ContextAmong persons diagnosed as having diabetes mellitus, the prevalence
of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0%
to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently
become infected, cause great morbidity, engender considerable financial costs,
and are the usual first step to lower extremity amputation.ObjectiveTo systematically review the evidence on the efficacy of methods advocated
for preventing diabetic foot ulcers in the primary care setting.Data Sources, Study Selection, and Data ExtractionThe EBSCO, MEDLINE, and the National Guideline Clearinghouse databases
were searched for articles published between January 1980 and April 2004 using
database-specific keywords. Bibliographies of retrieved articles were also
searched, along with the Cochrane Library and relevant Web sites. We reviewed
the retrieved literature for pertinent information, paying particular attention
to prospective cohort studies and randomized clinical trials.Data SynthesisPrevention of diabetic foot ulcers begins with screening for loss of
protective sensation, which is best accomplished in the primary care setting
with a brief history and the Semmes-Weinstein monofilament. Specialist clinics
may quantify neuropathy with biothesiometry, measure plantar foot pressure,
and assess lower extremity vascular status with Doppler ultrasound and ankle-brachial
blood pressure indices. These measurements, in conjunction with other findings
from the history and physical examination, enable clinicians to stratify patients
based on risk and to determine the type of intervention. Educating patients
about proper foot care and periodic foot examinations are effective interventions
to prevent ulceration. Other possibly effective clinical interventions include
optimizing glycemic control, smoking cessation, intensive podiatric care,
debridement of calluses, and certain types of prophylactic foot surgery. The
value of various types of prescription footwear for ulcer prevention is not
clear.ConclusionsSubstantial evidence supports screening all patients with diabetes to
identify those at risk for foot ulceration. These patients might benefit from
certain prophylactic interventions, including patient education, prescription
footwear, intensive podiatric care, and evaluation for surgical interventions.

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Preventing Foot Ulcers in Patients With Diabetes

The study group.

Significance: Chronic wounds include, but are not limited, to diabetic foot ulcers, venous leg ulcers, and pressure ulcers. They are a challenge to wound care professionals and consume a great deal of healthcare resources around the globe. This review discusses the pathophysiology of complex chronic wounds and the means and modalities currently available to achieve healing in such patients. Recent Advances: Although often difficult to treat, an understanding of the underlying pathophysiology and specific attention toward managing these perturbations can often lead to successful healing. Critical Issues: Overcoming the factors that contribute to delayed healing are key components of a comprehensive approach to wound care and present the primary challenges to the treatment of chronic wounds. When wounds fail to achieve sufficient healing after 4 weeks of standard care, reassessment of underlying pathology and consideration of the need for advanced therapeutic agents should be undertaken. However, selection ...

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Challenges in the Treatment of Chronic Wounds.

Foot infections are a common and serious problem in persons with diabetes Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations) This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy) Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation) Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures Employing multidisciplinary foot teams improves outcomes Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections

Benjamin A. Lipsky, Anthony R. Berendt, H. Gunner Deery, John M. Embil, Warren S. Joseph, Adolf W. Karchmer, Jack L. LeFrock, Daniel P. Lew, Jon T. Mader, Carl Norden, and James S. Tan Medical Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Northern Michigan Infectious Diseases, Petoskey, Michigan; Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; Section of Podiatry, Department of Primary Care, Veterans Affairs Medical Center, Coatesville, Pennsylvania; Division of Infectious Diseases, Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Dimensional Dosing Systems, Sarasota, Florida; Department of Medicine, Service of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; Department of Internal Medicine, The Marine Biomedical Institute, and Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, Texas; Department of Medicine, New Jersey School of Medicine and Dentistry, and Cooper Hospital, Camden, New Jersey; and Department of Internal Medicine, Summa Health System, and Northeastern Ohio Universities College of Medicine, Akron, Ohio

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Diagnosis and Treatment of Diabetic Foot Infections

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal.

Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision)

Foot ulcerations, infections, and Charcot neuropathic osteoarthropathy are three serious foot complications of diabetes mellitus that can too frequently lead to gangrene and lower limb amputation. Consequently, foot disorders are one of the leading causes of hospitalization for persons with diabetes and can account for expenditures in the billions of dollars annually in the U.S. alone. Although not all foot complications can be prevented, dramatic reductions in their frequency have been obtained through the implementation of a multidisciplinary team approach to patient management. Using this concept, the authors present a Clinical Practice Guideline for diabetic foot disorders based on currently available evidence. The underlying pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are thoroughly reviewed. Although these guidelines cannot and should not dictate the standard of care for all affected patients, they are intended to provide evidencebased guidance for general patterns of practice. The goal of a major reduction in diabetic limb amputations is certainly possible if these concepts are embraced and incorporated into patient management protocols.

Diabetic foot disorders: A clinical practice guideline

Heel pain, whether plantar or posterior, is predominantly a mechanical pathology although an array of diverse pathologies including neurologic, arthritic, traumatic, neoplastic, infectious, or vascular etiologies must be considered. This clinical practice guideline (CPG) is a revision of the original 2001 document developed by the American College of Foot and Ankle Surgeons (ACFAS) heel pain committee.

The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

Foot and ankle specialists agree that flatfoot is a frequently encountered pathology in the adult population. For the purpose of this document, adult flatfoot is defined as a foot condition that persists or develops after skeletal maturity and is characterized by partial or complete loss (collapse) of the medial longitudinal arch. Adult flatfoot may present as an incidental finding or as a symptomatic condition with clinical consequences ranging from mild limitations to severe disability and pain causing major life impediments. Adult flatfoot encompasses a wide variety of pathologic etiologies that may include a benign process reflecting continuation of a congenital problem, trauma, or a condition associated with systemic pathology. The adult flatfoot is often a complex disorder with a diversity of symptoms and various degrees of deformity. Pathology and symptoms are caused by structural loading

Diagnosis and treatment of adult flatfoot.

Foot and ankle specialists acknowledge that flatfoot deformity is a frequently encountered pathology in the pediatric population. Flattening of the medial arch is a universal finding in flatfoot and it is common in both pediatric and adult populations. Pediatric flatfoot comprises a group of conditions occurring in infants, children, and adolescents (1) that are distinguished by anatomy and etiologic factors (2, 3–8). Flatfoot may exist as an isolated pathology or as part of a larger clinical entity (4). These entities include generalized ligamentous laxity, neurologic and muscular abnormalities, genetic conditions and syndromes, and collagen disorders. Pediatric flatfoot can be divided into flexible and rigid categories. Flexible flatfoot is characterized by a normal arch during nonweightbearing and a flattening of the arch on stance (Fig 1). Flexible flatfoot may be asymptomatic or

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Steven R. Kravitz

Papers

Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision)

Diabetic foot disorders: A clinical practice guideline

The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010

Diagnosis and treatment of adult flatfoot.

Diagnosis and treatment of pediatric flatfoot.