Aims. Diabetic foot care is a significant burden on the NHS in England. We have conducted a nationwide survey to determine the current participation of orthopaedic surgeons in diabetic foot care in England. Methods. A questionnaire was sent to all 136 NHS trusts audited in the 2018 National Diabetic Foot Audit (NDFA). The questionnaire asked about the structure of diabetic foot care services. Results. Overall, 123 trusts responded, of which 117 admitted patients with diabetic foot disease and 113 had an orthopaedic foot and ankle surgeon. A total of 90 trusts (77%) stated that the admission involved medicine, with 53 (45%) of these admissions being exclusively under medicine, and 37 (32%) as joint admissions. Of the joint admissions, 16 (14%) were combined with vascular and 12(10%) with orthopaedic surgery. Admission is solely under vascular surgery in 12 trusts (10%) and orthopaedic surgery in 7 (6%). Diabetic foot abscesses were drained by orthopaedic surgeons in 61 trusts (52%) and vascular surgeons in 47 (40%). Conclusion. Orthopaedic surgeons make a significant contribution to both acute and elective diabetic foot care currently in the UK. This contribution is likely to increase with the movement of vascular surgery to a hub and spoke model, and measures should be put in place to increase the team based approach to the diabetic foot, for example with the introduction of a best practice tariff. Cite this article: Bone Jt Open 2022;3(8):618–622

Introduction. Diabetic foot disease is a major public health problem with an annual NHS expenditure in excess of £1 billion. Infection increases risk of major amputation fivefold. Due to the polymicrobial nature of diabetic foot infections, it is often difficult to isolate the correct organism with conventional culture techniques, to deliver appropriate narrow spectrum antibiotics. Rapid DNA-based technology using multi-channel arrays presents a quicker alternative and has previously been used effectively in intensive care and respiratory medicine. Methods. We gained institutional and Local Ethics Committee approval for a prospective cohort study of patients with clinically infected diabetic foot wounds. They all had deep tissue samples taken in clinic processed with conventional culture and real-time PCR TaqMan array. Results. 50 samples were taken from 39 patients between October 2020 and March 2022. 84% of patient were male, 88% had type 2 diabetes. The ulcers were of variable chronicity prior to sampling (range 1–113 weeks) and mean HbA1c was 67.2mmol/mol. Ulcers were on the heel (3), midfoot (6) and forefoot (41). Minimum follow up was 3 months. 6 ulcers healed, 24 patients were admitted due to foot disease, there were 2 major amputations and 4 deaths. TaqMan array results were available a mean of 4.3 days earlier than culture results. 9 patients had negative conventional cultures and 8 were negative onarray testing. 17 patients had the same organisms detected on culture and array. 16 of these 17 had additional organisms detected by array. The most frequent organisms detected on array that were not detected by culture were Staphylococcus spp., Enterobacter, Pseudomonas and fungi. Conclusion. TaqMan array shows promise in detecting infecting organisms from diabetic foot wounds and providing earlier results than standard culture, which may enable appropriate and timely antibiotic therapy

The October 2023 Foot & Ankle Roundup. 360. looks at: Risk factors for failure of total ankle arthroplasties; Effects of synovial fluid fracture haematoma to tissue-engineered cartilage; Coronal plane deformity in CMT-cavovarus feet using automated 3D measurements; Immediate weightbearing after ankle fracture fixation – is it safe?; Unlocking the mystery of Mueller-Weiss disease; Diabetic foot management: predictors of failure

