Presence Of Osteomyelitis Research Articles

Lumbosacral rotation flap: a simple method for covering sacral pressure injuries.

Pressure injuries (PIs) are among the most common skin and soft tissue wounds occurring in patients who are bedbound and/or immobile. PI management hinges on their prevention; however, reoccurrence poses a challenge to their management and requires a multidisciplinary approach. Here, the authors describe a lumbosacral rotation flap (LSRF) for the coverage of sacral PIs. A single-centre, retrospective analysis of prospectively collected data was carried out. All patients undergoing LSRF for sacral PIs were included. Patients with active systemic sepsis, immune compromise, hepatic or renal dysfunction were excluded. All patients underwent preoperative optimisation and wound cultures to direct antibiotic therapy after surgery. A total of nine patients underwent the procedure (seven male and two female). Mean age was 47.6 years with a mean ulcer size of 92.9 cm2. Bone biopsy indicated the presence of osteomyelitis in three patients. Of the LSRFs, two flaps showed minimal local complications in the form of marginal flap necrosis which was managed conservatively. All flaps healed well with no cases of flap loss or the need for secondary procedures. The results of this analysis showed that LSRF can be considered a first line of treatment of sacral PIs. They can be used to cover large defects. Due to their large base and flap size, readvancement in cases of recurrence is also possible.

Risk factors associated with amputations in patients with diabetic foot infection. Seven years of experience in a reference hospital in Panama. The diabetic foot study group at Chiriqui (the FOOTCHI study group)

AimsTo determine the risk factors associated with amputations in hospitalized patients with diabetic foot infection. Methodsthis is a prospective study conducted at a tertiary care hospital in Panama between January 2010 and December 2016. We included all patients admitted to the hospital with diabetes and diabetic foot infection. A total of 351 patients were included, and a survey to assess for demographic and clinical factors was completed prospectively until discharge. The outcome was lower limb amputation. ResultsSixty-one participants (17.4 %) required a lower limb amputation, and 22 (36.1 %) were major amputations. Several factors were associated with amputation in the univariate analysis: history of foot infection, history of amputation, peripheral arterial disease, a major index ulcer area, duration of the index ulcer >30 days, Grade III 3D severity according to Texas scale, a greater IDSA classification, the presence of necrosis and osteomyelitis. Nevertheless, multiple logistic regression revealed significant relationships between amputations and necrosis (P < 0.0001), osteomyelitis (P < 0.0001), and a severe IDSA classification (P = 0.008). ConclusionIn patients with diabetes foot infection, the presence of osteomyelitis, necrosis and a severe IDSA classification were strongly associated with amputation. Clinical relevanceThe rates of lower limb amputations in diabetic foot infections are higher in Hispanics than Caucasians, moreover, data on risk factors for amputation from diabetic foot infection in Latin American countries and specially Central American countries is scarce and there is no data in Panama.

Predictors of operative management in diabetic foot ulcers.

Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p<0.001), OR 2.19 (p<0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p<0.019) if osteomyelitis was present. Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.

Early Outcomes and Complications of Surgically Treated Diabetic Hallucal Infection

ObjectiveSeverely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal DFI treated with either conservative surgery or amputation. Setting and designThis is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all DFU were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. MethodsThe study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups. ResultsTen patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (p = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the re-amputation rate for the amputation group was 23.1% (p = 0.2). ConclusionThe study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seems to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to MRI bone infection signal could be considered to minimize the risk of subsequent surgeries and re-amputations.

Exploring Influential Variables in Emergency Amputations for Diabetic Foot Ulcer Patients

