Francisco Javier Álvaro-Afonso

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.

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.

Analysis of Ulcer Recurrences After Metatarsal Head Resection in Patients Who Underwent Surgery to Treat Diabetic Foot Osteomyelitis

Metatarsal head resection is a common and standardized treatment used as part of the surgical routine for metatarsal head osteomyelitis. The aim of this study was to define the influence of the amount of the metatarsal resection on the development of reulceration or ulcer recurrence in patients who suffered from plantar foot ulcer and underwent metatarsal surgery. We conducted a prospective study in 35 patients who underwent metatarsal head resection surgery to treat diabetic foot osteomyelitis with no prior history of foot surgeries, and these patients were included in a prospective follow-up over the course of at least 6 months in order to record reulceration or ulcer recurrences. Anteroposterior plain X-rays were taken before and after surgery. We also measured the portion of the metatarsal head that was removed and classified the patients according the resection rate of metatarsal (RRM) in first and second quartiles. We found statistical differences between the median RRM in patients who had an ulcer recurrence and patients without recurrences (21.48 ± 3.10% vs 28.12 ± 10.8%; P = .016). Seventeen (56.7%) patients were classified in the first quartile of RRM, which had an association with ulcer recurrence (P = .032; odds ratio = 1.41; 95% confidence interval = 1.04-1.92). RRM of less than 25% is associated with the development of a recurrence after surgery in the midterm follow-up, and therefore, planning before surgery is undertaken should be considered to avoid postsurgical complications.

The Best Way to Reduce Reulcerations: If You Understand Biomechanics of the Diabetic Foot, You Can Do It

Foot ulcer recurrence is still an unresolved issue. Although several therapies have been described for preventing foot ulcers, the rates of reulcerations are very high. Footwear and insoles have been recommended as effective therapies that prevent the development of new ulcers; however, the majority of studies have analyzed their effects in terms of reducing peak plantar pressure rather than ulcer relapse. Knowledge of biomechanical considerations is low, in general, in the team approach to diabetic foot because heterogeneous professionals having competence in recurrence prevention are involved. Assessment of biomechanical alterations define a foot type position; examining foot structure and recording plantar pressure could help in appropriate insole and footwear prescription and design. Patient education and compliance should be taken into consideration for better therapy success. When patients suffer from rigid deformities or have undergone an amputation, surgical offloading should be considered as an alternative.

Conservative Surgery of Diabetic Forefoot Osteomyelitis How Can I Operate on This Patient Without Amputation

Surgery is necessary in many cases of diabetic foot osteomyelitis. The decision to undertake surgery should be based on the clinical presentation of diabetic foot osteomyelitis. Surgery is required when the bone is protruding through the ulcer, there is extensive bone destruction seen on x-ray or progressive bone damage on sequential x-ray while undergoing antibiotic treatment, the soft tissue envelope is destroyed, and there is gangrene or spreading soft tissue infection. Several issues should be taken into account when considering surgery for treating diabetic foot osteomyelitis. It is necessary to have a surgeon available with diabetic foot expertise. Regarding location of diabetic foot osteomyelitis, it is important to consider whether isolated bone or a joint is involved. In cases in which osteomyelitis is associated with a bone deformity, surgery should be able to correct this. The surgeon should always reflect about whether extensive/radical surgery could destabilize the foot. The forefoot is the most frequent location of diabetic foot osteomyelitis and is associated with better prognosis than midfoot and hindfoot osteomyelitis. Many surgical procedures can be performed in patients with diabetes and forefoot ulcers complicated by osteomyelitis while avoiding amputations. Performing conservative surgeries without amputations of any part of the foot is not always feasible in cases in which the infection has destroyed the soft tissue envelope. Attempting conservative surgery in such cases risks infected tissues remaining in the wound bed leading to failure. The election of different surgical options depends on the expertise of the surgeons selected for the multidisciplinary teams. It is the aim of this article to provide a sample of surgical techniques in order to remove the bone infection from the forefoot while avoiding amputations.

The Influence of the Length of the First Metatarsal on the Risk of Reulceration in the Feet of Patients With Diabetes

Our aim was to identify the optimal diagnostic cutoff point on the scale of protrusion measurements of the first metatarsal (M1) to predict the probability of reulceration after metatarsal head resection in patients with diabetes mellitus. We conducted a prospective study of patients with diabetes who underwent resection of at least 1 metatarsal head in our department. After surgery, we measured the difference in length (protrusion) between the M1 and the longest of the 4 lesser metatarsals by radiographic view. The patients were divided into those in whom the M1 was the longest of the 5 metatarsals (group 1) and patients in whom at least one of the lesser metatarsals was longer than the M1 (group 2). They were followed-up for 12 months and were assessed for reulceration. Ninety-one patients were included in the present study: 43 (47%) in group 1 and 48 (53%) in group 2. In group 1, the longer the protrusion of M1 was, the higher the probability for reulceration (P < .001, 95% confidence interval = 0.813-0.997). In group 2, the shorter the protrusion of M1, the higher the probability for reulceration (P = .002, 95% confidence interval = 0.628-0.905). The optimal cutoff point for group 1 was 11 mm (sensitivity = 84.6%, specificity = 86.7%) for the probability of reulceration. In group 2, it was −7 mm (sensitivity = 81.8%, specificity = 65.4%). These results suggest that M1 protrusion is an optimum prognostic indicator for reulceration and could be recommended for detecting patients at risk of reulceration after surgery.