Aim. The aim of this paper is to analyse the cause of neuropathic diabetic foot ulcers and discuss their preventive measures. Methods. Review of patients with foot ulcers managed in our diabetic MDT clinics since Feb 2018 were analysed. Based on this observation and review of pertinent literature, following observations were made. Results. Forefoot. Progressive hindfoot equinus from contraction of gastroc-soleus-tendo-Achilles complex, with additional contraction of tibialis posterior and peroneal longus muscles and, progressive plantar flexed metatarsal heads secondary to claw toe deformity results in increased forefoot plantar pressures. In patients with insensate feet, this result in ulcer formation under the metatarsal heads from shear stress when walking. Callosity under the metatarsal heads is the earliest clinical sign. Most patients by this time have fixed tightness of the muscle groups as assessed by negative Silfverskiold test. Percutaneous tendo-Achilles lengthening (TAL) has shown to reduce the mid-forefoot plantar pressures by 32% and ulcer healing in 96% of patients within 10 weeks (± 4 weeks). Additional z-lengthening of peroneal longus and tibialis posterior tendons helped in patients with big-toe and 5. th. metatarsal head ulcers. Proximal metatarsal osteotomies further reduce the forefoot pressures to near normality. Midfoot. Midfoot ulcers are secondary to rocker-bottom deformity a consequence of Charcot neuroarthropathy (CN). Hindfoot equinus as described and relative osteopenia from neurally mediated increased blood flow (neurovascular theory) and repeated micro-trauma (neurotraumatic theory) result in failure of medial column osseo-ligamentous structures. As the disease progress to the lateral column, the cuboid height drops resulting in a progressive rocker bottom deformity. The skin under this deformity gradually breaks down to ulceration. In the pre-ulcerative stages of midfoot CN, TAL has shown to stabilise the disease progression and in some patents’ regression of the disease process was noted. The lump can excised electively and the foot accommodated in surgical shoes. Hindfoot. These develop commonly at the pressure areas and bony exostosis in non-ambulatory patients. In ambulatory patients, the most common cause are factors that result in over lengthening of tendo-Achilles such as after TAL, spontaneous tears, or tongue-type fractures. Conclusions. Early identification of factors that result in plantar skin callosity and treating the deforming forces prevent progression to ulceration. Total contact cast without treatment of these deforming forces results in progression of these callosities to ulceration while in the cast or soon after completion of cast treatment

Aim. The aim of this study was to compare outcomes between patients with diabetic foot soft-tissue infection and osteomyelitis. Methods. Medical records of patients with diabetic foot infection involving either soft-tissue (STI) or bone (OM) were retrospectively reviewed. Diagnosis was determined by bone culture, bone histopathology or imaging with magnetic resonance imaging (MRI) or single-photon emission computed tomography (SPECT/CT). Patient outcomes were recorded up to 1 year after admission. Results. Out of 294 patients included in the study, 137 were diagnosed with STI and 157 had OM. No differences in age (p=.40), sex (p=.79), race (p=.83), body-mass index (p=.79) or type of diabetes (p=.77) were appreciated between groups. Frequency of comorbidities (neuropathy, chronic kidney disease, peripheral arterial disease) also did not differ except for increased prevalence of cardiac disease in patients with STI (86.9%) compared to those with OM (31.8%) (p<.00001) and decreased prevalence of retinopathy (24.8% vs. 35.7%) (p=.04). Patients with OM had greater C-reactive protein (p<.00001), erythrocyte sedimentation rate (p<.00001) and white blood cell count (p<.00001). Among 1-year outcomes, patients with OM more often underwent surgery (p<.00001), had lower limb amputations (p<.00001), became reinfected (p=.0007), were readmitted for the initial problem (p=.008), had longer time to healing (p=.03) and had longer hospital length of stay (p=.00002). However, no differences in 1-year mortality (p=1.000), overall 1-year readmission (p=.06) or healing within 1-year (p=.64) were appreciated. Conclusion. In our study, OM was associated with more aggressive treatment, reinfection and longer time to healing than STI. However, despite being associated with more aggressive care and readmissions, patients with diabetic foot OM has similar 1-year mortality and healing rates to those with diabetic foot STI