Background: The primary reason for lower extremity amputations predominantly arises from diabetic foot conditions. This study's objective was to explore the clinical features and influencing factors associated with amputation among patients presenting with diabetic foot ulcers in emergency departments. Methods: This study was conducted through a retrospective examination of the medical records of 60 patients referred to the Emergency Unit due to diabetic foot ulcers. Results: Out of the 60 patients in this study, 34 (53.4%) were male, and 26 (46.6%) were female. The average age was 61.43\(\pm\)11.584 years, with an age range of 41 to 85 years. Notably, extremity amputation was not necessary for 34 patients (58.6%), whereas 24 patients (41.4%) did undergo amputation. Factors influencing the need for extremity amputation included the duration of the disease, the presence of coronary artery disease, the length of hospital stay, and the presence of osteomyelitis. Among the laboratory findings, factors associated with extremity amputation were levels of albumin, hemoglobin, leukocytes, neutrophils, neutrophil-to-lymphocyte ratio, hemoglobin A1c, and elevated erythrocyte sedimentation rate. Conclusion: The findings of our study indicate that in addition to classification systems, factors such as comorbidities, levels of albumin, hemoglobin A1c, sedimentation rate, and results from complete blood counts are pivotal in predicting the necessity for amputation in patients with diabetic foot ulcers seeking care in emergency units.

Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

SHOULDER SEPTIC ARTHRITIS IN PAEDIATRICS AND ADOLESCENTS: A RETROSPECTIVE REVIEW OF CLINICAL PRESENTATION, BACTERIOLOGICAL PROFILE, AND OUTCOMES

Shoulder septic arthritis is uncommon and frequently misdiagnosed, resulting in severe consequences. This study evaluated the demographics, bacteriological profile, antibiotic susceptibility, treatment regimens, and clinical outcomes.This is a 10-year retrospective observational analysis of 30 patients (20 males and 10 females) who were treated for septic arthritis of the shoulder. The data collecting process utilised clinical records, laboratory archives, and x-ray archives. We gathered demographic information, pre- and post-intervention clinical data, serum biochemical markers, and the results of imaging examinations. All patients had a surgical arthrotomy and joint debridement in the operating room, and specimens were taken for culture and sensitivity testing. The specimens were cultivated for at least seventy-two hours. Shoulder joint ranges of motion, comorbidities, and the presence of osteomyelitis were assessed clinically to determine the outcome. All statistical analyses were conducted using the STATA 17 statistical software. Analysis of correlation between categorical variables was performed using the chi-squared test.The majority of the study patients were black Africans (97%). The age range of the group was from 8 days to 17 years. At presentation, 33% of patients had a low-grade fever, whereas the majority (60%) had normal body temperature. The average length of symptoms was 3.9 days (ranged from 1 day to 15 days), and the majority of patients had an increased white cell count (83%) and C-reactive protein (98%). There was accumulation of fluid in the joint of all individuals who received shoulder ultrasound imaging. We noted a significant incidence of gram-positive cocci, which were mostly susceptible to first-line antibiotics. Shoulder stiffness affected 63% of patients and chronic osteomyelitis affected 50% of individuals. Neither the severity nor the duration of the symptoms was related to an increased risk of osteomyelitis.The results of this study revealed that the clinical characteristics and bacterial profile of septic arthritis of the shoulder conform to typical patterns. The likelihood of osteomyelitis and an unfavourable prognosis is considerable.

Use of Traditional Remedies for Treatment of Diabetic Foot Ulcers: A Cross-Sectional Study at a Tertiary Center in Saudi Arabia

Patients with diabetic foot ulcer (DFU) are prone to major complications including amputations. Traditional remedies (TR) have been used to treat DFU around the world. This study aims to identify the prevalence of TR among patients with DFU in our local cohort and its effect on DFU. 1408 patients were included in the analysis. Data were collected retrospectively from patients’ medical records. DFU characteristics include grading ulcers using the Wagner scale (WG) and infections (cellulitis and osteomyelitis). Ulcer management (UM) includes medical treatment, self-medical treatment, traditional treatment, and medical-traditional treatment. The mean age of the cohort was 60 years (SD = 12.4). The mean duration of diabetes was 18.6 years (SD = 9.3) and the mean duration of open wounds was 206.9 days (SD = 545.6). The majority were males (71%) and had type 2 diabetes (96%, SD = .204). Forty-three percent of patients were treated with TR (29% were self-prescribed and 14% prescribed by a physician) while 48% had medical treatment and 10% were self-treated using medical treatment. More than two-thirds of the cohort had cellulitis and/or osteomyelitis at the time of presentation. The use of traditional treatment was significantly associated with higher WG (WG 4 OR = 1.936, 95% CI: 1.338-2.800; WG 5 OR = 2.937, 95% CI:1.614-5.346; P &lt; 0.05). Moreover, osteomyelitis was associated with medical-traditional treatment (OR = 1.608, 95% CI: 1.006-2.572; P &lt; 0.05) and increased wound depth (WG 3 OR = 1.969, 95% CI: 1.193-3.250; WG 4 OR = 1.874, 95% CI: 1.115-3.15; P &lt; 0.05). There is high use of TR for the treatment of DFU in our cohort. High Wagner-grade of foot ulcers and the presence of osteomyelitis were highly associated with DFU. This study showed for the first time the use of traditional potions by medical physicians. Both physicians and patients need to be made aware of the detrimental effects of using traditional methods on DFU.

