foot based only on the palpation of foot pulses are not well known. The authors retrospectively studied a series of 173 patients with diabetes and limb- (moderate) or life- (severe) threatening infections with at least one palpable pedal pulse who were admitted to their department for the treatment of infected diabetic foot from January 1, 1998, to December 31, 2009. A total of 141 patients (81.5%) presented with limb-threatening/moderate infections and 32 (18.5%) with life-threatening/severe infections. In all, 49 patients (28.3%) presented with soft tissue infections only, 90 (52%) with osteomyelitis and 34 (19.7%) with a combined infection. Amputation was needed in 74 patients (42.7%), of whom 6 needed a major amputation (3.5% of overall). A total of 99 (57.2%) patients were treated by conservative surgery. Four patients (2.3%) died during the postoperative period (30 days). Limb salvage was achieved in 167 (96.5%) of the patients who were followed up until healing. Healing of the wounds by secondary intention was achieved in a median of 72 days. Clinical results permit the observation that a high rate of limb salvage can be achieved after the surgical treatment of limb- and life-threatening infections in patients with at least one palpable pedal pulse.