Aim. The primary aim of multidisciplinary management of diabetic foot disease is limb savage. Difficulty in eradication of infection with systemic antibiotics and obliteration of dead space created by debridement, are two major stumbling blocks in achieving this. Antibiotic loaded bio composites help achieve both these objectives. The aim of this study is to report the early results of antibiotic loaded bio composites in diabetic foot disease. Method. We present early results of 16 patients with diabetic foot disease and osteomyelitis in whom we used antibiotic loaded bio composite (CERAMENT G Bone Support, Lund, Sweden) for local antibiotic delivery and dead space eradication. A multidisciplinary team managed all patients. We performed magnetic resonance and vascular imaging preoperatively and adhered to a strict protocol involving debridement, culture specific systemic antibiotics and dead space obliteration with antibiotic loaded bio composite. The wound was managed with negative pressure wound therapy and all patients were kept non-weight bearing with a plaster back slab or walking boot. Skin cover where required was undertaken by our plastic surgeons. Results. According to the Cierny –Mader Classification 1 patient was type 1, 4 were defined as type 2, 7 were type 3 and 4 were type 4. Seven patients were classed as type B hosts and 9 were type A hosts. At a mean follow up of 38 weeks (26–60) we achieved infection clearance in 14 patients (88%). 10 (63%)wounds healed by secondary intention, 2 had split skin graft, and 1 had primary closure. 2 patients were still on negative pressure wound therapy at final follow-up, one of which has got clearance of infection. One patient is having regular dressings in the community. We had 2 patients who had below knee amputation, one due to significant vascular disease and the other at patient request. Conclusions. A multidisciplinary approach and a strict protocol including augmented debridement and Cerament G injection are effective for treatment of chronic osteomyelitis in diabetic foot disease. The early results with this bio composite antibiotic combination are encouraging

Diabetic foot problems are a common cause for hospitalisation in this group and up to 25% of diabetic patients will be affected. Prevalence of diabetes is rising, currently affecting 680000000 people worldwide. The enormity of this problem mandates any strategy that shortens therapeutic period and enhances success rates. Cerament G has been used in our unit as a treatment adjunct in diabetic foot treatment. Successful treatment is viewed as eradication of infection and a functional foot. Retrospective review of 40 months practice with 115 patients. Inclusion: all diabetic feet requiring surgery Cerament G used, protocol driven Microbiology pathway. Exclusion: Primary closure not possible. Cerament G not used. Outcome assessed in three groups: Total failure (further surgery required); slow to heal (healing by secondary intention); healed without problems. Healed 99 (eradication of infection and return to function), failure to heal 16 (success rate: 86.1%). Infection was the cause of failure in only in 2.6% (13 failures due to patient noncompliance or poor vascularity). Accepted success rate in treating osteomyelitis in diabetic feet is 68% (medical treatment only), combination of surgery and medical is 86%. Eradication of infection is the only end point return to function is not addressed. This study shows Cerament G with surgery/systemic antibiotics provides a 97.4% success rate. Therapeutic drivers in this field have been determined traditionally by Physicians and Vascular Surgeons (resection rather than reconstructive surgery.) Our assertion is that eradicating infection in a functionally useless foot is a waste of health resources. Our strategy is always the delivery of an intact functional foot residuum. Cerament G as an adjunct allows this goal in a cost-effective manner