Biochemical predictors of diabetic foot osteomyelitis: A potential diagnostic role for parathormone.

The aims of this study were to evaluate parathormone (PTH) levels in people with diabetic foot ulcers (DFU) and investigate the relationship between PTH levels and osteomyelitis (OM) in this population. Eighty-eight patients were admitted for DFU in a tertiary-care centre from October 2021 to May 2022. OM was diagnosed by clinical, laboratory, and radiological evaluations. Laboratory measurements and clinical parameters were collected from medical records. Participants in the study were divided into two groups according to the diagnosis of OM (patients with OM, group 1 [n=54] and patients without OM, group 2 [n=34]). Compared with group 2, patients in group 1 were younger and had a longer duration of diabetes. Erythrocyte sedimentation rate and fibrinogen were significantly higher in group 1 compared with group 2. PTH levels were significantly lower (group 1 vs. group 2, median [interquartile range] 16.2 (11.6, 31.0) vs. 23.7 (17.0, 38.1), p=0.008) and alkaline phosphatase was significantly higher (97.0 (79.0, 112.0) vs. 88.0 (63.0, 107.0), p=0.031) in group 1. In multiple linear regression analysis, the only independent predictors of PTH concentrations were alkaline phosphatase levels (β-coefficient 0.441, p<0.001) and the presence of OM (β-coefficient -0.290, p=0.038). In a population of patients with diabetes and OM admitted to a tertiary university centre, PTH levels were lower as compared with diabetic individuals without OM. The OM and alkaline phosphatase levels were independent predictors of PTH levels in this selected population.

Predictors of Digital Amputation in Diabetic Patients With Surgically Treated Finger Infections.

Diabetes is a well-established risk factor for severe digital infection, and patients are more likely to require digital amputation for adequate source control. This study aims to identify factors predictive of digital amputation compared with preservation in patients with diabetes who present with surgically treated finger infections. Current Procedural Terminology (CPT) and International Classification of Diseases Versions 9 and 10 (ICD-9/10) databases from a single academic medical center were queried to identify patients with type 1 or type 2 diabetes mellitus who underwent surgical treatment in the operating room for treatment of a digital infection from 2010 to 2020. Electronic medical records were reviewed to obtain historical and acute clinical variables at the time of hospital presentation. Bivariate and multivariable regression were used to identify factors associated with amputation. In total, 145 patients (61 digital amputation, 84 digital preservation) met inclusion criteria for this retrospective cohort study. Mean hospital stay was 6 days, and the average patient underwent 2 operations. Multivariable analysis revealed that the presence of osteomyelitis, ipsilateral upper extremity dialysis fistula, end-stage renal disease, and vascular disease each had significant independent predictive value for amputation rather than digital preservation. Digital amputation is common in the setting of diabetic finger infection. The 4 variables found to independently predict the outcome of amputation can be understood as factors which decrease the likelihood of successful digital salvage and increase the potential consequence of ongoing uncontrolled infection. Further study should focus on clinical factors affecting surgical decision making and how the treatment rendered affects patient outcomes.

Pilot study of the diagnostic value of CRP:albumin ratio for osteomyelitis in patients with diabetic foot ulcers.

