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Over the past generation, limb preservation programs and diabetic foot services have begun to proliferate within academic health science centers as well as within health-care systems in general. We describe four key components for a successful program that, developed sequentially with temporal overlap, can allow the program to scale. The first component includes establishment of a ‘hot foot line’ for urgent emergency department/inpatient referral. The second includes development of a wound-healing clinic to address outpatient care through to remission. The third component focuses on the diabetic foot in remission to maximize ulcer-free days following healing. The fourth and final component focuses on implementation of local and widespread screening clinics to identify and triage patients into appropriate therapeutic and surveillance programs for healing, remission, and primary prevention. Along with developing each of these components, we describe discrete methods to quantify success.

Objective : The purpose of this study was to evaluate risk factors for methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized for diabetic foot infections. Methods : We reviewed hospital admissions for foot infections in patients with diabetes which had nasal swabs, and anaerobic and aerobic tissue cultures at the time of admission. Data collected included patient characteristics and medical history to determine risk factors for developing an MRSA infection in the foot. Results : The prevalence of MRSA in these infections was 29.8%. Risk factors for MRSA diabetic foot infections were history of MRSA foot infection, MRSA nasal colonization, and multidrug-resistant organisms (p

Background: The management of chronic diabetic foot ulcers (DFU) poses a great challenge to the treating physician and surgeon. The aim of this study was to identify the risk factors, clinical presentation, and outcomes associated with chronic DFU > 6 months’ duration. Methods: This prospective study was performed in Jabir Abu Eliz Diabetic Centre (JADC), Khartoum, Sudan. A total of 108 patients who had DFU for >6 months were included. Recorded data included patient's demographics, DFU presentation, associated comorbidities, and outcomes. DFU description included size, depth, protective sensation, perfusion, and presence of infection. Comorbidities assessed included eye impairment, renal and heart disease. All patients received necessary local wound care with sharp debridement of any concomitant necrotic and infected tissues and off-loading with appropriate shoe gear and therapeutic devices. Results: The mean age of the studied patients was 56+SD 9 years with a male to female ratio of 3:3.3. The mean duration of DFU was 18±SD 17 months (ranging from 6 to 84 months). Ulcer healing was significantly associated with off-loading, mainly the use of total contact cast (TCC) (p=0.013). Non-healing ulcerations were significantly associated with longer duration of the chronic DFU > 12 months (p=0.002), smoking (p=0.000), poor glycemic control as evidenced by an elevated HbA1c (>7%), large size (mean SD 8+4 cm), increased depth (p 6 months’ duration included the presentation of an ulcer with increased size and depth, with associated skin callus and neuroischemia, in a diabetic patient with a history of smoking and increased HbA1c >7%. Off-loading mainly with the use of TCC is an effective method of managing long-standing DFU.

Background: Staphylococcus aureus (S. aureus) is one of the major pathogens causing chronic infections. The ability of S. aureus to acquire resistance to a diverse range of antimicrobial compounds results in limited treatment options, particularly in methicillin-resistant S. aureus (MRSA). A mechanism by which S. aureus develops reduced susceptibility to antimicrobials is through the formation of small colony variants (SCVs). Infections by SCVs of S. aureus are an upcoming problem due to difficulties in laboratory diagnosis and resistance to antimicrobial therapy.Methods: A prospective study was performed on 120 patients diagnosed with both type 2 diabetes mellitus and infected diabetic foot ulcers. The study was carried out from July 2012 to December 2013 in Hospital General de Mexico. The samples were cultured in blood agar, mannitol salt agar, and MacConkey agar media, and incubated at 37°C in aerobic conditions.Results: We describe the first known cases of diabetic foot infections caused by MRSA-SCVs in patients diagnosed with type 2 diabetes mellitus and infected diabetic foot ulcers. In all of our cases, the patients had not received any form of gentamicin therapy.Conclusions: The antibiotic therapy commonly used in diabetic patients with infected diabetic foot ulcers fails in the case of MRSA-SCVs because the intracellular location protects S. aureus-SCVs from the host's defenses and also helps them resist antibiotics. The cases studied in this article add to the spectrum of persistent and relapsing infections attributed to MRSA-SCVs and emphasizes that these variants may also play a relevant role in diabetic foot infections.Keywords: diabetic foot; infection; ulcer; small colony variants; methicillin-resistant Staphylococcus aureus(Published: 17 March 2015)Citation: Diabetic Foot & Ankle 2015, 6: 26431 - http://dx.doi.org/10.3402/dfa.v6.26431

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD11.4) compared to the control group of 56.3 years (SD12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate. Keywords: diabetic foot; osteomyelitis; ulcer; amputation; neuropathy (Published: 1 October 2012) Citation: Diabetic Foot & Ankle 2012, 3 : 18809 - http://dx.doi.org/10.3402/dfa.v3i0.18809

Conservative management of Charcot foot neuroarthropathy remains efficacious for certain clinical scenarios. Treatment of the patient should take into account the stage of the Charcot neuroarthopathy, site(s) of involvement, presence or absence of ulceration, presence or absence of infection, overall medical status, and level of compliance. The authors present an overview of evidence-based non-operative treatment for diabetic Charcot neuroarthropathy with an emphasis on the most recent developments in therapy. Keywords: diabetic foot; osteomyelitis; Charcot neuroarthropathy; ulcer; bone stimulation(Published: 11 May 2011)Citation: Diabetic Foot & Ankle 2011, 2: 6418 - DOI: 10.3402/dfa.v2i0.6418

Objectives: This is a prospective study of the clinical efficacy of the V.A.C. Granufoam Bridge Dressing for the treatment of diabetic foot ulcers. Materials and methods: Five consecutive patients with diabetic foot ulcers were treated with V.A.C. Granufoam Bridge Dressings and studied over a period of 22-48 days. The indications for treatment included diabetic patients with open ray amputation wounds and wounds post-drainage for abscess with exposed deep structures. Clinical outcome was measured in terms of reduction in wound dimensions, presence of wound granulation, microbial clearance, and development of wound complications. Results: Our results showed that with V.A.C. therapy, wound healing occurred in all patients. The number of dressings required ranged from 8 to 10. The baseline average wound size was 23.1 cm 2 . Wound areas shrunk by 18.4-41.7%. All subjects achieved 100% wound bed granulation with an average length of treatment of 33 days. Microbial clearance was achieved in all cases. All wounds healed by secondary intention in one case and four cases required split-thickness skin grafting. Conclusion: The V.A.C. Granufoam Bridge Dressing is effective in the treatment of diabetic foot ulcers. It promotes reduction of wound area, wound bed granulation, and microbial clearance. By allowing placement of the suction pad outside the foot, it allowed patients to wear protective shoes and to walk non-weight bearing with crutches during V.A.C. therapy. Keywords: diabetic foot, negative pressure wound therapy, ulcer, neuropathy (Published: 4 March 2011) Citation: Diabetic Foot & Ankle 2011, 2 : 5893 - DOI: 10.3402/dfa.v2i0.5893