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients

Background and aim. In 2019, specific diagnostic and antibiotic treatment recommendations for diabetic foot infection (DFI) and osteomyelitis (DFO) were introduced in our institution. They include principles on numbers of biopsies to obtain for microbiological/histopathological examinations, labeling anatomic localization, and antibiotic treatment (ABT) duration based on the aforementioned findings. ABT should be stopped after complete resection of infected bone. In case of incomplete resection, treatment is continued for 4–6 weeks. Two years after the introduction of these recommendations, we investigated the degree of implementation for hospitalized patients. Method. Adult patients with DFI/DFO undergoing surgical intervention from 01/2019–12/2021 were reviewed retrospectively. Diagnostic procedures were assigned to each episode when performed ≤30 days before surgical invention. Chi-square and Mann-Whitney-U tests were performed where appropriate. Results. We included 80 patients with 117 hospital episodes and 163 surgical interventions (mean 1.5 episodes and 2 interventions per patient). The mean age was 69.6 (SD 11.5) years, 75% were male. Vascular examination and MRI were performed in 70.9% and 74.4% of episodes, respectively. Impaired perfusion and DFO were confirmed in 34.9% and 56.3%, respectively. Blood cultures were sampled in 34.2%, bacteremia detected in 7.7% with S. aureus being the most common microorganism. Biopsies were obtained in 71.8% of operations, in 90.5% of those 3–5 samples. These were sent for histological examination in 63.2% of the interventions. In 43.6% the anatomic location was labeled ‘proximal to the resection margin’. Preoperative antibiotics were administered in 41.9% of the episodes because of concomitant soft-tissue infections. The most commonly used compound was amoxicillin/clavulanate (74.4%). ABT duration varied significantly when there were signs of DFO in preoperative MRI (p=0.015). The mean duration of antibiotic therapy was 9 (IQR 5–15) days in surgically cured episodes and 40.5 (IQR 15–42) days in cases with resection margins in non-healthy bone (p<0.0001). The results were similar when analyzing treatment duration with respect to osteomyelitis in histology: 13 (IQR 8–42) versus 29 (IQR 13–42) days, respectively (p=0.026). Conclusions. The adherence to recommendations in terms of biopsy sampling was excellent, moderate for sending samples to histology and poor for labeling the anatomic location. The adherence to ABT duration was good but can be improved by shortening treatment duration for surgically cured cases. Results of preoperative MRI appear to be influential on the decision-making for treatment duration

We performed 55 operations in 40 patients affected by diabetic foot and referred to the Diabetic Day Hospital from 1998 to 2003. Surgical procedures can be grouped as: (a) emergency operations: mostly for surgical debridment; (b) operations such as functional amputation of the limb at various levels; and (c) conservative operations such as preventive correction of deformities or restoration of morphology and function. We performed 39 amputations; 15 conservative procedures (including ring external fixation in “Charcot foot”); and one emergency procedure (sepsis). We never used local ischaemia while operating diabetic patients. Patients follow-up ranges from 6 months to 6 years. One fourth of patients died for reasons not directly associated with diabetic foot but often related to the diabetes. The vast majority of patients mantained adequate control of the disease, wore special “diabetic shoes”, and judged the result of the operation very positively and consider their situation much improved after the operation. Surgical wound closure took from 2 to 20 weeks (mean 6 weeks). More than half of the patients can walk without support. It is relevant to note that about half of the patients had previous operations for the same problem but about 90% of the patients required no further operation after the one we performed. Orthopaedic surgical treatment may effectively restore walking ability in those patients who lost it because of diabetic foot problems

