Lower Extremity Complications Research Articles

Rescuing Sisyphus: The Team Approach to Amputation Prevention

The singular event in ?1 human evolution that first separated us from our simian ancestors was long held to be brain enlargement, but the tipping point was a more pedestrian development. Relatives of Lucy (Australopithecus afarensis) walked in the volcanic ash of Laetoli, Tanzania, 3.6 million years ago. Analysis of their fossil footprints strongly suggests these still partly-arboreal ancestors walked likemodern humans, fully erect with extended limbs, rather than with the less efficient apelike, bent-knee, bent-hip gait. By 2 million years ago, genus Homo had abandoned arboreal life altogether; freeing of the hands associated with permanent adoption of bipedalism thus preceded, and likely drove, brain enlargement. As Darwin suggested, bipedal walking is the defining feature of our human lineage. The 21st century is witnessing a worldwide epidemic of diabetes, which is accompanied by one of its most feared sequela: limb amputation. Limb loss often reduces quality of life, functional status, and independence. Amputation may thus steal a defining characteristic of one’s humanity— bipedalism. Lower-extremity complications remain among the most common reasons for hospitalization in diabetic patients. During their lifetime, approximately one in four people with diabetes will develop a foot ulcer, the precursor of amputation. It is sobering to consider that one diabetes-related amputation is performed every 30 seconds around the world, a figure that exceeds all other causes of limb loss, including those from landmines. Diabetic wounds are caused largely by neuropathy and repetitive trauma from everyday activity. These wounds, when infected, all too frequently result in amputation. Concomitant vascular disease further complicates matters. A graphic plot of noninvasive vascular studies used to predict wound healing generally assumes a sigmoid-curve. This curve follows a rather steep incline centrally, with flat plains of nonhealing at the bottom left (low flow/pressure) and likely healing at the top right (normal flow/pressure). Revascularization may ‘‘push’’ ischemic wounds up this incline, expediting healing. Conversely, with protection (by surgical and nonsurgical off-loading) and debridement, neuropathic wounds in the absence of ischemia predictably heal. Unmonitored, these wounds are prone to recur. Diabetic foot care is highly variable, often fragmented, and lacks standardization. A wide variety of clinicians, frequently working in isolation, manage diabetic foot problems. Contemplation of this steep, slippery slope to healing and the resulting frustration it causes clinicians evokes the pre-Homeric tale of Sisyphus in Hades. This solitary tragic figure was condemned to roll a boulder up an incline only to have it roll back down in a neverending pointless cycle. Despite major advances in wound-healing and revascularization procedures, amputation rates in diabetic patients remain unchanged or even increased in many regions, creating a burden worthy of an epic tragedy. But what if Sisyphus no longer had to toil endlessly alone, but instead had a partner to assist him? Over the past decade, many modern-day clinical protagonists have learned that teamwork matters. Recent studies suggest that interdisciplinary teams employing an integrated ‘‘toe and flow’’ care philosophy can reduce the incidence of major amputations. Podiatry and vascular surgery are natural allies in the struggle against amputation. Last year, leaders of the Society for Vascular Surgery (SVS) and the *Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona Health Sciences Center, Tucson, AZ. †Amputation Prevention Center, Valley Presbyterian Medical Center, Van Nuys, CA. Corresponding author: Joseph L. Mills, Sr, MD, and David G. Armstrong, DPM, PhD, Professors of Surgery, Division of Vascular and Endovascular Surgery, SALSA (Southern Arizona Limb Salvage Alliance), University of Arizona College of Medicine, Tucson, AZ 85724. (E-mail: jmills@u. arizona.edu or armstrong@usa.net)

Receipt of Care and Reduction of Lower Extremity Amputations in a Nationally Representative Sample of U.S. Elderly

