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More inpatient hospital days are used for the care of diabetic foot infection than for any other diabetic sequela. Both the number of lower extremity amputations and the overall treatment cost of treating diabetic infections may be reduced by using a team approach in the care of the infected diabetic pedal wound. The authors propose an evaluation and treatment protocol of infected pedal ulcerations in an urban, community teaching institution when admitted to an established, multidisciplinary diabetic foot care team. The hospital course of 111 patients admitted with a primary diagnosis of infected pedal ulceration are retrospectively reviewed. Results revealed an average-length hospital stay of 7.4 days with a 96% limb-salvage rate. The authors suggest that in the treatment of the infected pedal wound, a diabetic foot care team with a well developed treatment protocol may yield a consistently favorable outcome and a cost-effective hospital course.
This retrospective study reviewed the culture results of 112 admissions to a multidisciplinary diabetic foot care team with a primary diagnosis of infected diabetic pedal ulceration. An average of 1.5 +/- 0.9 species per patient (P < 0.0001) were isolated. Eighty-nine percent of wounds cultured grew two or fewer organisms. Anaerobic species were isolated in only 5% of all cultures. Of these isolates, the distinction between anaerobic colonization and true anaerobic infection is made. Results suggest that aggressive early hospitalization, coupled with aggressive intraoperative debridement, may yield less microbiologically complex infections that may be controlled with less expensive narrow spectrum antibiotic therapy. Diagnosis of the infected pedal ulceration of a patient with diabetes is a clinical one. If this diagnosis is combined with appropriate surgical intervention, microbiologic correlation, and antimicrobial therapy, the result may be a less complex hospital course and improved outcome.
The authors draw attention to the importance of evaluation of the contralateral limb when treating unilateral sequelae secondary to distal symmetrical polyneuropathy. Plantar pressure measurements of the contralateral limb during total contact casting are reviewed. The results of thermometric evaluation before and after initiation of repetitive stress were reviewed. The results suggest that the patient walking in a total contact cast may experience a reduced focal pressure on the contralateral limb when compared with uncasted walking and three-point walking with crutches. Dermal thermometry may be a highly sensitive tool in evaluating even mild increases in repetitive stress. To explain this decrease in contralateral stress, the authors examine the features inherent to the total contact cast and propose the concept of proprioceptive stability.
The aim of this longitudinal study was to report on the clinical characteristics and treatment course of acute Charcot's arthropathy at a tertiary care diabetic foot clinic. Fifty-five diabetic subjects, with a mean age of 58.6 +/- 8.5 years, were studied. All patients were treated with serial total contact casting until quiescence. Following casting and before transfer to prescription footwear, patients were eased into unprotected weightbearing via a removable cast walker. This cohort was followed for their entire treatment course and for a mean 92.6 +/- 33.7 weeks following return to shoes. Pain was the most frequent presenting complaint in these otherwise insensate patients (76%). The mean duration of casting was 18.5 +/- 10.6 weeks. Patients returned to footwear in a mean 28.3 +/- 14.5 weeks. Nine per cent of the population had bilateral arthropathy. These subjects were casted significantly longer than the unilateral group (p < 0.02). Surgery was performed on 25% of patients, with approximately two-thirds of these procedures involving plantar exostectomies and one-third fusions of affected joints. Patients receiving surgery remained casted significantly longer than non-surgical patients (p < 0.05). Additionally, men were casted longer than women (p < 0.008). Acute Charcot's arthropathy requires prompt, uncompromising reduction in weightbearing stress. Our data show that the ambulatory total contact cast is very effective for this. Regardless of the specific treatment method instituted, it is imperative that appropriate and aggressive treatment be undertaken immediately following diagnosis to help prevent progression to a profoundly debilitating, limb-threatening deformity.