Background: The occurrence of osteomyelitis in diabetic foot often dictates different treatment approach. The diagnosis of osteomyelitis, though, is sometimes difficult. When X rays are not diagnostic or equivocal, a nuclear medicine studies are often performed. In common practice bone scan with Tc. 99. m-MDP combined with In. 111. labeled leucocytes scintigraphy are used. Although highly sensitive, these procedures may be hampered by coexisting pathological processes such as neuroarthropathy, trauma, or cellulites. In addition, poor resolution of the In. 111. images, complicates the interpretation weather the observed uptake (e.g. infection) is in the soft tissue or within the bone. Positron emission tomography (PET) using 2-Deoxy-2-[18F]-Fluoro-D-Glucose (FDG) is a useful clinical tool for the assessment of malignancies. FDG, a nonspecific tracer of increased intracellular glucose metabolism, accumulates in sites of infection and inflammation as well. PET is highly sensitive but may lack the ability to define the anatomic location of a focus of increased FDG accumulation. The hybrid PET/CT technology, providing precise registration of metabolic and structural imaging data, obtained in one session on a single device, may improve diagnosis and localization of infection. Goals: The present study assesses the role of PET/CT imaging using FDG for the diagnosis of diabetic foot osteomyelitis. Methods: Fourteen diabetic patients (M=10, F=4; age range 29–70 years) with 18 clinically suspected sites of infection underwent PET/CT following the injection of 185–370 MBq FDG for suspected osteomyelitis complicating diabetic foot. PET, CT and hybrid images were independently evaluated for the diagnosis and localization of an infectious process. Additional data provided by PET/CT for localization of infection in the bone or soft tissues was recorded. The final diagnosis was based on histopathological findings and bacteriological assays obtained at surgery or clinical and imaging follow up. Results: PET detected 14 foci of increased FDG uptake suspected as infection in 10 patients. PET/CT correctly localized 8 foci in 4 patients to bone, indicating osteomyelitis. PET/CT correctly excluded osteomyelitis in 5 foci in 5 patients, with the abnormal FDG uptake limited to infected soft tissues only. One site of mildly increased focal FDG uptake was localized by PET/CT to diabetic osteoarthropathy changes demonstrated on CT. Four patients showed no abnormal increased FDG uptake, and no further evidence for an infectious process in the foot on clinical and imaging follow up. Conclusion: FDG-PET can be used for diagnosis of diabetes-related infection. The precise anatomic localization of increased FDG uptake provided by PET/CT enables accurate differentiation between osteomyelitis and soft tissue infection

Introduction. Total contact casting (TCC) is one of the most commonly utilized modalities in the management of diabetic feet. We undertook a retrospective review to determine the prevalence of symptomatic VTE events in patients treated in a weight bearing TCC in our diabetic foot unit, and to formulate guidelines for VTE prophylaxis. Methods. Electronic records were reviewed to identify all patients treated in a TCC between 2014 and 2021. Data collection included patient demographics, comorbidities, period of immobilization in TCC, the incidence of VTE events, and any VTE prophylaxis prescribed during their period in TCC. Results. 549 patients were identified who had at least one episode of TCC. Mean age was 67 years (range 28 to 94 years) and the mean duration in cast was 10.2 weeks (range 0.3–46 weeks). Only 6 patients (1.1%) were prescribed chemical thrombo-prophylaxis during their period in TCC. Mean body mass index (BMI) for these patients was 32.3 (Range 18.4–58.9). Other significant comorbidities: 81% (n-444) of patients had associated cardio-vascular comorbidities; 54 % (n-296) had renal comorbidities including 22% (n-121) having had dialysis and 4.2% (n-23) with renal transplants. Eight of the 549 patients (1.5%) had suffered a VTE event of which only 2 (0.36%) were during the period of immobilization in TCC. One was a symptomatic DVT (0.18%) and the another was an asymptomatic (incidental) finding of pulmonary embolism (PE). There was no mortality related to the VTE episodes. Conclusion. NICE guidelines state that one should “Consider pharmacological VTE prophylaxis for patients with lower limb immobilization”. Our study finds that patients treated in a weight bearing TCC do not require routine pharmacological VTE prophylaxis, in spite of an extended period of lower limb immobilization and significant medical comorbidities

