A universally accepted histopathologic classification of diabetic foot osteomyelitis does not currently exist. We sought to evaluate the histopathologic characteristics of bone infection found in the feet of diabetic patients and to analyze the clinical variables related to each type of bone infection.
We conducted an observational prospective study of 165 diabetic patients with foot ulcers who underwent surgery for bone infection. Samples for microbiological and histopathologic analyses were collected in the operating room under sterile conditions.
We found four histopathologic types of osteomyelitis: acute osteomyelitis (n = 46; 27.9%), chronic osteomyelitis (n = 73; 44.2%), chronic acute osteomyelitis (n = 14; 8.5%), and fibrosis (n =32; 19.4%). The mean ± SD time between the initial detection of ulcer and surgery was 15.4 ± 23 weeks for acute osteomyelitis, 28.6 ± 22.4 weeks for chronic osteomyelitis, 35 ± 31.3 weeks for chronic acute osteomyelitis, and 27.5 ± 27.3 weeks for the fibrosis stage (analysis of variance: P = .03). Bacteria were isolated and identified in 40 of 46 patients (87.0%) with acute osteomyelitis, 61 of 73 (83.5%) with chronic osteomyelitis, 11 of 14 (78.6%) with chronic acute osteomyelitis, and 25 of 32 (78.1%) with fibrosis.
Histopathologic categorization of bone infections in the feet of diabetic patients should include four groups: acute, chronic, chronic acute, and fibrosis. We suggest that new studies should identify cases of fibrosis to allow comparison with the present results. (J Am Podiatr Med Assoc 103(1): 24–31, 2013)
The purpose of this article is to present reference guidelines to assist clinicians when treating diabetic patients with foot wounds. Diabetic patients with limb-threatening foot ulcers often have multiple coexisting medical conditions that frequently become impediments to the resolution of foot wounds. Each foot wound is unique and its etiology is multifactorial; therefore, each foot wound should be managed differently. The treatment algorithm presented in this article is divided into three categories: Algorithm I describes the treatment of septic foot wounds, which may be considered true podiatric surgical emergencies; Algorithm II describes the treatment of ischemic foot ulcers or gangrene with or without underlying osteomyelitis; and Algorithm III describes the treatment of neuropathic foot ulcers with or without underlying osteomyelitis. (J Am Podiatr Med Assoc 92(6): 336-349, 2002)
We report an unusual case of Aeromonas hydrophilia septicemia in a nonmobile diabetic patient secondary to contaminated well water used for bathing with a portal of entry through chronic forefoot and heel ulcers. To date, there are no documented cases similar to this patient's presentation. Aeromonas hydrophilia is commonly distributed among aquatic environments and tends to be found during warmer months. It is a rare cause of disease but can be life threatening and deadly, as in our case, in immunocompromised individuals. As podiatric physicians, we must remain diligent and have a high index of suspicion to identify patients at risk for this rare but serious infection and administer treatment aggressively to limit morbidity and mortality.
Group B and F Beta Streptococcus Necrotizing Infection–Surgical Challenges with a Deep Central Plantar Space Abscess
A Diabetic Limb Salvage Case Report
We present the case of a 66-year-old, type II diabetic male with a deep wound to the plantar-lateral aspect of his right hallux. On examination, the central plantar compartment of his right foot was moderately erythematous and tender on palpation. After obtaining a deep wound culture, treatment was complicated by a progression of a group B and F beta streptococcus, necrotizing infection. The patient underwent a right hallux amputation, followed by a plantar medial incision for drainage of an abscess to the medial and central plantar compartments of the foot. Due to the extent and limb threat of the infection, the patient ultimately underwent a transmetatarsal amputation. Advanced healing modalities were also employed to decrease wound healing times, which allowed the patient to achieve early weightbearing and return to activities of daily living. This study depicts how the astute podiatric surgeon needs to make a decision in a timely manner to surgically debride all nonviable and necrotic tissue in order to minimize further amputation and preserve foot function.
Background: Diabetic foot infections (DFIs) can lead to limb loss and mortality. To improve patient care at a safety-net teaching hospital, we created a multidisciplinary limb salvage service (LSS).
Methods: We recruited a cohort prospectively and compared it to a historical control group. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious diseases consultations according to a standardized protocol. A retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed.
Results: A total of 250 patients were divided into two groups: the pre-LSS (n = 92) and the LSS (n = 158) groups. There were no significant differences in baseline characteristics. Although all patients were ultimately diagnosed with diabetes, more patients in the LSS group had hypertension (71% versus 56%; P = .01) and a prior diagnosis of diabetes mellitus (92% versus 63%; P < .001) compared to the pre-LSS group. Significantly, with the LSS, fewer patients underwent a below-the-knee amputation (3.6% versus 13%; P = .001). There was no difference in the length of hospital stay or 30-day readmission rate between the groups. Further broken down into Hispanic versus non-Hispanic, we noted that Hispanics had significantly lower rates of below-the-knee amputations (3.6% versus 13.0%; P = .02) in the LSS cohort.
Conclusions: The initiation of a multidisciplinary LSS decreased the below-the-knee amputation rate in patients with DFIs. Length of stay was not increased, nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary LSS dedicated to the management of DFIs is both feasible and effective, even in safety-net hospitals.
Gout is a purine metabolism disease. Tophaceous gout may cause joint destruction and other systemic problems and sometimes may be complicated by infection. Infection and sinus with discharge associated with tophaceous gout are serious complications, and treatment is difficult. We present a patient with tophaceous gout complicated by infection and discharging sinus treated by bilateral amputation at the level of the first metatarsus.
A 43-year-old man previously diagnosed as having gout, and noncompliant with treatment, presented with tophaceous gout associated with discharging sinus and infection on his left first metatarsophalangeal joint. Because of the discharging sinus associated with the tophaceous deposits, the soft-tissue and bony defects, and the noncompliance of the patient, amputation of the first ray was undertaken, and a local plantar fasciocutaneous flap was used to close the defect. After 8 months, the patient was admitted to the emergency department with similar symptoms in his right foot, and the same surgical procedure was performed.
One year after the second surgery, the patient had no symptoms, there was no local inflammatory reaction over the surgical areas, and laboratory test results were normal.
Gout disease with small tophi often can be managed conservatively. However, in patients with extensive lesions, risk of superinfection justifies surgical treatment. Results of complicated cases are not without morbidity; therefore, early surgical treatment may prevent extremity loss and further complications. In severe cases, especially with compliance issues, amputation provides acceptable results.
Reconstruction of bone and soft-tissue defects after an open reduction and internal fixation of a severly comminuted calcaneal fracture presents a challenge to the treating surgeon. We present a case report in which an abductor digiti minimi muscle flap was used to cover a complicated wound with calcaneal osteomyelitis and wound dehisence at the surgical incision. This muscle flap provides an easy, reliable, and quick method to cover open wounds at the lateral aspect of the foot and ankle. (J Am Podiatr Med Assoc 98(2): 139–142, 2008)
While performing a distal first metatarsal bunion correction, care is always taken to stabilize the capital fragment during relocation and until fixation is completed. The underlying concern is that one false move could cause the capital fragment to end up on the floor. There are articles relating what surgeons have done when this has happened, but there is no evidence-based literature relating to guidelines or policy for decontaminating dropped bone. This case study relates what happened to me after saying, “Can you pick that up for me please?” (J Am Podiatr Med Assoc 101(2): 190–191, 2011)