To determine effectiveness of receipt of care from podiatrist and lower extremity clinician specialists (LEC specialists) on diabetes mellitus (DM)-related lower extremity amputation. Medicare 5 percent sample claims, 1991-2007. Individuals with DM-related lower extremity complications (LECs) were followed 6 years. Visits with podiatrists, LEC specialists, and other health professionals were tracked to ascertain whether receipt of such care reduced the hazards of an LEC amputation. Individuals were stratified based on disease severity, Stage 1--neuropathy, paresthesia, pain in feet, diabetic amyotrophy; Stage 2--cellulitis, charcot foot; Stage 3--ulcer; Stage 4--osteomyelitis, gangrene. Half the LEC sample died within 6 years. More severe lower extremity disease increased risk of death and amputation. Persons visiting a podiatrist and an LEC specialist within a year before developing all stage complications were between 31 percent (ulceration) and 77 percent (cellulitis and charcot foot) as likely to undergo amputation compared with individuals visiting other health professionals. Individuals with an LEC had high mortality. Visiting both a podiatrist and an LEC specialist in the year before LEC diagnosis was protective of undergoing lower extremity amputation, suggesting a benefit from multidisciplinary care.

An Update on Pharmacological Interventions for Diabetic Foot Ulcers

Diabetic foot ulcers are the most common lower extremity complications of diabetes. Peripheral neuropathy and peripheral vascular disease are the underlying risk factors for diabetic foot ulcers, subsequently leading to infections and requiring antimicrobial therapy for the management of the disease. Each risk factor is a target for clinical intervention, with the intent to delay or prevent disease progression to amputation. The effective therapy includes interdisciplinary care, which involves optimized pharmacological interventions in concert with other treatments such as debridement strategies and specialized wound dressings. The pharmacological therapy alone cannot lead to successful therapy, and therefore, these supplementary techniques/modalities should not be overlooked. It is therefore the aim of this report to review various pharmacological interventions, specific to the diabetic foot and wound healing, along with incorporation of advanced therapies required to achieve a multifaceted treatment of diabetic foot ulcers and provide basis for superior drugs as well as drug delivery systems.

Techniques and Results of Portal Vein/Superior Mesenteric Vein Reconstruction Using Femoral and Saphenous Vein During Pancreaticoduodenectomy

Objectives: Patients with pancreatic tumors may have portal vein (PV) and/or superior mesenteric vein (SMV) invasion. In such cases, lower extremity veins can provide an autogenous conduit for PV/SMV reconstruction. Little data exist, however, describing the technique of PV/SMV reconstruction, the patency of such reconstructions, and the morbidity of using lower extremity veins for PV/SMV reconstruction during pancreaticoduodenectomy. Methods: Thirty-four patients (mean age, 62.6 years) underwent PV/SMV reconstruction during pancreaticoduodenectomy using lower extremity vein. Saphenous vein was preferred for patching and femoral vein for replacement. We analyzed preoperative imaging, reconstruction patency, vein harvest morbidity, and late mortality. Results: All 34 patients had preoperative CT imaging and/or endoscopic ultrasound (EUS) imaging. Of the 34 patients, 14 had evidence of PV/SMV invasion on CT or EUS, 14 did not, and 6 studies were indeterminate. Twenty-five patients had follow-up imaging, and 22 (88%) had patent reconstructions. Fifteen patients had PV/SMV replacement using femoral vein. Of these 15 patients, 7 had minor postoperative lower extremity edema that resolved over time, 5 had wound complications from the femoral vein harvest site, 3 of which required minor operative procedures for treatment. Fifteen patients had PV/SMV patching with greater saphenous vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Four patients had PV/SMV patching using femoral vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Compared with patients undergoing pancreaticoduodenectomy without PV/SMV reconstruction, Kaplan-Meier analysis showed there was no difference in late mortality. Conclusions: Preoperative imaging may fail to detect PV/SMV involvement in patients undergoing pancreaticoduodenectomy. PV/SMV reconstruction with leg vein provides good patency with minimal postoperative lower extremity complications and no increase in late mortality. The lower extremities should be routinely included in the operative field of patients undergoing pancreaticoduodenectomy.