Aim. The aim of this work was to evaluate, via foot and ankle TC scans, the outcomes of the use of a bone substitute (CERAMENT|™G) and the growth of native bone in the treatment of osteomyelitis (OM) of the diabetic foot. Method. In nine patients from July 2014 to December 2016 we used a Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in OM diabetic foot cases. Of these nine patients, three were female and six were male and their ages were between 49 and 72 years. Four patients had hindfoot involvement and underwent partial calcanectomy. Two patients presented a rocker-bottom Charcot foot pattern III according to Sanders and Frykberg's classification and were treated with esostectomy of the symptomatic bony prominence of the midfoot. One patient presented OM of the 3°, 4° and 5° metatarsal bones. One patient underwent partial resection of the midfoot and hindfoot with arthrodesis stabilised by an internal-external hybrid fixator. One patient with a Charcot foot pattern IV-V underwent partial talectomy and calcanectomy with arthrodesis stabilised by an internal-external hybrid fixator. In all these patients - after removal of the infected bone - we applied 10 to 20 ml CSH + HA + GS filling the residual spaces with the aim of stabilising the remaining bone fragments. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues. In March 2018, the above nine patients underwent foot and ankle TC scans to evaluate bone growth. Results. The first four patients showed new bone formation in the calcaneus. Two patients with previous midfoot destruction showed chaotic but stable bone formation. The patient with metatarsal OM showed partial bone healing with residual pseudoarthrosis. Both the two patients who underwent arthrodesis with hybrid fixators showed a plantigrade and stable foot even though a heel wound is still present in one of the patients. All patients except this one are now wearing suitable shoes as post-operative wounds have healed. The patient still with the heel wound is walking with an aircast brace. Conclusion. The TC scans have shown new bone formation sufficient to stabilise the foot and allow ambulation. In particular, very good results come from the filling of the calcaneus, probably due to the anatomy of the bone itself

Aim. Since July 2013 our group has been using an antibiotic bone substitute, composed of calcium sulphate, hydroxyapatite and gentamicin sulphate (CSH + HA + GS), in the treatment of osteomyelitis (OM) in diabetic foot. The aim of this work was to evaluate the mid-term efficacy of this treatment regime on outcomes. A favourable outcome in diabetic foot includes no recurrence of OM, healed soft tissues and the ability to weight-bear. Method. To date we have used the CSH + HA + GS bone substitute in 24 diabetic patients with OM. In this study we reviewed patients treated from July 2013 to December 2014, in which we used CSH + HA + GS to treat OM of the forefoot, midfoot and hind foot, and evaluated how many patients are able to walk and fully weight-bear at present. We identified 11 pts treated during this time period; 1 with bilateral 1. St. metatarsal-head OM due to plantar ulcers, 5 with midfoot OM secondary to Charcot deformities and ulcers, 5 with hind foot OM due to pressure ulcers or Charcot deformity. We continuously monitored the patients for recurrence of OM, ulcers and soft tissue inflammation in our outpatient department. Results. Of the 11 patients, two died during follow up (both patients had calcaneal ulcers; one died in the 1. st. month and one in the 2. nd. month after treatment, both due to cardiovascular disease). For the remaining nine patients, we had an average of 25 (17–33) months follow-up. One patient did not heal, presenting with a persistent mid-foot lesion in a Charcot foot. Another patient with bilateral forefoot ulcers had a plantar ulcer recurrence under the left 1. st. metatarsal foot, 19 months after bone substitute application and primary healing. This patient is still weight-bearing on the right foot, as are the remaining 6 patients. In 7 patients (1 with bilateral forefoot, 4 with mid-foot and 3 with hind foot OM) no recurrence of OM or ulcers was observed. Conclusions. This study suggests that a CSH + HA + GS bone substitute can be used to treat diabetic foot OM. Our mid-term results show good clinical outcomes in terms of ulcer healing, no recurrence of OM and weight-bearing

Diabetic foot is a disease with social, familiarly and economic charge. Usually the patients with neuropathic diabetic foot have a compromise in large vessels of the calf that invalids most of the techniques of Plastic Surgery for reconstruction for skin losses of the foot. The authors describe the utilization of little fragments of skin (proximally 4 mm diameter) draw under local anaesthesia in the tight. The receptor area due not have infection and clean of necrotic tissue. Tendons have also due excised or recovered of granulation tissue With this technique they have treated 4 patients; 3 have total recuperation of the lesion and in one, with a scar in the hallux, all the skin has lost. The largest area of the lesion treated has 8 x 6 cm, and time o healing has 12 weeks. The reconstitution of the donor area is complete at 4 weeks with no scars. The authors conclude that this technique is valid for dorsal loss of skin due to neuropathic diabetic foot

