Diabetic Foot and Ankle

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- See:
      - Diabetes Menu
      - AliMed - diabetic resources

- Pathological Conditions:
    - vascular pathology:
    - diabetic charcot foot and ankle:
    - neuropathic ulceration:
    - ankle fractures in diabetics:
          - main pitfall is failure to mistake an early charcot ankle fracture for a "simple ankle fracture;"
                - failure to consider a charcot ankle fracture may lead to disasterous consequences for the surgeon and patient;
          - in the study by McCormack and Leith (JBJS 1998), the authors noted a 42% complication rate in the treatment of diabetic ankle fractures vs no complications
                in a match series of ankle frx patients without diabetes;
                - of 19 patients treated surgically, 6 developed major complications, and two patients required amputation;
                - diabetic patients w/ displaced ankle fractures treated non op showed a high incidence of loss of reduction and malunion but these caused few symptoms;
                - the authors recommend strong consideration of non operative treatment in these patients;
          - take care to apply generous padding to the cast inorder to avoid pressure ulceration; 
          - Steinman Pin Augmentation:
                - Steinmann pins placed across the ankle and subtalar joints to augment fixation and to prevent collapse;
                - pins are left in place for 6-8 weeks;

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Examination of the Diabetic Foot and Ankle

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- Diabetic Foot Infections:
    - management of cellulitis or infected superficial ulcerations:
          - see Wagner grading system for diabetic foot infections:
          - non operative treatment is indicated for patients who are not septic;
                - ie, no high fever, normal WBC, no altered mentation;
          - cultures from ulcers are unreliable (need to treat based on deep cultures obtained from researach studies);
          - enterococci may be most common and therefore a logical starting medication would be augmentin or unasyn;
    - osteomyelitis in the diabetic patient:
    - management of deep infections:
          - surgical debridement is indicated for all patients who appear acutely toxic;
          - be especially careful of the patient with pain/skin changes on both the dorsum and plantar surface of the foot;
                - these patients will need both dorsal and plantar incisions for adequate debridement;
          - see:
                - amputations in the diabetic patient:
                - compartmental anatomy of the foot:
                - wound dressings
    - references:
          - Treatment of resistant ulcers on the plantar surface of the great toe in diabetics.
          - Management of diabetic midfoot ulcers.
          - Diabetic foot infections. Bacteriologic analysis.

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    - Diabetic Neuropathy:
             - cymbalta
             - neurontin
             - lyrica

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The diabetic foot: evolving technologies.

Management of the diabetic foot.      Harrelson J: Orthop Clin North Am 1989;20:605.

Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections.

One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study.

Ankle fractures in diabetics.  Complications of surgical management.     RG McCormack and JM Leith.  JBJS. Vol 80-b. No 4. July 1998. p 689.                    .......

Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds.

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