Osteomyelitis may complicate diabetic foot ulcers (DFUs). As a new inflammation-based prognostic factor, CRP:albumin ratio's significance is not known in osteomyelitis among patients with or without diabetes. Patients with type 2 diabetes and DFUs were divided into two groups: group 1 (n=47) comprised patients without osteomyelitis, and group 2 (n=50) comprised patients with osteomyelitis. Erythrocyte sedimentation rate (ESR) (88.5±23.0 versus 42.0±22.2), white blood cell count (WBC) (14.7±6.9x103 versus 10.0±4.4x103), C-reactive protein (CRP) level (15.6±9.9 versus 2.4±3.3) and CRP:albumin ratio (6.6±4.9 versus 0.7±1.0) were significantly higher, and albumin level was significantly lower in group 2 compared to group 1 (p<0.001 for all). The presence of osteomyelitis was significantly and positively correlated with ESR (r=0.721; p<0.001), WBC (r=0.380; p<0.001), CRP (r=0.667; p<0.001) and CRP:albumin ratio (r=0.638; p<0.001), and negatively correlated with albumin (r=-0.590; p<0.001). A CRP:albumin ratio of 1.74 or above could predict osteomyelitis with 92.0% sensitivity, 80.9% specificity, and the best area under the curve (AUC) score (AUC=0.957; 95% CI: 0.924-0.991). ESR (odds ratio (OR): 1.071 (1.025-1.119); p=0.02) and CRP:albumin ratio (OR: 2.65 (1.437-4.885); p=0.002) were independent predictors in the final model for stepwise linear regression analyses for the estimation of osteomyelitis. CRP:albumin ratio is a cheap and repeatable inflammatory marker and can successfully detect osteomyelitis in patients with DFU.

Reconstruction of Lateral Malleolar Defects: Adipofascial Turnover Flap Based on the Peroneal Artery Perforator

Background: Lateral malleolar defects are a commonly encountered clinical issue, with several treatment options available from local flaps to microsurgical reconstruction. However, ankle defects are difficult to manage, especially in patients with comorbidities. We report here our experience of lateral malleolar reconstruction using adipofascial turnover flaps based on the peroneal artery perforator.Methods: A total of nine patients who underwent peroneal artery perforator-based adipofascial turnover flap coverage from December 2011 to February 2016 were retrospectively evaluated. Data were collected on the patients’ age, sex, etiology, comorbidities, anesthesia type, combined surgery, presence of osteomyelitis, bacterial profiles, vascular status, defect size, flap size, flap elevation time, follow-up period, and complications.Results: The mean age of the patients was 66.4 years. The most common cause of the wound was pressure injury. Seven patients had one or more comorbidities, and four patients were current smokers. Three patients were diagnosed with chronic osteomyelitis. Percutaneous transluminal angioplasty was performed in two patients. The mean defect size was 8.4 cm&lt;sup&gt;2&lt;/sup&gt;, and the mean follow-up period was 30.7 months. All nine flap transfers were successful without major complications. However, in one case, partial skin graft loss occurred, requiring additional skin grafting.Conclusion: The peroneal artery perforator-based adipofascial turnover flap is a safe and reliable method to reconstruct lateral malleolar defects. The operative technique is simple and convenient to perform and hence a useful option for reconstructing lateral malleolar defects. This is especially true for patients with comorbidities who are typically not indicated for more complex procedures.

Evaluation of Current Pressure Ulcer Staging.

We sought to assess health professionals' satisfaction with the National Pressure Injury Advisory Panel staging system (NPUAP). A paper survey assessing the satisfaction with the NPUAP was distributed to participants of a national wound care meeting. A total of 88 surveys were completed. Results were tabulated using SPSS. The survey response rate was 50%. Nearly all respondents (95.0%) used NPAUP for documentation. 75.3% indicated that a better staging system was needed. When participants were asked to evaluate their current staging system, 63.5% stated that the system does not adequately reflect patient's clinical condition, 61.6% felt that the current staging system was not easily reproducible, 58.0% believed that the current staging system was generally easy-to-use, and 43.9% indicated that it is unable to suggest management recommendations. When asked about an ideal classification system, the respondents proposed incorporating tissue necrosis (97.6%), depth of tissue involvement (96.3%), discharge documentation (92.5%), presence of osteomyelitis (90%), local infection (88.8%), and systemic infection (80.0%). Overall, 67.0% of the participants wanted to use a classification system that would reflect the progress of injury healing and could be used to indicate the need for intervention. Health care workers caring for pressure injury patients indicated dissatisfaction with the NPAUP.