Background. Diabetes is bad, common and diabetic foot ulcers (DFU) once established lead to high rates of amputation. In Nottingham our standard management for infected diabetic foot ulcers is surgical debridement, microbiological sampling, packing with gentamicin beads and targeted antibiotic therapy. Recently we have switched to packing with Stimulan, which is a purified synthetic calcium sulphate compound that can be mixed with patient appropriate antibiotics, is biodegradable and delivers better elution characteristics compared to gentamicin beads. Aim. To assess the efficacy of Stimulan compared to Gentamicin beads in the surgical management of infected diabetic foot ulcers. Methods. In 2012/13 the department audited its results of DFU surgical management with gentamicin beads. In 2014/5 the audit was repeated but Stimulan was used instead due to the perceived advantages Patients with infected DFU that could comply with treatment were included. Patients who had other sources of sepsis, non-compliant or moribund were excluded. Treatment pathways were identical apart for the use of Stimulan in 2014/5. The primary outcome measure was ulcer healing. The secondary outcome measure was length of stay and recurrence. Results. Each group had 23 patients. The gentamicin group had a DFU for 12.3 months(3weeks-5 years) before presentation for surgery compared to the Stimulan group 6.1 months(2weeks-5years). Both groups had failed non-surgical management. The majority of the ulcers were located on the forefoot. In the stimulan group 70% (16/23) of ulcers had healed with an average of 4 months(2–7 months) compared to 57% (13/23) in the Gentamicin group within 6months(1–12). The length of stay was shorter in the Stimulan group 7 days (1–70) compared to 28days(1–70) in the Gentamicin group. Conclusion. In our review Stimulan was superior to Gentamicin beads in the management of infected diabetic foot ulcers. We believe it has a role to play in limb salvage

Aim of this work was to evaluate the efficacy of a new antibiotic bone substitute (CERAMENTTM|G) in the treatment of osteomyelitis (OM) in diabetic foot. From June 2013 to April 2015 we used a new Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in cases of diabetic foot OM. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues, maintaining high gentamicin concentrations for some weeks. In 20 patients, with or without Charcot neuroarthropathy and post-lesional osteomyelitis, after removal of infected bone we applied 10 to 20 ml CSH + HA + GS, filling the residual spaces and aiming to stabilize the remaining bone fragments. When needed, these arthrodeses were stabilized by external-internal hybrid fixators. X-ray evaluations and, when indicated, MRI evaluations were performed before and after surgical intervention, and 3 months post-op. Revascularization with percutaneous angioplasty was performed when needed. 20 patients affected by OM were treated, 4 of them having 1st metatarsal head involvement, 4 having heel involvement, 12 tarsal and hindfoot involvement. After surgical intervention all of them were treated with standard medication and pressure relief. The three 1st metatarsal OM cases healed, both in regards to infection and lesions. One of the patients is still ongoing. One of the patients with heel OM presented with a worsening of the infection and was treated by major amputation, another one presented with good soft tissue growth and, two months from the intervention, and in the absence of clinical signs of OM relapse, was treated with a sural fasciocutaneous pedicled flap; of the remaining two patients one heald and the other is still ongoing; 11 of the 12 patients who had midfoot or hindfoot partial resections healed, one patient is still ongoing. The healed patients are all wearing suitable shoes. The use of a new CSH + HA + GS bone substitute has shown to be efficacious in inducing OM healing and preserving foot structures in diabetic feet

