The Effect of Honey, Aloe Vera, and Hydrocolloid Dressing on the Healing Process of Murine Excisional Wounds.

Chronic ulcers are a major health problem associated with high costs and a loss of quality of life. Because of this, the search for products that accelerate wound healing is a constant, given the need for alternatives that help to alleviate this serious health problem. We analyzed the efficacy of 2 natural products-honey and aloe vera-versus hydrocolloid (HC) dressings as a control group in healing full-thickness wounds. For this purpose, we performed full-thickness excisions of the skin, including the panniculus carnosus, in mice. We inserted a nitrile ring into the subcutaneous cellular tissue simulating the second-intention wound healing course. We found that aloe vera reduced the diameter of the wounds compared to honey (p < .001) and the control group (p < .001).

Interventions in the management of infection in the foot in diabetes: a systematic review.

The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabetic Foot conducted a systematic review seeking all published reports relating to any type of treatment for infection of the foot in persons with diabetes published as of 30 June 2014. This review, conducted with both PubMed and EMBASE, was used to update an earlier one undertaken on 30 June 2010 using the same search string. Eligible publications included those that had outcome measures reported for both a treated and a control population that were managed either at the same time, or as part of a before-and-after case design. We did not include studies that contained only information related to definition or diagnosis, but not treatment, of DFI. The current search identified just seven new articles meeting our criteria that were published since the 33 identified with the previous search, making a total of 40 articles from the world literature. The identified articles included 37 randomised controlled trials (RCTs) and three cohort studies with concurrent controls, and included studies on the use of surgical procedures, topical antiseptics, negative pressure wound therapy and hyperbaric oxygen. Among the studies were 15 RCTs that compared outcomes of treatment with new antibiotic preparations compared with a conventional therapy in the management of skin and soft tissue infection. In addition, 10 RCTs and 1 cohort study compared different treatments for osteomyelitis in the diabetic foot. Results of comparisons of different antibiotic regimens generally demonstrated that newly introduced antibiotic regimens appeared to be as effective as conventional therapy (and also more cost-effective in one study), but one study failed to demonstrate non-inferiority of a new antibiotic compared with that of a standard agent. Overall, the available literature was both limited in both the number of studies and the quality of their design. Thus, our systematic review revealed little evidence upon which to make recommendations for treatment of DFIs. There is a great need for further well-designed trials that will provide robust data upon which to make decisions about the most appropriate treatment of both skin and soft tissue infection and osteomyelitis in diabetic patients.

Tratamiento de úlceras infectadas de pie diabético. Efectividad clínica de un apósito de fibra de alginato e hidrocoloide, con plata. Análisis de resultados de una serie de casos / Treatment of infected diabetic foot ulcers clinical effectiveness of a dressing of alginate and hydrocolloid, with silver fiber. Analysis of results of a series of cases

Introducción. Niveles altos de carga bacteriana han demostrado una influencia negativa en la cicatrización de las úlceras. El uso de apósitos antimicrobianos con plata puede controlar el nivel de carga bacteriana de las heridas. El objetivo de este estudio fue evaluar la respuesta terapéutica de un apósito de fibra de alginato e hidrocoloide, con plata, en úlceras infectadas de pie diabético. Material y métodos. Se analizó una serie de casos de 6 pacientes con úlceras de pie diabético, sin enfermedad vascular periférica y diagnosticadas de colonización crítica y/o infección local mediante la recogida de signos clínicos inflamatorios. Los pacientes fueron tratados durante un período mínimo de 2 semanas. Se analizó el porcentaje de reducción del área de la úlcera desde el día de la inclusión hasta la retirada del apósito antimicrobiano. Resultados. El tratamiento tuvo una mediana de 5 semanas con una duración mínima de 2 y máxima de 6. La mediana del porcentaje de reducción de la superficie de las heridas fue de 47,7% (rango: 0,5%-90%). La media del porcentaje de reducción de la lesión a las 2 semanas fue del 58% y a la tercera semana del 67,14%. Todos los pacientes habían disminuido sus dimensiones a las 3 semanas de tratamiento de forma significativa (p<0,05). Conclusión. El uso de un apósito de fibra de alginato e hidrocoloide, con plata, favorece la cicatrización de las úlceras de pie diabético con infección local, reduciendo los signos clínicos inflamatorios de forma significativa en un período de 3 semanas (AU)

