Aims/hypothesis We sought to identify factors related to shortterm outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. Methods Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1-5, below ankle) (n=2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31.The characteristics of the remaining 2,480 patients were: 1,465 men, age 68±15 years (range 18-96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. Results The healing rate without major amputation in surviving patients was 90.6% (n=1,867). Sixty-five per cent (n=1,617) were healed primarily, 9% (n=250) after minor amputation and 8% after major amputation; 17% (n=420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to comorbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. Conclusions/interpretation Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.

SummaryThe International Working Group on the Diabetic Foot appointed an expert panel to provide evidence-based guidance on the management of osteomyelitis in the diabetic foot. Initially, the panel formulated a consensus scheme for the diagnosis of diabetic foot osteomyelitis (DFO) for research purposes, and undertook a systematic review of the evidence relating to treatment. The consensus diagnostic scheme was based on expert opinion; the systematic review was based on a search for reports of the effectiveness of treatment for DFO published prior to December 2006.The panel reached consensus on a proposed scheme that assesses the probability of DFO, based on clinical findings and the results of imaging and laboratory investigations.The literature review identified 1168 papers, 19 of which fulfilled criteria for detailed data extraction. No significant differences in outcome were associated with any particular treatment strategy. There was no evidence that surgical debridement of the infected bone is routinely necessary. Culture and sensitivity of isolates from bone biopsy may assist in selecting properly targeted antibiotic regimens, but empirical regimens should include agents active against staphylococci, administered either intravenously or orally (with a highly bioavailable agent). There are no data to support the superiority of any particular route of delivery of systemic antibiotics or to inform the optimal duration of antibiotic therapy. No available evidence supports the use of any adjunctive therapies, such as hyperbaric oxygen, granulocyte-colony stimulating factor or larvae.We have proposed a scheme for diagnosing DFO for research purposes. Data to inform treatment choices in DFO are limited, and further research is urgently needed.

Protein energy malnutrition is an important determinant of clinical outcome in older patients after hip fracture, but the effectiveness of nutritional support programs in routine clinical practice is controversial. We performed a prospective, randomized, controlled clinical trial to determine if nutritional supplementation decreased fracture-related complications in a selection of otherwise healthy patients with hip fractures. Patients were randomized to intervention or control groups. The control group (n = 40) was given ordinary hospital food and beverage. The intervention group (n = 40) also was administered a 1000 kcal daily intravenous supplement for 3 days, followed by a 400 kcal oral nutritional supplement for 7 days. We recorded daily fluid and energy intake during the first 10 days of hospitalization and fracture-related complications up to 4 months. The total fluid and energy intake in the intervention group neared optimal levels. The control group received 54% and 64% of optimal energy and fluid intake, respectively. The risk of fracture- related complications was greater in the control group (70%) than in the intervention group (15%). Four patients in the control group died within 120 days postoperatively. The comprehensive balanced nutrition supplement resulted in lower complication rates and mortality at 120 days postoperatively.