Does the location of the ulcer affect the interpretation of the probe-to-bone test in the diagnosis of osteomyelitis in diabetic foot ulcers?

The Infectious Diseases Society of America guidelines [1] include the probe-to-bone test as a standardized test for the diagnosis of osteomyelitis in diabetic foot ulcers. From 1995 until the present there have been five diagnostic validations of the probe-to-bone test, the most recent of which was carried out in 2011 [2]. The present study aims to assess the influence of the location of the ulcer on the interpretation of the probe-to-bone test. A cross-sectional study was conducted from October 2009 to June 2011 on 123 patients attending the Diabetic Foot Unit at the University Clinic of Podiatry, Complutense University of Madrid. Patients had Type 1 or Type 2 diabetes according to the criteria of the American Diabetes Association [3] with diabetic foot ulcers, with clinical suspicion of osteomyelitis fulfilling at least one of the following criteria: the presence of two or more signs of inflammation, such as pain, redness, heat, foul odour, lymphangitis or crepitus, coupled with the presence of suppuration or even bone fragments, swollen, erythematous toe with loss of normal contours or ‘sausage toe’, and ulcers with discharge that did not improve with appropriate treatment over a period of at least 6 weeks [4]. Patients who underwent surgery in the preceding 3 months, patients without neuropathy, but with ischaemic signs, and patients with diabetic foot ulcers with exposed bone were excluded. Absent distal pulses, an ankle–brachial index less than 0.9 and transcutaneous oxygen pressure (tcpO2) less than 30 mmHg were considered to be signs of ischaemia [5]. The neurological examination was undertaken using Semmes–Weinstein 5.07⁄10-g monofilaments and a neurothesiometer (Novalab Ib erica, Madrid, Spain). Patients who did not feel one of the two tests were diagnosed with neuropathy [6]. Three podiatrists with different levels of experience in the management of diabetic foot ulcers performed the probe-to-bone test as described by Grayson et al. [7]. We classified them into three levels of experience in the treatment of the diabetic foot: inexperienced (no experience), medium experience (6 months but less than 1 year), experienced (more than 2 years). The test results were recorded confidentially by a fourth clinician. To analyse the correlation we applied the kappa agreement index and used the scale of Landis and Koch [8] to study the strength of agreement. A total of 123 patients were included; the mean age of the patients was 65 13.3 years, with a mean duration of diabetes of 16.0 12.2 years. Fourteen patients (11%) had Type 1 diabetes and 109 patients (89%) had Type 2 diabetes. Mean HbA1c was 52 3 mmol/mol (6.9 1.9%). Each of these patients had a single ulcer. Of the ulcers, 75% (n = 92) were classified as neuropathic and 25% (n = 31) were classified as neuroischaemic. Mean wound duration was 35.4 95.3 weeks. The ulcers explored were located on lesser toes (30.9%, n = 38), hallux (22.8%, n = 28), central metatarsals (18.7%, n = 23), first metatarsal (14.6%, n = 18) and fifth metatarsal (13%, n = 16).

Charcot neuroarthropathy triggered and complicated by osteomyelitis. How limb salvage can be achieved.

Charcot neuroarthropathy is a severe complication in the feet of patients with diabetes, which can lead to a major amputation. Osteomyelitis and surgery for osteomyelitis have been reported as trigger mechanisms of developing Charcot neuroarthropathy. However, the development of acute Charcot neuroarthropathy triggered by osteomyelitis during conservative antibiotic treatment is not well outlined in the medical literature.

What Is the Clinical Utility of the Ankle-Brachial Index in Patients With Diabetic Foot Ulcers and Radiographic Arterial Calcification?

The purpose of this study was to analyze the influence of radiographic arterial calcification (RAC) on the clinical interpretation of ankle-brachial index (ABI) values in patients with diabetic foot ulcers. We analyzed a retrospective clinical database of 60 patients with diabetic foot ulcers from the Diabetic Foot Unit (Complutense University, Madrid, Spain) between January 2012 and March 2014. For each patient, anteroposterior XR-plains were evaluated, and the ABI and toe-brachial index (TBI) were assessed by an experienced clinician. To analyze the correlation among quantitative variables, we applied the Pearson correlation coefficient. Fifty percent (n = 9/18) of our patients with a normal ABI and RAC had a TBI < 0.7 associated with peripheral arterial disease (PAD). In patients with RAC, the prevalence of a normal ABI (72%, 18/25) was higher than in patients without RAC (52%, 11/21). The Pearson correlation coefficient among the ABI and TBI in patients with an ABI < 1.4 (n = 46) was lesser (r = .484, P = .001) than in patients with an ABI < 1.4 but without RAC (n = 21; r = .686, P = .001). ABI values between 0.9 and 1.4 would be falsely considered as normal and could underestimate the prevalence of PAD, especially in patients with neuropathy, diabetic foot ulcers, or RAC.