Introduction: High levels of bacterial load have shown a deleterious influence on wound healing. Using antimicrobial dressings can control ulcers’ bioburden. The aim of our study was to evaluate the improving of infected diabetic foot ulcers due an alginate’s fiber and hydrocolloid silver dressing. Material and Methods: We analysed a case series of 6 patients with diabetic foot ulcers without peripheral vascular disease and diagnosed from critical colonization and / or local infection according the presence of inflammation clinical signs. Patients were treated for a minimum period of two weeks. We analysed the percentage reduction in ulcer area from the day of enrolment to antimicrobial dressing removal. Results: The duration of treatment had a median of 5 weeks with a minimum of 2 weeks and up to 6. The median percentage of area reduction of the wounds was 47.7% (range: 0.5%-90%). The mean percentage reduction on the lesion was 58% from 2 weeks and 67.14% at 3 weeks. All patients had reduced significantly their size at 3 weeks from beginning of treatment (p<0.05). Conclusion: The use of an alginate’s fiber and hydrocolloid silver dressing promotes healing on diabetic foot ulcers with local infection, reducing the inflammatory clinical signs significantly over a period of three weeks (AU)

Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads.

AIMS: To analyse the risk of reulceration caused by the transfer of lesions in patients with diabetes, undergoing resection of at least one metatarsal head. METHODS: A total of 119 patients with diabetes from the Diabetic Foot Unit (Complutense University, Madrid, Spain), who underwent resection of at least one metatarsal head were analysed prospectively from November 2006 to December 2011 to assess reulceration in the other metatarsal head. RESULTS: Seven patients were excluded for being subjected to a pan-metatarsal head resection and 11 patients dropped out. During a median follow-up period of 13.1 months (interquartile range 6.1-22.8 months), 41% of patients suffered from reulcerations. Reulceration frequency in patients operated on the 1st, 2nd, 3rd, 4th, 5th and several metatarsal heads was 9 (69%), 8 (44%), 12 (52%), 2 (25%), 6 (19%) and 4 (50%) events, respectively. The Cox regression model showed hazard ratios that were significant for the location of the metatarsal resection. The first metatarsal showed the highest risk for reulceration (hazard ratio 3.307; 1.472-7.430) and the fifth metatarsal showed the lowest risk (hazard ratio 0.339; 0.138-0.832). CONCLUSIONS: Reulceration is a frequent event following resection of a metatarsal head and should be regarded as an implicit complication of the intervention. The location of the resection determines the risk of reulceration, which is highest for patients operated on the first metatarsal head and lowest for patients operated on the fifth metatarsal head.

Charcot neuroarthropathy triggered and complicated by osteomyelitis. How limb salvage can be achieved.

BACKGROUND: Charcot neuroarthropathy is a severe complication in the feet of patients with diabetes, which can lead to a major amputation. Osteomyelitis and surgery for osteomyelitis have been reported as trigger mechanisms of developing Charcot neuroarthropathy. However, the development of acute Charcot neuroarthropathy triggered by osteomyelitis during conservative antibiotic treatment is not well outlined in the medical literature. CASE REPORTS: Two patients apparently developed mid and rear foot Charcot neuroarthropathy, which was clinically suspected while being treated with antibiotics for osteomyelitis. One of them presented osteomyelitis of the navicular bone and subsequently developed acute Charcot neuroarthropathy of the tarsometatarsal joints. The other presented calcaneal osteomyelitis with pathological fracture and developed Charcot neuroarthropathy of the transverse tarsal joint. No offloading had been implemented in either case. A major amputation had been indicated in both cases in their teaching hospitals. Limb salvage was achieved in both cases by means of surgery, culture-guided post-operative antibiotics, intraosseus instillation of super-oxidized solution, bed rest before placing a total contact cast and stabilization of the unstable foot with a total contact cast with an opening for checking the healing course and to detect any complications. The mechanisms of the development of acute Charcot neuroarthropathy in a patient with osteomyelitis are discussed. CONCLUSIONS: Osteomyelitis in the feet of patients with diabetes and neuropathy may trigger the development of acute Charcot neuroarthropathy. Fractures and dislocated joints may subsequently become infected from the index focus, producing a severe infected and unstable foot that may require a major amputation. Limb salvage can be achieved in specialized departments.