Finite Element Study into the effect of footwear temperature on the Forces transmitted to the foot during quasi- static compression loading

The determination of plantar stresses using computational footwear models which include temperature effects are crucial to predict foam performance in service and to aid material development and product design. Finite Element Method (FEM) provides an efficient computational framework to investigate the foot-footwear interaction. The aim of this research is to use FEM to investigate the effect of varying footwear temperature on plantar stresses. The results obtained will provide data which can be used to help optimise shoe design in terms of minimising damaging stresses in the foot particularly for individuals with diabetes who are susceptible to lower extremity complications. The FE simulation results showed significant reductions in foot stresses with the modifications from FE model (1) without footwear to model (2) with midsole only and to model (3) with midsole and insole. In summary, insole and midsole layers made from various foam materials aim to reduce the Ground Reaction Forces (GRF's) and foot stresses considerably and temperature variation can affect their cushioning and consequently the shock attenuation properties. The loss of footwear cushioning effect can have important clinical implications for those individuals with a history of lower limb overuse injuries or diabetes.

Stratification of persons with diabetes into risk categories for foot ulceration

Patients with diabetes mellitus are at a higher risk of lower extremity complications as compared to their non-diabetic counterparts. To study risk factors for diabetic foot ulcer disease and stratify patients with diabetes into risk categories for foot ulceration. Cross-sectional descriptive study over five months period. Diabetic outpatient clinic, at the Kenyatta National Hospital. Two hundred and eighteen ambulatory subjects with diabetes mellitus without active foot lesions. The prevalence of previous foot ulceration was 16% while that of previous amputation was 8%. Neuropathy was present in 42% of the study subjects and was significantly associated with age, male gender, duration of diabetes, random blood sugar, systolic blood pressure and the presence of foot deformity. Peripheral arterial disease was present in 12% and showed significant association with male gender. Foot deformities were observed in 46% of study subjects and were significantly associated with age, male gender, and presence of neuropathy. Subsequently 57% were categorised into IWGDF group 0--no neuropathy, 10% were placed in group 1--neuropathy alone, 16% were put in group 2--neuropathy plus either peripheral arterial disease or foot deformity and 17% were placed in risk group 3--previous foot ulceration/amputation. More than one third (33%) of diabetic patients were found to be at high risk for future foot ulceration (IWGDF groups 2 and 3). Published evidence exists that shows improved outcomes with interventions targeting individual patients with diabetes at high-risk of foot ulceration. Long term prospective studies to determine outcomes for the different risk categories should be carried out locally.

Anterior urethral reconstruction using the circular fasciocutaneous flap technique: long-term follow-up

The circular fasciocutaneous skin flap technique (FCF) yields excellent short-term results for complex anterior urethral reconstruction. We performed an observational retrospective and descriptive study to report our long-term experience. A total of 36 adults with anterior urethral strictures (AUS) exceeding 3cm underwent single-stage urethroplasty using the FCF. Exclusion criteria were: lichen sclerosus, absence of the urethral plate and hypospadias. All had a minimum follow-up of 7years. Mean age was 49.7years. Radiological work-up was supplemented by urethral ultrasound showing a mean stricture length of 5.9cm. A circumferential island of distal penile skin was mobilized on a vascularized pedicle and used for urethral reconstruction. Tube repairs were not included. Outcome was considered a failure when post-operative instrumentation was needed. The Mann-Whitney U test was used for statistical analysis. Mean follow-up was 96.7months (86-117). All received a ventral onlay repair secondary to stricturotomy. Complication rate was 8.3% (3/36): A flimsy stricture at the proximal anastomotic site occurred in 1 requiring optical urethrotomy. In 2 patients, glans dehiscence was noted. No penile skin necrosis was observed proximal to the flap-harvesting site. We did not observe neurovascular lower extremity complications. Long-term success rates exceeded 90%. FCF-urethroplasty yields excellent long-term results with no late stricture recurrence. All complications occurred early after surgery underlining the durability of pedicled genital skin flaps. Despite extensive stricture, disease complication rates and morbidity were low. In case of paucity of local skin or lichen scleroses, oral grafts are required for optimal treatment.