Application of the S (AD) SAD System as a Prognostic and Evaluation Tool for the Multidisciplinary Treatment of a Diabetic Foot Ulcer

Introduction: Foot ulcers combined with infection is one of the main complications of type 2 diabetes mellitus (DM2), and when not diagnosed and treated, amputation is the most frequent outcome. Thus, patients with DM2 are ten times more likely to be hospitalized for infections when compared to normal ones. For this reason, it is indisputable that diabetic foot ulcers have a major impact on health and the early approach can reduce the chances of amputations. Case Report: A 48-year-old woman, admitted with an ulcer on her right foot for 30 days, reports worsening and pain for 7 days. Previous history of DM2 diagnosed 2 years ago, using metformin irregularly. On physical examination, he had edema, flushing, impaired tibial pulses and ulcer in the calcaneus with exudate in the right lower limb. In addition, he had a BMI of 32.5, showing overweight. Having considered the hypothesis of a diabetic foot associated with hyperglycemia, the S (AD) SAD system (SEPSIS, ARTERIOPATY, DENERVATION) was applied, in order to assess the prognosis of foot ulcer (healing), setting a score of 10 due to the presence of an affected area greater than 3 cm², affected depth up to the joint capsule, presence of osteomyelitis, reduced pulses, and reduced sensitivity at the site. In this sense, the system suggested an expectation for cure in a period greater than 6 months and with a high risk for limb amputation. The exams were consistent with the hypothesis of hyperglycemia, revealing decompensated diabetes mellitus. Thus, he presented elevated glycated hemoglobin (11.8%), estimated mean glycemia (292 ml / dL), and elevated basal glucose (191 mg / dL). Treatment with antibiotic therapy was initiated for 30 days and the patient was asked to go to the health service three times a week to perform debridement with SF 0.9% and apply the ionic silver dressing to treat the ulcer. In addition, the patient received guidance related to dietary reeducation, and started treatment with empagliflozin to control DM2. The patient progressed with progressive ulcer healing and weight reduction. After 3 months of treatment, after monitoring and multidisciplinary intervention, the patient had an adequate glycated hemoglobin rate (6.9%) and the patient achieved total healing of the ulcer, with improved sensitivity and peripheral circulation of the affected limb. Conclusion: Although ulcers are a frequent problem, there are difficulties not only in choosing the most appropriate approach, but also in a system that provides a prognosis and that makes it possible to assess the risk of amputation. Therefore, the S (AD) SAD system, a reproducible tool that favored decision making, provided a prognosis for slow healing and a high risk for amputation. Thus, the multidisciplinary team was able to measure the severity of the condition, choose a treatment, and evaluate the success of the approach adopted, which configured the total healing in 3 months.

Pathogenetic rationale for usage of recombinant interleukins in the patients with mandibular fractures to prevent post-traumatic osteomyelitis

