Magnus Eneroth

Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment†

The International Working Group on the Diabetic Foot appointed an expert panel to provide evidence‐based guidance on the management of osteomyelitis in the diabetic foot. Initially, the panel formulated a consensus scheme for the diagnosis of diabetic foot osteomyelitis (DFO) for research purposes, and undertook a systematic review of the evidence relating to treatment. The consensus diagnostic scheme was based on expert opinion; the systematic review was based on a search for reports of the effectiveness of treatment for DFO published prior to December 2006.

Clinical characteristics and outcome in 223 diabetic patients with deep foot infections

Clinical characteristics and outcome in 223 consecutive diabetic patients with deep foot infections are reported. Patients were treated by a multidisciplinary diabetic foot-care team at the University Hospital, Lund, Sweden, and were prospectively followed until healing or death. About 50% of patients lacked clinical signs of infection, such as a body temperature > 37.8°C, a sedimentation rate > 70 mm/hour, and white blood cell count (WBC) > 10 × 10 9 /liter. Eighty-six percent had surgery before healing or death. Thirty-nine percent healed without amputation; 34% healed after a minor and 8% after a major amputation. Sixteen percent were unhealed at death, and 3% were unhealed at the end of the observation period. Of those unhealed at death or follow-up, 4 patients had had a major and 11 a minor amputation. After correction for age and sex, duration of diabetes < 14 years, palpable popliteal pulse, a toe pressure > 45 mmHg, and an ankle pressure > 80 mm Hg, absence of exposed bone and a white blood cell count < 12 × 10 9 /liter were all related to healing without amputation in a logistic regression analysis. We conclude that although only 1 in 10 had a major amputation, nearly all diabetic patients with a deep foot infection needed surgery and more than one third had a minor amputation before healing or death in spite of a well-functioning diabetic foot-care team responsible for all included patients.

Deep Foot Infections in Patients with Diabetes and Foot Ulcer: An Entity with Different Characteristics, Treatments, and Prognosis

We report findings in 223 consecutively included people with diabetes, foot ulcer and a deep foot infection treated by a multidisciplinary diabetic foot care team at the University Hospital in Lund, Sweden. The aim of the present study was to evaluate type and characteristics of deep foot infections and their relation to choice of treatment and outcome. Three different groups of deep foot infections were identified; osteomyelitis only (n = 112), deep soft tissue infection only (n = 46) and combined infections (osteomyelitis and deep soft tissue infection, n = 65). The various types of deep foot infections had different characteristics, treatment and prognosis. Patients with a deep soft tissue infection only or a combined infection had a significantly (p < 0.05) higher; (1) body temperature (38.0 and 38.0 vs. 37.3 degrees C), (2) erythrocyte sedimentation rate (75 and 80 vs. 56 mm/h) and (3) white blood count (11.0 and 12.0 vs. 8 x 10(9)) at diagnosis compared with those who had osteomyelitis only. Patients with a deep soft tissue infection only or a combined infection also had a significantly (p < 0.05) shorter time to surgery (2 and 4 vs. 10 days), higher mean number of surgical procedures (1.9 and 2.1 vs. 1.4 procedures) and higher percentage of patients had intravenous antibiotics (87 and 84 vs. 46%) compared with those who had osteomyelitis only. Amputation before healing was more common in patients with a combined infection (62%) compared with those who had osteomyelitis only (37%) or a deep soft tissue infection only (30%). The findings in the present study indicate that deep foot infections in patients with diabetes is a heterogeneous entity, in which the type of deep foot infection is related to choice of treatment strategy and to outcome. Therefore, these various types of infections has to be considered in future studies of deep foot infections in people with diabetes.

Costs of Deep Foot Infections in Patients with Diabetes Mellitus

AbstractObjective: To calculate costs for the management of deep foot infections and to identify the most important factors related to treatment costs. Design: Costs for in-hospital care, surgery, investigations, antibacterials, visits to the foot-care team, orthopaedic appliances and topical treatment were calculated retrospectively from diagnosis until healing or death. Multiple regression analysis was used to identify factors that independently affect costs. Setting: A multidisciplinary foot-care team. Patients: 220 prospectively followed patients with diabetes mellitus and deep foot infections who were referred to the team from 1986 to 1995. Main Outcome Measures and Results: Total cost for healing without amputation was Swedish kronor (SEK)136 600 per patient, while the corresponding cost for healing with minor amputation was SEK260 000 and with major amputation was SEK234 500. All costs were quoted in SEK at 1997 price levels (£1 sterling and

Nutritional Supplementation Decreases Hip Fracture-related Complications.

US1 equalled approximately SEK12.50 and SEK7.64, respectively). The cost of antibacterials was 4%of total costs. The cost of topical treatment was 51% of total costs and related to wound healing time. Number of weeks between diagnosis of deep foot infection and healing, and number of surgical procedures were variables that explained 95% of costs in the multiple regression analysis. It was not possible to find any parameters present at diagnosis that could contribute to an explanation of total treatment costs. Conclusions: Topical treatment accounted for the largest proportion of total costs and the most important cost driving factors were wound healing duration and repeated surgery. Costs of antibacterials should not be used as an argument in the choice between early amputation and conservative treatment.

Nonoperative treatment of Achilles tendon rupture: 196 consecutive patients with a 7% re-rupture rate.

Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture, but the effectiveness of nutritional support programs in routine clinical practice is controversial. We performed a prospective, randomized, controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures. Patients were randomized to intervention or control groups. The control group (n = 40) was given ordinary hospital food and beverage. The intervention group (n = 40) also was administered a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months. The total fluid and energy intake in the intervention group neared optimal levels. The control group received 54% and 64% of optimal energy and fluid intake, respectively. The risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 days postoperatively. The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively. Level of Evidence:Therapeutic Level I. See the Guidelines for Authors for a complete description of levels of evidence.