Techniques and results of portal vein/superior mesenteric vein reconstruction using femoral and saphenous vein during pancreaticoduodenectomy

Patients with pancreatic tumors may have portal vein (PV) and/or superior mesenteric vein (SMV) invasion. In such cases, lower extremity veins can provide an autogenous conduit for PV/SMV reconstruction. Little data exist, however, describing the technique of PV/SMV reconstruction, patency of such reconstructions, and the morbidity of using lower extremity veins for PV/SMV reconstruction during pancreaticoduodenectomy. Thirty-four patients underwent PV/SMV reconstruction during pancreaticoduodenectomy using lower extremity vein. The saphenous vein was preferred for patching and femoral vein for replacement. We analyzed preoperative imaging, reconstruction patency, vein harvest morbidity, and late mortality. The mean age was 62.6 years. All 34 patients had preoperative computed tomography (CT) imaging and/or endoscopic ultrasound (EUS) scan. Fourteen of the 34 patients had evidence of PV/SMV invasion on CT or EUS scans, 14 did not, and six studies were indeterminate. Twenty-five patients had follow-up imaging, and 22 (88%) had patent reconstructions. Fifteen patients had PV/SMV replacement using femoral vein. Seven of these 15 had minor postoperative lower extremity edema that resolved over time, five had wound complications from the femoral vein harvest site, three of which required minor operative procedures for treatment. Fifteen patients had PV/SMV patching with the great saphenous vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Four patients had PV/SMV patching using femoral vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Compared with patients undergoing pancreaticoduodenectomy without PV/SMV reconstruction, by Kaplan-Meier analysis, there was no difference in late mortality. Preoperative imaging may fail to detect PV/SMV involvement in patients undergoing pancreaticoduodenectomy. The PV/SMV reconstruction with leg vein provides good patency with minimal postoperative lower extremity complications and no increase in late mortality. The lower extremities should be routinely included in the operative field of patients undergoing pancreaticoduodenectomy.

A systematic review of the effects of Chronic Kidney Disease on lower extremity Peripheral Arterial Disease and Peripheral Neuropathy with recommendations on the development of clinical guidelines

Objectives and relationship to conference themes The effects of systemic disease on the lower extremity of high-risk patient groups, namely Diabetes and Rheumatic disease is well recognised and established within the Podiatrist’s scope of practice. However, it appears limited information is known within in the Podiatry profession about patients with Chronic Kidney Disease (CKD) and the onset of lower extremity complications. The main objective of the study was to systematically review the prevalence of lower extremity Peripheral Arterial Disease (PAD) and Peripheral Neuropathy (PN) in CKD and provide recommendations on the development of clinical guidelines.

Synchronous Urethral Stricture Reconstruction via 1-Stage Ascending Approach: Rationale and Results

We present our experience with the reconstruction of synchronous urethral strictures. Of 482 anterior urethroplasties performed by a single surgeon between 1997 and 2008 we identified and reviewed 30 patients who underwent reconstruction for multiple separate strictures. An ascending approach from distal to proximal was used and all repairs were completed at 1 stage. A total of 13 combinations of techniques were used to complete the repairs. A 2-phase technique was used in which the patient remained supine during buccal mucosa harvest and repair of strictures distal to the penoscrotal junction, and was then repositioned into the high lithotomy position as needed for stricture repair in the bulbar urethra. In each case normal intervening urethra was preserved intact. The number, length and location of strictures, operative time and patient outcomes were evaluated. No position related complications occurred during or after surgery despite a mean operative time of 4.5 hours (range 2.5 to 6.4). No infectious wound complications were reported despite repositioning the legs to the high lithotomy position. Three patients (10%) were known to have required treatment for recurrent stricture after surgery. One-stage reconstruction for synchronous urethral strictures may be safely and effectively performed using a systematic, ascending reconstructive approach with creative application of tissue transfer techniques. Decreasing patient time in the high lithotomy position appears to prevent related lower extremity complications.