The paper presents the results on spontaneous and induced production of IFNγ, IL-4, IL-13 cytokines in blood cells of patients with mandibular fractures and post-traumatic osteomyelitis. Osteomyelitis of the jaw represents one of the urgent challenges in modern medicine. There are many reasons for development of purulent necrotic processes of the jaw bones, including disorders of innate and adaptive immune response. Currently, the immunological aspects of post-traumatic complications of maxillofacial region remain poorly understood. There are no unambiguous and systematic studies of immune mechanisms in pathogenesis of post-traumatic osteomyelitis of the lower jaw. The aim of our study was to theoretically confirm application of recombinant interleukins (IL-1β, IL-2, IFNγ) in the patients with jaw fractures, in order to prevent osteomyelitis, as based on the studies of spontaneous and induced cytokine production (IFNγ, IL-4, IL-13). Spontaneous and stimulated production of IFNγ, IL-4, and IL-13 cytokines by blood cells was determined using specific reagent kits from RD Diagnostic Inc. (USA). The results were recorded using an ELISA Multiscan analyzer (Finland). Statistical significance of intergroup differences was determined by the Mann–Whitney method. The level of statistical significance at which the null hypotheses were rejected was 0.05. To stratify the cases of post-traumatic osteomyelitis and uncomplicated mandibular fracture, the models were developed with a singlelayer neural network, using the nnet R-studio package. To assess quality of the models, the areas under the ROC curves (AUC), Akaike criterion (AIC), and the relative classification accuracy (OTC) were used, which was determined as the ratio of correctly established model diagnosis numbers to the total number of patients. The study results demonstrate that the patients with mandibular fractures exhibit a moderate impairment of LPS-induced IL-4 and IFNγ production by leukocytes with IL-13 activation. In presence of osteomyelitis, this imbalance is promoted, thus suggesting an impaired ability of the cells to produce IL-4 and IFNγ. An opportunity for usage immunomodulation when treating the patients with mandibular fractures is represented by P = 1/(1+e-z) where z is defined via IL-1β, IL-2 and IFNγ levels on the first day of observation. In vitro supplementation with recombinant IL-1β and IFNγ modulates cell function, improving the cytokine profile. The prognostic models, imitating binary logistic regression, were used to demonstrate that recombinant IL-1β could be used to prevent patients with mandibular fractures from developing post-traumatic osteomyelitis (AIC = 13.2, AUC = 0.96, р = 0.026).

Multidrug resistant organism predicts ulcer recurrence following surgical management of diabetic foot osteomyelitis.

Diabetic foot ulcers commonly precede diabetic foot osteomyelitis (DFO) and once the latter occurs, surgical management is often performed. The presence of osteomyelitis is an independent risk factor for the development of re-ulceration. We investigated the relationship between causative organisms in osteomyelitis and 1-year diabetic foot outcomes (re-ulceration, amputation, and death) following surgical management in an observational cohort of 223 patients. Univariate and multivariate analyses were performed for available demographic, clinical, and laboratory data. In addition, random forest plots were used to identify microbiologic predictors of 1-year outcomes. Patients with osteomyelitis managed surgically were younger and exhibited more painful peripheral neuropathy than outpatients with diabetes alone (both P < .0001). Osteomyelitis proximal margin cultures were diverse, at times polymicrobial, and included multidrug-resistant organisms in 13.9% of the cohort. In patients who underwent surgery, 44.5% experienced a re-ulceration on the same foot within 12 months of surgery. The presence of multidrug-resistant organisms on proximal bone culture was found to be a significant predictor of diabetic foot ulcer recurrence in univariate modelling (P < .001) and importance rankings. This is the first study to use prediction modelling to identify a relationship between multidrug-resistant organisms and diabetic foot ulcer recurrence following DFO.

Determinants of wound healing in patients hospitalized for diabetic foot ulcer: results from the MEDFUN study.

The high amputation rates from diabetic foot ulcer (DFU) in Nigeria and prolonged hospitalization due to poor wound healing is a source of concern. Furthermore, factors that affect wound healing of DFUs have not yet been well studied in Nigeria, whereas knowing these factors could improve DFU outcomes. Therefore, the objective of this study was to determine the factors that are associated with the wound healing in patients hospitalized for DFU. The Multi-Center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study involving 336 diabetic patients hospitalized for DFU and managed by a multi-disciplinary team until discharge or death. Demographic, clinical, and biochemical characteristics were documented. Test statistics used were chi square, t-test, univariate, and multivariate logistic regression. The study endpoints were ulcer healing, LEA, duration of hospitalization, and mortality. Here we present data on wound healing. The mean ± SD age was 55.9±12.5 years. Univariate predictors of wound healing were ulcer duration more than 1 month prior to hospitalization (p<0.001), peripheral arterial disease (PAD) (p<0.001), foot gangrene (p<0.001), Ulcer grade ≥3 (p=0.002), proteinuria (p=0.005), anemia (p=0.009), renal impairment (p=0.021), glycated hemoglobin ≥7% (0.012), and osteomyelitis (p<0.001). On multivariate regression, osteomyelitis was the strongest independent predictor of wound healing after adjusting for all other variables (OR 0.035; 95% CI 0.004-0.332). This was followed by PAD (OR 0.093; 95% CI 0.028-0.311), ulcer duration >1 month (OR 0.109; 95% CI 0.030-0.395), anemia (OR 0.179; 95% CI 0.056-0.571). Presence of osteomyelitis, duration of ulcer greater than 1 month, PAD, Wagner grade 3 or higher, proteinuria, presence of gangrene, anemia, renal impairment, and HbA1c ≥7% were the significant predictors of wound healing in patients hospitalized for DFU. Early identification and prompt attention to these factors in a diabetic foot wound might significantly improve healing and reduce adverse outcomes such as amputation and death.