Relationship of limited joint mobility and foot deformities with neurological examination in patients with diabetes.

AIMS: The aim is to define the association of forefoot deformity and limited joint mobility in the ankle and hallux joints in patients with diabetes mellitus subject to different diagnostic tests for diabetic neuropathy. Prospective study with 118 type 2 diabetic patients (68 men, mean age of 65.6±9.9 years) enrolled consecutively from the Diabetic Foot Unit of the Complutense University of Madrid subject to evaluation of plantar surface sensitivity by 10-g Semmes-Weinstein Monofilament, vibratory threshold by biothesiometer, and sudomotor dysfunction by Neuropad®. The patients presented with limited joint mobility of the ankle and the first metatarsophalangeal joints, and forefoot deformities were registered. Statistical analysis was done through a univariate model to test the association between neurological and biomechanical alteration. There was an association of abnormal Monofilament (p=0.01; OR=3.9) and biothesiometer tests (p=0.01; OR=2.6) with the presence of forefoot deformity. Furthermore, a relation was found between abnormal Monofilament (p=0.02; OR=4.8) and biothesiometer (p<0.00; OR=12.8) tests with limited mobility of the first metatarsophalangeal joint both in loading and off-loading. Abnormal sudomotor function test was related with limited joint mobility of the ankle joint with the knee flexed (p=0.04; OR=2.8). CONCLUSIONS: The results of this study show discordance between biomechanical abnormalities and neuropathy depending on the diagnostic test used. Tests that assess large myelinated nerve fibers are associated with the presence of deformities. Abnormal sudomotor function test is associated with limited joint mobility and this test has a greater capacity for selecting patients at risk.

[Treatment of infected diabetic foot ulcers clinical effectiveness of a dressing of alginate and hydrocolloid, with silver fiber. Analysis of results of a series of cases]. / Tratamiento de úlceras infectadas de pie diabético.

INTRODUCTION: High levels of bacterial load have shown a deleterious influence on wound healing. Using antimicrobial dressings can control ulcers' bioburden. The aim of our study was to evaluate the improving of infected diabetic foot ulcers due an alginate's fiber and hydrocolloid silver dressing. MATERIAL AND METHODS: We analysed a case series of 6 patients with diabetic foot ulcers without peripheral vascular disease and diagnosed from critical colonization and/or local infection according the presence of inflammation clinical signs. Patients were treated for a minimum period of two weeks. We analysed the percentage reduction in ulcer area from the day of enrolment to antimicrobial dressing removal. RESULTS: The duration of treatment had a median of 5 weeks with a minimum of 2 weeks and up to 6. The median percentage of area reduction of the wounds was 47.7% (range: 0.5%-90%). The mean percentage reduction on the lesion was 58% from 2 weeks and 67.14% at 3 weeks. All patients had reduced significantly their size at 3 weeks from beginning of treatment (p < 0.05). CONCLUSION: The use of an alginate's fiber and hydrocolloid silver dressing promotes healing on diabetic foot ulcers with local infection, reducing the inflammatory clinical signs significantly over a period of three weeks.

Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series.