Improved wound healing in transtibial amputees receiving supplementary nutrition

Background The best treatment for acute Achilles tendon rupture is unknown. Patients and methods We assessed the outcome of nonoperative treatment in 196 consecutive individuals with an acute total Achilles tendon rupture who were followed until healing. The mean duration of treatment in cast or orthosis was 8 weeks. After 4 years, a questionnaire was sent to all patients who were still alive (182) to supplement and confirm the retrospective data. The questionnaire was completed by 176/182 patients (97%). Results The re-rupture frequency was 7% (n = 14). 7 patients suffered other complications (7 deep venous thrombosis and 1 pulmonary embolism). At follow-up, 62% of the patients reported full recovery. Interpretation The low re-rupture rate after nonoperative treatment challenges the claim in recent studies that acute rupture of the Achilles tendon should be operated.

The value of debridement and Vacuum-Assisted Closure (V.A.C.) Therapy in diabetic foot ulcers.

Summary. The objective of this prospective study of matched controls was to find out whether supplementary nutrition would improve wound healing and decrease mortality in patients undergoing transtibial amputation for occlusive arterial disease. The nutritional status of 32 consecutive transtibial amputees was assessed and 28 were classified as malnourished. Supplementary nutrition was given reaching an average intake of 2098 kcal/day for a total of 11 days. In 24 patients, at least 5 days of preoperative supplementary nutrition were given, followed by postoperative treatment for a total of 11 days. Four patients who had an immediate operation were given only postoperative treatment, and 4 were excluded. The controls were 32 amputees in another hospital and matching procedures were carried out with corrections for diabetes, sex, age, smoking habits, previous vascular surgery and living conditions before amputation. Healing, including those healed before death in both groups, occurred in 26 of the nutrition group compared to 13 in the control group, which was statistically significant. Nine patients died within 6 months in the nutrition group compared to 14 of the controls (not significant). Malnutrition was present in nearly 90% of transtibial amputees and supplementary nutrition improved healing, but not mortality.Résumé. L’objectif de cette étude prospective a été d’étudier si une augmentation de l’apport nutritionnel peut ameliorer la cicatrisation et réduire la mortalité chez les malades ayant subi une amputation de jambe en raison d’une maladie vasculaire. L’état nutritionnel de trente-deux patients consécutifs ayant subi une amputation de jambe a étéévalué. Vingt-huit ont été considérés comme malnutris. Une nutrition additionnelle leur a été donnée avec un apport moyen de 2098 kcal par jour pendant 11 jours. Chez 24 malades une nutrition additionnelle, de cinq jours au moins en préopératoire, a été suivie par un traitement postopératoire pour atteindre un total de 11 jours. Quatre malades necessitant une amputation en urgence n’ont re*u le traitement que postopératoire et quatre malades ont été exclus. Trente deux amputés de jambe venant d’un hopital universitaire voisin ont été utilisés comme contrôle, après associations des cas tenant compte de l’age, le sexe, du diabète, de la consommation de tabac, des opérations vasculaires précédentes et des conditions de vie antérieure à l’amputation. L’étude de la cicatrisation a montré que 26 amputés étaient cicatrisés dans le groupe ayant bénéficié d’un apport nutritionnel contre 13 dans le groupe de controle, P= 0.001. Neuf patients sont morts dans les premier six mois dans le groupe ayant bénéficié d’un apport nutritionnel contre 14 dans le groupe de controle, (n. s.). Cette étude montre clairement que près de 90% des amputés de jambe étaient malnutris et qu’un apport nutritionnel a amelioré la cicatrisation du moignon sans pour autant augmenter la survie.

Sustained reduction in major amputations in diabetic patients - 628 amputations in 461 patients in a defined population over a 20-year period

Treatment of diabetic foot ulcers includes a number of different regimes such as glycaemic control, re‐vascularization, surgical, local wound treatment, offloading and other non‐surgical treatments. Although considered the standard of care, the scientific evidence behind the various debridements used is scarce. This presentation will focus on debridement and V.A.C. Therapy, two treatments widely used in patients with diabetes and foot ulcers.

Localization of the chromosomal breakpoints of the t(12 ; 16) in liposarcoma to subbands 12q13.3 and 16p11.2

Background and purpose With an ageing population and an increasing incidence of diabetes, reduction of the number of diabetes-related amputations becomes increasingly difficult to achieve and maintain. There is controversy in this respect regarding the degree of success. We started a multidisciplinary treatment program for diabetic foot ulcers in 1982, and have now assessed incidence rates of amputations from 1982 through 2001. Methods In a defined population, gradually increasing from 199,000 to 234,000, all diabetes-related amputations of the lower extremity from toe to hip were recorded from January 1, 1982 to December 31, 2001, using several sources of information. Results The incidence of major amputations decreased by 0.57 from 16 (11–22) to 6.8 (6.1–7.5) per 100,000 inhabitants between the first and last 4-year period. The most substantial decrease was seen in patients aged 80 years and older. The fraction of amputations with a final level at or below the ankle (n = 240) increased from 0.23 in the first 4-year period to 0.31, 0.49, 0.47, and 0.49 in the following 4-year periods. The overall fraction of re-amputation was 0.34 in the first 4- year period and 0.27, 0.21, 0.32, and 0.21 in the following 4-year periods. The fraction of amputations in diabetic patients that were channeled through the footcare team prior to amputation increased from 0.51 in the first 4- year period to 0.83, 0.86, 0.90, and 0.90 in the following 4-year periods. Interpretation Our findings indicate that a substantial decrease in the incidence of major lower extremity amputations in diabetic patients has been achieved and maintained.