Javier Aragón-Sánchez

IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes.

Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low). Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate).

Diagnosing diabetic foot osteomyelitis: is the combination of probe‐to‐bone test and plain radiography sufficient for high‐risk inpatients?

Diabet. Med. 28, 191–194 (2011)

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.

Treatment of Diabetic Foot Osteomyelitis: A Surgical Critique:

Osteomyelitis is one of the most frequent infections of the diabetic foot accounting for 10-15% of mild infections and almost 50% of severe infections. The definitive diagnosis of foot osteomyelitis requires obtaining bone samples for microbiological and histopathological studies. The treatment of osteomyelitis of the foot in diabetic patients continues to be debated. Until recently, most experts considered that the standard treatment for diabetic foot osteomyelitis should be the surgical removal of infected bone. Recent data suggest that antibiotic treatment can achieve an apparent remission of osteomyelitis though it is difficult to identify patients for this approach. One of the main arguments used to justify the solely antibiotic treatment of osteomyelitis is the alteration of foot biomechanics produced as a consequence of surgery. Conservative surgery combined with antibiotics is an attractive option in treating diabetic foot osteomyelitis because it may reduce the changes in the biomechanics of the foot and minimize the duration of antibiotic therapy. It is currently accepted that the combination of antibiotics with surgical removal of the infected bone may cure the majority of diabetic foot osteomyelitis. Recent literature emphasizes the role of antibiotics in the management of foot infections while little effort is dedicated to reviewing the surgical treatment of this challenging diabetic complication, apart from amputation. More research, including studies of adjunctive therapies in cases of bone infection in the feet of diabetic patients is required.

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)

Seminar review: A review of the basis of surgical treatment of diabetic foot infections.

Infection is an extremely challenging complication of foot ulcers in patients with diabetes. Surgery as part of a multidisciplinary approach is key in the management of many types of diabetic foot infections (DFIs). Unfortunately, the surgical treatment of DFIs is based more on clinical judgment and less on structured evidence, which leaves unresolved doubts. The clinical presentation of DFIs is varied. This review examines the basis of nonvascular surgical treatment of DFIs, emphasizing the importance of the anatomic concepts of the foot, the variety of its clinical presentations, and the concepts of timing surgery. Recent evidence and case reports based on the author’s experience are presented in 2 parts. The first part examines clinical presentation of infections, whereas the second part deals with imaging, foot anatomy, and some case reports.

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.

Diabetic foot infections: what have we learned in the last 30 years?

BACKGROUND Infection is a common epiphenomenon of advanced diabetic foot disease and the most common reason for diabetes-related hospitalizations and lower extremity amputations. Major advances have been made in the past three decades in our understanding and management of diabetic foot infections (DFIs). The optimal treatment of DFIs clearly involves multidisciplinary input. METHODS A comprehensive search of the literature on DFIs from January 1960 through June 2015 was performed, with an emphasis on information published in the past 30 years. RESULTS There have been many new insights into the microbiology, diagnosis, and treatment of DFIs, although the implementation of this knowledge in clinical practice has been suboptimal. Today, the use of evidence-based guidelines, multidisciplinary teams, and institution-specific clinical pathways helps guide optimal care of this multifaceted problem. Patients are more often treated in the ambulatory setting, with antibiotic regimens that are more targeted, oral and shorter course, and with more conservative (but earlier) surgical interventions. New diagnostic and therapeutic methods are being developed at an accelerating pace. CONCLUSIONS The worldwide increase in the incidence of diabetes and longer lifespan of diabetic patients will undoubtedly increase the incidence of DFIs. Clinicians caring for diabetic patients should have an understanding of current methods for preventing, diagnosing, and treating DFIs.

Reducing Major Lower Extremity Amputations After the Introduction of a Multidisciplinary Team for the Diabetic Foot

We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of −6.6% (95% CI = −10.2 to −2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes.