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Improving Outcomes
(or why Im not going into vascular!)
John C. Lantis II, MD
Assistant Professor of Surgery
College of Physicians and Surgeons
Columbia University
Epidemiology
Cellulitis
Epidemiology
25
Epidemiology
(of amputation)
25-50 % of diabetic foot infections lead to minor
amputations
10-40 % require major amputations
10-30 % of patients with a diabetic foot ulcer will
go on to amputation
Pathophysiology
Metabolic
derangement
Faulty wound healing
Neuropathy
Angiopathy
Mechanical stress
Patient and provider neglect
granuloma formation
Prolonged persistence of abscess
Higher rate of carriage of Staph Aureus in the
nares
Bullae, necrobiosis
Nail fungi (Tenia)
PMN functions
Migration,
Ketosis
Sensory Neuropathy
Unaware
of a foreign body
Pressure
in shoes
Abrasions in shoes
Tears or brakes in the skin
Motor Neuropathy
Architectural
Hammer
deformities
or claw toe
High plantar arch
Subluxation of metatarsals
Autonomic Neuropathy
Anhidrosis
Dry, cracked
Arterial
skin
to venous shunting
Temperature regulation disorders
Angiopathy
Can
Microangiopathy
Certainly
+/-
Pulsatile
Foot Anatomy
Compartments, low amount of soft tissue, tendon sheaths
Deep plantar space
Calcaneal
Microbiology
Infection
Microbiology
Normal
Coag
Acute
skin bacteria
wound
Monomicrobial
Chronic
(Gram positive)
wound
Polymicrobial
Wound Cultures
Uninfected
If
wound
Infected
Help
wound
Wound Cultures
Deep
Wound Cultures
Staph
Diagnosis
Clinical presentation
Presence of purulence
Pain, swelling, ulceration, sinus tract formation, crepitation
Systemic infection (fever, rigors, vomitting, tachycardia, change
in mental status, malaise)
Surprisingly
uncommon
Clinical Presentation
60
years old
66 % male
DM 15-20 years
66 % PVD
80 % loss of protective sensation
33 % have lesion for > 1 month
50% lack fever, leukocytosis or elevated ESR
Evaluation
Describe
Evaluation
Measure
wound (? Photograph ?)
Determine inflow
Neurologic status? Sensation, motor, autonomic
Cleanse and debride wound
Culture the cleansed wound (curettage)
Plain radiographs
Osteomyelitis
50-60
and Mader
Osteomyelitis
Larger
(>2cm)
Deeper (>3mm)
ESR > 70 mm/hr
If you can touch bone 90% correlation with osteo
Xray changes take 2 weeks to occur
Sensitivity
55 %, specificity 75%
Focal osteopenia, cortical erosions, periosteal reaction
Osteomyelitis
Bone
(technitium Tc 99)
85%
Leukocyte
85%
scans
MRI
Sensitivity
Osteomyelits
Etiologic
Staph
organisms
Treatment
Debridement
Minor Remove
Treatment
Surgical
Salvage
Treatment
Plantar
abscess
Disappearance
Foot
edema
Central plantar infections worse outcomes
Wide incision and drainage necessary
Treatment
Antibiotics
Do
Treatment
Empiric
antibiotic therapy
Staph
Strep
GNR
Enterococcus
Anaerobes
*Tailor
to clinical progress
Treatment
Prospective
Antibiotic thoughts
Bactrim/Flagyl
Antibiotic thoughts
Duration
of therapy
No
good studies
Once active infection resolved plus 2 days
Osteomyelitis
6
weeks
Can use Flouoquinolones and clindamycin