AIMS/HYPOTHESIS: The aim of this study was to determine the rate of recurrence, reulceration and new episodes of osteomyelitis and the duration of postoperative antibiotic treatment in a prospective cohort of patients with diabetes who underwent conservative surgery for osteomyelitis. METHODS: The prospective cohort included patients with diabetes and a definitive diagnosis of osteomyelitis who were admitted to the Diabetic Foot Unit (Surgery Department, La Paloma Hospital, Las Palmas de Gran Canaria, Spain) and underwent surgical treatment from 1 November 2007 to 30 May 2010. RESULTS: Eighty-one patients were operated on for osteomyelitis during the study period. Seven patients were lost to follow-up at different stages of the study. The median duration of follow-up was 101.8 weeks (quartile 1 = 56.6, quartile 3 = 126.7). Forty-eight patients (59.3%) underwent conservative surgery, 32 (39.5%) had minor amputations and there was one (1.2%) major amputation. Twenty patients (24.7%) required reoperation because of persistent infection. Postoperative antibiotic treatment over a median period of 36 days was provided. Wound healing was achieved by secondary intention for a median of 8 weeks. Sixty-five patients were available for follow-up after healing. The percentage of recurrence, reulceration, and new episodes of osteomyelitis was 4.6% (3/65), 43% (28/65) and 16.9% (11/65), respectively. Mortality during follow-up (excluding in-hospital deaths and patients lost to follow-up) was 13% (9/69). CONCLUSION: 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 role of a specialized approach for patients with diabetes, critical ischaemia and foot ulcers not previously considered for proactive management.

AIMS: To analyse the outcome of the proactive management of patients with diabetes, critical limb ischaemia and foot ulcers using percutaneous transluminal angioplasty as the only vascular procedure and adjuvant conservative surgery when indicated. METHODS: A retrospective study of patients with diabetes included in our database who sought a second opinion in our unit and met the following criteria: foot ulcer and critical limb ischaemia in patients for whom any proactive vascular treatment had not previously been considered by other teams. RESULTS: Twenty patients underwent endovascular procedures. Success was achieved in 19 cases (95%). No post-operative mortality (within 30 days after the procedure) was found. Additional surgery was required in eight cases (40%): one calcaneal ostectomy and seven minor amputations. The need for surgery was associated with infection (P < 0.01). Limb salvage was sustained during a mean period of follow-up of 642 days (SD 488) in 19 cases (95%). Healing was achieved in 14 cases (70%), four are still healing (20%), one underwent major amputation (5%) and the last one died before being healed (5%). Three patients died during follow-up (15%). CONCLUSIONS: Management of patients with diabetes, foot ulcers and critical limb ischaemia by means of a proactive approach including endovascular procedures in specialized settings provides a high rate of limb salvage. This may result in lowering the number of lower limb amputations in our community.

Impact of diabetic foot related complications on the Health Related Quality of Life (HRQol) of patients--a regional study in Spain.

The diabetic foot reduces the health-related quality of life (HRQoL) in patients with diabetes mellitus. This study aims at ascertaining the impact of the etiological factors of the diabetic foot on the various aspects of HRQoL. This is a comparative study involving type 1 or type 2 (n = 421) diabetic patients divided into 2 groups. Group 1 (n = 258) includes diabetic patients without foot lesions and group 2 (n = 163) includes patients suffering from a diabetic foot ulcer. The HRQoL of the sample was assessed by using the SF-36 Health Questionnaire. The overall HRQoL score was 68.58 ± 18.24 in group 1 and 50.99 ± 18.98 in group 2 (P < .001). The diabetic foot-related etiological factors that significantly reduce these patients' HRQoL are neuropathy, amputation history, and poor metabolic control (P < .001). Quality of life was lower in women with diabetic foot than in men. Neuropathy--regarded as the main etiological factor in the diabetic foot--also proved to be a variable that reduces the HRQoL. Paradoxically, peripheral vascular disease did not prove to have a negative impact on the quality of life.

Diagnosing diabetic foot osteomyelitis: is the combination of probe-to-bone test and plain radiography sufficient for high-risk inpatients?