Incidence of Osteomyelitis in Sacral Decubitus Ulcers and Recommendations for Management.

Stage-4 pressure ulcers are defined as ulcerations that violate the fascia and expose underlying bone, muscle, and tendon. Exposed bone is always colonized by bacteria, but this does not necessarily lead to osteomyelitis. The rates of osteomyelitis in exposed bone in stage-4 pressure ulcers range from 14% to 86%.There has been no evidence that the presence of osteomyelitis leads to higher complication rates following flap coverage. There has been no evidence that bone biopsy and preoperative treatment of osteomyelitis have any benefit before flap coverage.

Mid-term walking ability after Charcot foot reconstruction using the Ilizarov ring fixator.

Failed conservative treatment and complications are indications for foot reconstruction in Charcot arthropathy. External fixation using the Ilizarov principles offers a one-stage procedure for deformity correction and resection of osteomyelitic bone. The aim of this study was to determine whether external fixation with an Ilizarov ring fixator leads reliably to walking ability. 29 patients treated with an Ilizarov ring fixator for Charcot arthropathy were retrospectively analyzed. Radiologic fusion at final follow up was assessed separately on conventional X-rays by two authors. The association between walking ability and the presence of osteomyelitis at the time of reconstruction, and the presence of fusion at final follow up was investigated using Fisher's exact test. Mean follow up was 35months (range 5.3-107) months; mean time of external fixation was 113days. Ten patients (34.5%) reached fusion, but 19 did not (65.5%). Two patients needed below knee amputation. 26 of the remaining 27 patients maintained walking ability, 23 of those without assistive devices. Walking ability was independent from the presence of osteomyelitis at the time of reconstruction and from the presence of fusion. Foot reconstruction with an Ilizarov ring fixator led to limb salvage in 93%. The vast majority (96.3%) of patients with successful limb salvage was ambulatory, independent from radiologic fusion, and presence of osteomyelitis at the time of reconstruction. These findings encourage limb salvage and deformity correction in this difficult-to-treat disease, even with underlying osteomyelitis.

Performance of a rapid two-sequence screening protocol for osteomyelitis of the foot.

Compare a two sequence protocol to a standard protocol in the detection of pedal osteomyelitis (OM) and abscesses and to identify patients that benefit from a full protocol. One hundred thirty-two foot MRIs ordered to assess for OM were enrolled, and the following items were extracted from the clinical reports: use of IV contrast, the presence of OM, reactive osteitis, and a soft tissue abscess. Using only one T1 nonfat-suppressed and one fluid sensitive fat-suppressed sequences, two experienced musculoskeletal radiologists reviewed each case for the presence of OM, reactive osteitis, or an abscess. A Kappa test was calculated to assess for interobserver agreement, and diagnostic performance was determined. The McNemar test was used to assess for the effect of contrast. Agreement between both observers and the clinical report on the presence of osteomyelitis was substantial ( k= 0.63 and 0.72, p < 0.001), while the agreement for abscess was fair (k = 0.29 and 0.38, p < 0.001). For osteomyelitis, both observers showed good accuracy (0.85 and 0.86). When screening bone for a normal versus abnormal case, this method was highly sensitive (0.97-0.98), but was less sensitive for abscess (0.63-0.75). Fifty-one percent of exams used contrast, and it did impact the diagnosis of abscess for one observer. This rapid protocol is accurate in making the diagnosis of OM, and its high sensitivity makes it useful to screen for patients that would benefit from a full protocol.