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Marie-France
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Authors E. Chantelau

Title The perils of procrastination: effects of early vs. delayed
detection and treatment of incipient Charcot fracture

Citation Diabet Med 2005; 22:1707-1712

At the onset of acute diabetic Charcot foot, therapeutic intervention
may be delayed because plain X-rays may not show fractures. This study
assessed the clinical course of acute Charcot foot in 24 patients
without evidence of definite fractures on the first X-ray after onset of
symptoms, who were referred to the foot clinic for diagnosis and
treatment either early or delayed, i.e. before or after definite
fractures were detectable on repeat X-rays. 11 patients were referred
early (incipient Charcot foot, case group), and 13 patients were
referred delayed (overt Charcot foot, control group). In the foot
clinic, both groups were immediately treated with off-loading and total
contact casting. After the healing process of the Charcot foot was
complete, the extent of fractures and subsequent deformities were
evaluated. Based on X-rays at the onset of symptoms, in 19 of the 24
patients the condition had been misdiagnosed prior to referral (in 11
patients as sprain injury). Additional imaging techniques (MRI, CT scan
or bone scintigraphy) had been performed in 10 patients prior to
referral. While these techniques had been used more frequently in the
cases vs. the controls (P = 0.012), misdiagnosis was less frequent in
the cases vs. the controls (P = 0.013). Only 1 out of 11 case patients
developed extended foot fractures and severe deformity, vs. 12 out of 13
control patients (P < 0.001). Therefore early detection of incipient
Charcot foot is facilitated by imaging techniques other than plain
X-rays. Immediate off-loading of incipient Charcot foot appears to
minimize fractures and incapacitating deformities.
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Authors L. Kessler, Y Piemont, F Ortega, O Lesens, C Boeri, C Averous,
R Meyer, Y Hansmann, D Christmann, J Gaudias, M Pinget

Title Comparison of microbiological results of needle puncture vs.
superficial swab in infected diabetic foot ulcer with osteomyelitis

Citation Diabet Med 2006; 23:99-102

This is a prospective study of 2 methods for the bacteriological
diagnosis of osteomyelitis related to diabetic foot ulcer: needle
puncture performed across normal skin surrounding the foot ulcer and
superficial swabbing of the ulcer. Patients with diabetes and with a
foot ulcer complicated by bone or joint infection, as detected by X-ray
imaging, were included in the study. Ulcer swabbing and needle puncture
were performed in each patient. To reach the tissue nearest the bone
surface, needle puncture was guided by X-ray imaging and the drop of
fluid obtained by aspiration was used for both aerobic and anaerobic
bacterial culture. 21 patients were included. The mean number of
microorganisms isolated by needle puncture was significantly lower
compared with that obtained by superficial swabbing: 1.09 vs. 2.04 (P <
0.02). Three bacterial species were isolated by needle puncture only in
one patient while three or more bacterial isolates were obtained by
superficial swabbing in six patients. No bacterial isolate was detected
in 5 patients by needle puncture and in two patients by superficial
swabbing. Staphylococcus aureus accounted for 70% of cases (7 patients)
when a single bacterial species was obtained by needle puncture. After
needle puncture, no wound complication or infection was observed.
Culture of samples obtained by needle puncture revealed one or two
bacterial isolates in two-thirds of diabetic patients with osteomyelitis
following foot ulcer. Given the lack of complications, this invasive
diagnostic technique should be considered for deep direct sampling in
diabetic patients with osteomyelitis related to foot ulcer when surgical
debridement is contraindicated or delayed.
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Authors N. Pound, S. Chipchase, K. Treece, F. Game and W. Jeffcoate

Title Ulcer-free survival following management of foot ulcers in
diabetes

Citation Diabet Med 2005; 22:1306-1309

All referrals to a specialist diabetic foot clinic over a 31-month
period were analysed and outcomes were determined after a minimum
follow-up of 6 months. 370 patients were referred with a total of 1031
ulcers. 121 (32.7%) never became ulcer free: 56 (46.3% of 121) remained
unhealed, the ulcers of 12 (9.9% of 121) had been resolved by
amputation, 2 remained unhealed after amputation (1.7% of 121) and 51
(13.8% of 370) had died. 231 (62.4% of 370) became ulcer free at some
stage. 5 of these were excluded because of an earlier amputation. 91of
the remaining 226 (40.3%) developed a recurrent or new ulcer after a
median 126 days. Of the 135 who did not have a recurrence, 133 (58.8% of
226; 35.9% of 370) survived ulcer free and with limbs intact, while two
died. Outcome was unknown in 18 (4.9%). Those who never became ulcer
free were older (P < 0.001) and with a greater prevalence of ischaemia
(P < 0.001). Those who healed but went on to suffer a new ulcer had a
greater prevalence of neuropathy (P = 0.027) than those who remained
ulcer free. The authors conclude that the use of ulcer-free survival can
be used as an indication of the effectiveness of foot ulcer management.
It could be adopted as a measure to compare performance between
different specialist units.


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