AIMS: To investigate the accuracy of the sequential combination of the probe-to-bone test and plain X-rays for diagnosing osteomyelitis in the foot of patients with diabetes. METHODS: We prospectively compiled data on a series of 338 patients with diabetes with 356 episodes of foot infection who were hospitalized in the Diabetic Foot Unit of La Paloma Hospital from 1 October 2002 to 31 April 2010. For each patient we did a probe-to-bone test at the time of the initial evaluation and then obtained plain X-rays of the involved foot. All patients with positive results on either the probe-to-bone test or plain X-ray underwent an appropriate surgical procedure, which included obtaining a bone specimen that was processed for histology and culture. We calculated the sensitivity, specificity, predictive values and likelihood ratios of the procedures, using the histopathological diagnosis of osteomyelitis as the criterion standard. RESULTS: Overall, 72.4% of patients had histologically proven osteomyelitis, 85.2% of whom had positive bone culture. The performance characteristics of both the probe-to-bone test and plain X-rays were excellent. The sequential diagnostic approach had a sensitivity of 0.97, specificity of 0.92, positive predictive value of 0.97, negative predictive value of 0.93, positive likelihood ratio of 12.8 and negative likelihood ratio of 0.02. Only 6.6% of patients with negative results on both diagnostic studies had osteomyelitis. CONCLUSIONS: Clinicians seeing patients in a setting similar to ours (specialized diabetic foot unit with a high prevalence of osteomyelitis) can confidently diagnose diabetic foot osteomyelitis when either the probe-to-bone test or a plain X-ray, or especially both, are positive.

Triggering mechanisms of neuroarthropathy following conservative surgery for osteomyelitis.

BACKGROUND: The purpose of this study was to raise awareness and stimulate discussion of the possible triggering factors of Charcot neuroarthropathy by presenting the case of one patient who had both undergone surgery and was suffering from osteomyelitis. CASE REPORT: We have extracted one case from our data set for a patient who underwent conservative surgery for osteomyelitis and subsequently developed acute Charcot in the midfoot. We present the clinical findings, photographs and X-ray studies. Preoperative X-ray showed irregular severe bone destruction in the fourth metatarsal head and a fracture of the fourth metatarsal bone. No signs of midfoot Charcot neuroarthropathy were found in this preoperative X-ray. The third and fourth metatarsal bones were both removed and the surgical wound was left open to heal by second intention. Histopathological study confirmed osteomyelitis in the bone sample. Twenty-five days after surgery, the surgical wound showed no signs of infection and healing progressed in a satisfactory way. However, the foot was swollen, erythematous and warm. Skin temperature was two degrees higher than the contralateral foot. X-ray was taken and acute neuroarthropathy of the tarso-metatarsal joints was diagnosed. CONCLUSIONS: Charcot neuroarthropathy appears to have been triggered by bone infection and/or surgery. We believe that the pivotal factor in the development of acute Charcot neuroarthropathy in this case was the weight bearing in the deformed foot so soon after the operation. Immobilization of the foot is critical as it serves to decrease the inflammation which has a key role in the development of Charcot neuroarthropathy.

Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series.

AIMS: The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). METHODS: We abstracted data of a series of 185 consecutive patients with diabetes and foot osteomyelitis undergoing surgery within the first 12 h after admission at a single hospital. Bone infection was confirmed by histopathological studies. Only cases where Staphylococcus aureus was isolated from bone specimens were included in this analysis. We analysed several variables between the two groups: MRSA vs. MSSA. RESULTS: MRSA bone infection was associated with higher body temperature (P = 0.02) and white blood cell count (P = 0.02) than MSSA. Patients with MRSA infections underwent a greater number of surgical procedures (P = 0.03). Limb salvage was achieved in 93.6% of the patients, with no statistically significant difference in limb salvage rates between MRSA and MSSA-related osteomyelitis. CONCLUSIONS: From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis.