Aims/hypothesis We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of footsparing surgery and avoidance of amputation. Methods A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death. Results Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection. Conclusions/interpretation Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.

A low rate of recurrence of osteomyelitis after surgical treatment for osteomyelitis was achieved. Despite new episodes, our approach to managing this cohort of patients with diabetes and foot osteomyelitis achieved 98.8% limb salvage.

The aim of this study was to analyze the outcomes of treatment of necrotizing soft-tissue infections (NSTIs) in the feet of diabetic patients and to determine factors associated with limb salvage and mortality. A retrospective study of a consecutive series of 145 diabetic patients suffering from NSTIs treated in the Diabetic Foot Unit, La Paloma Hospital was done. NSTIs were classified as necrotizing cellulitis if it involved the subcutaneous tissue and the skin, as necrotizing fasciitis if it involved the deep fascia, and as myonecrosis in those cases where muscular necrosis was present. In the necrotizing cellulitis group (n = 109), 8 (7.3%) major amputations were performed. In the necrotizing fasciitis group (n = 25), 13 (52%) major amputations were undertaken. In the myonecrosis group (n = 11), 6 (54.5%) major amputations were performed. Predictive variables related to limb loss were fasciitis (OR = 20, 95% CI = 3.2-122.1) and myonecrosis (OR = 53.2, 95% CI = 5.1-552.4). Predictive variables of mortality were age >75 years (OR = 10.3, 95% CI = 1.9-53.6) and creatinine values >132.6 micromol/L (OR = 5.8, 95% CI = 1.1-30.2). NSTIs of the foot are an important cause of morbidity and mortality in diabetic patients.When fascia and/or muscle are involved, there are significant risks of major amputation.

From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis.

The purpose of this study was to analyze the outcomes of major lower extremity amputations (MLEAs) in a series, including diabetic patients, with the aim to study whether diabetes mellitus is a risk factor of in-hospital mortality and perioperative complications. A retrospective analysis of 283 MLEAs (221 of these patients were diabetic and 62 were nondiabetic) performed between January 1, 1998, and December 31, 2008, at the General Surgery Department and Diabetic Foot Unit of La Paloma Hospital in Las Palmas de Gran Canaria (Canary Islands) was done. The significant risk factors of mortality were >" xbd="324" xhg="301" ybd="1481" yhg="1446"/>75 years of age (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 1.4-11.7), postoperative cardiac complications (OR = 12.3, 95% CI = 3.7-40.2) and postoperative respiratory complications (OR = 3.8, 95% CI = 1.0-13.3). No statistically significant risk factors were found related to the presence of systemic and wound-related complications. In diabetic patients, the significant risk factors of mortality were postoperative cardiological complications (OR = 13.6, 95% CI = 3.1-59.6), postoperative respiratory complications (OR = 5.9, 95% CI = 1.0-35.5), and first episode of amputation (OR = 5.9, 95% CI = 1.4-24.3). There were no statistically significant differences in the outcome of major amputations between diabetic and nondiabetic patients. Hospital stay was significantly longer in diabetic patients (P < .01) though when the patients with diabetic foot infections were excluded, this difference was not found.

Outcomes of surgically treated limb- and life-threatening infections in patients with diabetes and a well-vascularized foot based only on the palpation of foot pulses are not well known. The authors retrospectively studied a series of 173 patients with diabetes and limb- (moderate) or life- (severe) threatening infections with at least one palpable pedal pulse who were admitted to their department for the treatment of infected diabetic foot from January 1, 1998, to December 31, 2009. A total of 141 patients (81.5%) presented with limb-threatening/moderate infections and 32 (18.5%) with life-threatening/severe infections. In all, 49 patients (28.3%) presented with soft tissue infections only, 90 (52%) with osteomyelitis and 34 (19.7%) with a combined infection. Amputation was needed in 74 patients (42.7%), of whom 6 needed a major amputation (3.5% of overall). A total of 99 (57.2%) patients were treated by conservative surgery. Four patients (2.3%) died during the postoperative period (30 days). Limb salvage was achieved in 167 (96.5%) of the patients who were followed up until healing. Healing of the wounds by secondary intention was achieved in a median of 72 days. Clinical results permit the observation that a high rate of limb salvage can be achieved after the surgical treatment of limb- and life-threatening infections in patients with at least one palpable pedal pulse.

Surgery is usually used to treat diabetic foot osteomyelitis (DFO), whether primarily or in cases in which antibiotics are not able to control infection. In many cases, the bone is only partially removed, which means that residual infection remains in the bone margins, and the wound is left open to heal by secondary intent. The use of culture-guided postoperative antibiotic treatment and adequate management of the wound must be addressed. No trials exist dealing with local treatment in the postoperative management of these cases of complicated DFO. We decided to test a super-oxidized solution, Dermacyn Wound Care (DWC; Oculus Innovative Sciences Netherlands BV, Sittard, Netherlands) to obtain preliminary experience in patients in whom infected bone remained in the surgical wounds. Our hypothesis was that DWC could be useful to control infection in the residual infected bone and surrounding soft tissues and would thus facilitate healing. Fourteen consecutive patients who underwent conservative surgery for DFO, in whom clean bone margins could not be assured, were treated in the postoperative period with DWC. Eleven cases were located in the forefoot, 6 on the first ray and the rest in lesser toes, 1 in the Lisfranc joint, and 2 on the calcaneus. No side effects appeared during treatment. Neither allergies nor skin dermatitis were found. Limb salvage was successfully achieved in 100% of the cases. Healing was achieved in a median period of 6.8 weeks.

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