Practical thermal monitoring solutions: empowering diabetic foot care teams for prevention of lower extremity complications

Practical thermal monitoring solutions: empowering diabetic foot care teams for prevention of lower extremity complications

Measurement of Skin Perfusion Pressure in Hemodialyzed Patients: Association with Toe/Brachial Index

AbstractBACKGROUNDPatients with diabetes mellitus or renal failure may have calcified lower leg arteries, causing a falsely raised ankle/brachial index (ABI). In such cases, other combined noninvasive complementary observations may be useful. The purpose of this study was to investigate vascular complications of lower extremities in chronic hemodialyzed patients by measuring skin perfusion pressure (SPP) and the toe/brachial index (TBI).METHODSSixty‐five patients treated with regular hemodialysis were recruited. ABI, TBI, and SPP of the foot were measured in outpatient settings.RESULTSSPP was positively correlated with toe pressure (r = 0.560, p < 0.001) and with TBI (r = 0.481, p < 0.001). On the basis of the ABI results and diabetes status of the patients, 129 limbs were divided into 4 groups. For those in the normal ABI class (ABI >0.9), SPP and TBI were decreased in the diabetic normal ABI group compared with those in the non‐diabetic normal ABI group.CONCLUSIONSThese findings not only support that diabetes is a risk factor for arteriosclerosis but also suggest that even in a normal ABI class, diabetic patients with end‐stage renal disease are already susceptible to arteriosclerotic assault of peripheral arterial complications. SPP measurement is a noninvasive, beneficial observation for lower extremity peripheral arterial disease in hemodialyzed patients at risk.

Integrating pressure distribution measurement and gait analysis: A contribution to the diabetic foot

Diabetes mellitus is a biochemical disease; however, a large number of lower extremity complications of the disorder are due to biomechanical dysfunction. Foot ulcers are a common and challenging problem for patients with diabetes and for the clinicians who provide their care and often result in great morbidity (through amputation), not to mention the cost to health-care systems worldwide. Using methods to prevent these ulcers can, therefore, avoid a large number of amputations due to diabetes.

Vascular complications of the lower extremities in diabetic patients on peritoneal dialysis

Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development. We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease. 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p<0.05), more often had peripheral neuropathy (p<0.002), as well as coronary artery disease (p<0.044). They had lower serum albumin (p<0.005), significantly higher serum phosphorus (p<0.047) and they received higher doses of erythropoietin (p<0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA(1c), body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca x P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p<0.0066 and p <0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all. In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patient's feet, especially in those with low serum albumin and peripheral neuropathy.

Guest Editorial: are diabetes‐related wounds and amputations worse than cancer?

Certainly one of the most feared complications of diabetes is the lower extremity amputation 1. This fear is not unwarranted. Diabetes-related ulcer and amputation may be associated with surprisingly high 5-year mortality. Moulik et al.2 reported a 5-year mortality of 45%, 18% and 55% for neuropathic, neuroischaemic and ischaemic ulcers, respectively. As expected, mortality was higher in ischaemic ulcers than neuropathic ulcers. However, it is fairly evident based on these data that all types of diabetic foot ulcers are associated with high morbidity and mortality. Similarly, approximately half the persons receiving a diabetes-related amputation will not be alive in 5 years. Certainly, peripheral vascular disease may be implicated as a significant factor associated with shorter life span. Criqui reported the 10-year mortality in patients with peripheral arterial disease and found a substantially higher risk of mortality among patients with large vessel peripheral arterial disease – a factor that may be even more profound today than when it was reported in the early 1990s 3, 4. Faglia et al. related this high mortality with the absence of revascularisation, citing a 1.7-fold greater risk for death in ischaemic subjects who might have benefited from intervention 5. How do these data compare with other serious medical conditions, such as cancer? If one reviews Figure 1, one might conclude that persons with lower extremity complications of diabetes have 5-year mortality rates similar or worse than many common types of cancer 6-10. In fact, some high-risk subgroups such as persons with renal disease requiring distal bypass may have 5-year mortality rates approaching 95% 10. Five-year mortality (%). Perhaps now is the time to change our discussion with health-care administrators, policy makers and especially ourselves. The disease state that many of us treat routinely is, quite literally, killing our patients at a rate comparable to cancer. Addressing this issue aggressively may alter this and make a difference for millions of people worldwide.