To evaluate the results of the reconstructive surgical treatment of complicated forms of infected osteoarthropathy with diabetic foot syndrome (DFS). The analysis of the results of the treatment of 58 patients with infectious complications of osteoarthropathy with the neuropathic form of the DFS, the average age 57.7+1.2 years. In 5 patients with Type I according to the Sanders & Frykberg classification, grade C according to the Roger classification of with neuropathic ulcers caused by deformation of the bones we employed corrective mini-osteotomy. In 32 patients with Type I, grade D with the infected ulcers associated with destruction of the metatarsal bones and the metatarsophalangeal joints, we performed the resection of the affected bones, subsequently filling the defects with antibiotic impregnated collagen sponge (AICS*), and then we closed the wound with primary suture. In 15 patients with Type II, grade D we performed the resection of the affected bones and stabilize the mid-foot using compressive screws and AICS. In 4 patients with Type III, grade D we perfomed the following resection of the affected bones we used AICS and the extrafocal corrective osteosynthesis using the Ilizarov's method. In 2 patients with Type IV+V, grade D we did an amputation using the Syme's technique and osteosynthesis using the Ilizarov's method. There was one case of septic instability of the compressive screw after more than one month: the screw was then removed; and there was one case of an unstable bone fragment: its removal was necessary. No recurrence of the trophic ulcers or osteomyelitis of the foot bones was observed during a 6 – 24 mounth follow-up in any other treated patients. The described methods are promising in the treatment of patients with DFS; their effectiveness can be evaluated after randomized trials will be completed

Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing Minimally Invasive Surgical Techniques of percutaneous metatarsal neck osteotomies, metatarsal head debridement, mid-foot closing-wedge osteotomies and hind-foot arthrodesis, for the surgical management of diabetic foot pathology. The potential socio-economic benefits analysis with regards to reduction in out-patient and theatre time, patient length of stay and time to healing are also postulated. Methods. Minimally Invasive Surgical Techniques of metatarsal neck osteotomy, metatarsal head debridement, closing wedge osteotomy, mid-fusion and hind-foot arthrodesis nailing are described. Procedures are preformed as day cases with fluoroscopic guidance. Low speed, high torque burrs and wedges, create the osteotomies, which can be held with percutaneous fixation. Comparative cost analysis of conservative treatment, including clinic visits, out-patient debridement, dressings, intravenous and oral antibiotics, versus Minimally Invasive Surgical Techniques is presented. Results. Six patients had metatarsal osteotomies for mechanical ulceration. Five reported good outcome. One patient required revision to forefoot arthroplasty due to mal-union. Five patients had debridement of metatarsal heads, which healed on average at six to eight weeks. Eight patients had mid-foot arthrodesis. Two infected cases required removal of metalwork. Three patients had hind-foot arthrodesis for arthritis following ankle fracture with degeneration and deformity. Patients had good short and early medium term outcomes, with no reports of below-knee amputation. This technique is reproducible once the initial learning curve is mastered. Comparative cost analysis, suggests significant financial savings by reducing inpatient admissions, clinic visits and theatre time. Conclusion. Minimally Invasive Surgical Techniques may provide an alternative surgical management for diabetic patient with foot and ankle pathology

Diabetic foot syndrome with osteomyelitis of metatarsal head show frequent recurrence and need a very long antibiotic treatment, often only to see the inflammation flare up once antibiotic are dismissed. We present our initial experience about 3 patients presenting a clinical and radiologically confirmed osteomyelitis of the metatarsal head. We treated them with limited resection of metatarsal head, microbiologic sample and filling of the remaining metatarsal canal by means of an absorbable antibiotic loaded bone graft substitute, packing an absorbable antibiotic sponge (Gentamycin) in place of the metatarsal head and direct skin closure. All patients had an orthesis avoiding fore-foot weight bearing during the first month, but allowing them to walk normally. Follow up took place on a weekly rhythm during the first month, every fortnight during the 2° month and after this once a month. Actually the follow up period extends from 4 – 7 months. None of the treated 3 patients did need any second look operation nor did they present any local complications. Due to the type of resorbable implant used, some oozing of transparent liquid during the first 4 weeks may present and is to be considered normal. This new method presents a valid alternative to the more classic “two step cement nail” procedure of active osteomyelitis treatment. We consider planing long term study and a multicenter randomized trial