Foot and Ankle Problems of Aboriginal and Non-Aboriginal Diabetic Patients with End-Stage Renal Disease

There is little information available about the profile of lower extremity morbidity in diabetic patients with end-stage renal disease (ESRD) in the Canadian Aboriginal and non-Aboriginal population. A retrospective review of medical records in 127 diabetic patients on hemodialysis at a tertiary health care center was performed. Patient interviews and physical examinations were performed in 77 of these patients (36 Aboriginal, 41 non-Aboriginal), and followup evaluation was done in 39 patients at an average of 1 year later. Aboriginal patients were an average of 7 years younger than non-Aboriginal patients. Comorbidities of diabetes and ESRD were frequent. Peripheral neuropathy and inability to occlude the vessels were present in the majority of feet. Lower extremity complications were frequent, including prior foot ulcer in the majority of patients and an amputation in more than one fourth of the patients. Aboriginal patients had a significantly greater frequency of prior foot ulcer, mean number of foot ulcers per patient, amputation, prior osteomyelitis, and Charcot foot than non-Aboriginal patients. Almost all patients were at risk for future foot ulcer, but many patients did not inspect their feet daily. Home care was significantly less frequently available for Aboriginal than non-Aboriginal patients. The majority of patients had inadequate custom or prefabricated shoes and did not wear insoles on the day of examination. Aboriginal patients cited financial cost, insufficient family support, and language barriers as reasons for inadequate foot care and footwear more frequently than non-Aboriginal subjects. A significantly smaller frequency of Aboriginal patients had good knowledge of footwear or diet than non-Aboriginal patients. Lower extremity complications were significantly more frequent in Aboriginal than non-Aboriginal diabetic patients with ESRD. Financial cost and knowledge deficit were barriers to adequate foot care and footwear. These findings support the need for a formal foot care and footwear program for this high-risk population.

Longitudinal Incidence and Prevalence of Adverse Outcomes of Diabetes Mellitus in Elderly Patients

The natural history of type 2 diabetes mellitus (DM) in the elderly has not been previously described in a national longitudinal sample. This national longitudinal analysis (January 1, 1991, to December 31, 2004) examines mortality and morbidity rates in a representative sample of elderly patients newly diagnosed as having DM. Medicare beneficiaries diagnosed as having DM in 1994 (n=33,772) were compared with a control group (n=25,563) regarding death, lower extremity complications, nephropathy, retinopathy, cardiovascular complications, and cerebrovascular complications. The DM group had excess mortality of 9.2% by year 11 compared with the control group. By 2004, 91.8% of the DM group experienced an adverse complication compared with 72.0% of the control group. The DM group had a higher prevalence and incidence of microvascular and macrovascular complications at all time points compared with controls. Patients with DM were at increased risk for all lower extremity complications, particularly those requiring surgical intervention (gangrene, debridement, and amputation). Cardiovascular complications were a leading cause of morbidity, with 57.6% of the DM group diagnosed as having heart failure compared with 34.1% of the controls. Elderly persons newly diagnosed as having DM experienced high rates of complications during 10-year follow-up, far in excess of elderly persons without this diagnosis, implying a substantial burden on the individual and on the health care system.

Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis

We sought to assess the accuracy of the probe-to-bone (PTB) test in diagnosing foot osteomyelitis in a cohort of diabetic patients with bone culture proven disease. In this 2-year longitudinal cohort study, we enrolled 1,666 consecutive diabetic individuals who underwent an initial standardized detailed foot assessment, followed by examinations at regular intervals. Patients were instructed to immediately come to the foot clinic if they developed a lower-extremity complication. For all patients with a lower-extremity wound, we compared the results of the PTB test with those of a culture of the affected bone. We called PTB positive if the bone or joint was palpable and defined osteomyelitis as a positive bone culture. Over a mean of 27.2 months of follow-up, 247 patients developed a foot wound and 151 developed 199 foot infections. Osteomyelitis was found in 30 patients: 12% of those with a foot wound and 20% in those with a foot infection. When all wounds were considered, the PTB test was highly sensitive (0.87) and specific (0.91); the positive predictive value was only 0.57, but the negative predictive value was 0.98. The PTB test, when used in a population of diabetic patients with a foot wound among whom the prevalence of osteomyelitis was 12%, had a relatively low positive predictive value, but a negative test may exclude the diagnosis.

Optimising Antimicrobial Therapy in Diabetic Foot Infections

Foot infections are common and the most serious lower extremity complication contributing to amputations, particularly in patients with diabetes mellitus. Infection is most often a consequence of foot ulcerations, which typically follows trauma to a neuropathic foot. Foot infections may be classified as mild, moderate and severe; this largely determines the approach to therapy. Gram-positive bacteria are the sole causative pathogens for most mild and moderate infections. These infections can usually be treated with culture-based narrow-spectrum antibacterials along with appropriate surgical debridement in an outpatient setting. In contrast, severe infections are often polymicrobial, requiring hospitalisation and treatment with broad-spectrum antibacterials along with appropriate medical and surgical interventions. The initial empirical antibacterial regimen may be tailored based on the results of culture and sensitivity tests from properly obtained specimens. Several antibacterial regimens have demonstrated effectiveness in randomised controlled trials, but no single regimen has shown superiority. Managing diabetic foot osteomyelitis is particularly controversial and requires reliable cultures to select an appropriate antibacterial regimen. Surgical resection of the infected and necrotic bone favours a good outcome in chronic osteomyelitis. The recommended duration of antibacterial therapy ranges from 1 to 4 weeks for soft tissue infection, to >6 weeks for unresected osteomyelitis. The incidence of meticillin-resistant Staphylococcus aureus infection is increasing in both the healthcare setting and the community. This should be considered when selecting an antibacterial, especially if the patient does not improve with initial antibacterial therapy. Certain other organisms, such as Pseudomonas aeruginosa and Enterococcus spp., while potentially pathogenic, are often colonisers that do not require targeted therapy.

Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients

The purpose of this study was to evaluate the effectiveness of a temperature monitoring instrument to reduce the incidence of foot ulcers in individuals with diabetes who have a high risk for lower extremity complications. In this physician-blinded, randomized, 15-month, multicenter trial, 173 subjects with a previous history of diabetic foot ulceration were assigned to standard therapy, structured foot examination, or enhanced therapy groups. Each group received therapeutic footwear, diabetic foot education, and regular foot care. Subjects in the structured foot examination group performed a structured foot inspection daily and recorded their findings in a logbook. If standard therapy or structured foot examinations identified any foot abnormalities, subjects were instructed to contact the study nurse immediately. Subjects in the enhanced therapy group used an infrared skin thermometer to measure temperatures on six foot sites each day. Temperature differences >4 degrees F (>2.2 degrees C) between left and right corresponding sites triggered patients to contact the study nurse and reduce activity until temperatures normalized. The enhanced therapy group had fewer foot ulcers than the standard therapy and structured foot examination groups (enhanced therapy 8.5 vs. standard therapy 29.3%, P = 0.0046 and enhanced therapy vs. structured foot examination 30.4%, P = 0.0029). Patients in the standard therapy and structured foot examination groups were 4.37 and 4.71 times more likely to develop ulcers than patients in the enhanced therapy group. Infrared temperature home monitoring, in serving as an "early warning sign," appears to be a simple and useful adjunct in the prevention of diabetic foot ulcerations.