3 Steps for Diagnosing Diabetic Foot Osteomyelitis

Perform or order each of the following§ Probe-To-Bone test§ Erythrocyte sedimentation rate; consider C-reactive

protein and possibly Procalcitonin§ Plain X-rays

If DFO still suspected consider ordering one of the following:§ Magnetic Resonance

Imaging§ 18F-FDG- positron emission

tomography/computed tomography (CT)

§ Leukocyte scintigraphy (with or without CT).

Findings compatible with osteomyelitis?

YesNo

§ Strongly consider aseptically sampling affected bone (percutaneously or surgically, but not per wound) for culture and histopathology (if possible).

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Treat as soft tissue infection

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5 Steps to Manage Acute Charcot Neuro - Osteoarthropathy

1CLINICAL PRESENTATION

In patients with neuropathy§ Red§ Hot§ Swollen foot

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Suspect Charcot Foot

Yes

In case of ulcer§ Infection§ Underlying

osteomyelitis

Exclude common pathologies

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Pain not prominent

PLAIN X-RAY

Negative

Magnetic Resonance Imaging

(Cast while waiting)

Positive

NEGATIVE

Positive

BELOW KNEE CAST + CRUTCHES AND REFER TO A SPECIALISED DIABETIC FOOT UNIT

Imaging techniques

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§ Gout arthritis§ Deep vein

thrombosis (positive duplex vein scan)

§ Joint distortion§ Cellulitis

How to Manage People who are at Risk of Diabetic Foot Ulceration (DFU) ?

Very Low RISK High RISK

NO Loss of Protective Sensation(LOPS)

NO Peripheral Artery Disease(PAD)

LOPSORPAD

LOPS + PADOR

LOPS + Foot deformityOR

PAD + Foot deformity

LOPS OR PAD +

§ History of DFU§ Major or minor amputation

OR

§ End stage renal disease

Low RISK Moderate RISK

ExamineONCE A YEAR

ExamineONCE EVERY 6 MONTHS

ExamineONCE EVERY 3 MONTHS

ExamineONCE EVERY 1-3 MONTHS

Examine for signs and symptoms of LOPS and PAD

Screen for risk factors: DFU, amputation, renal disease, foot deformities, LJM*, pre-ulcerative signs, callus

Provide with foot care: education, removal of callus and nail care

Provide with appropriate therapeutic footwear + orthotic devices

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Provide with appropriate custom-made footwear (if foot deformitieor pre-ulcerative sign is present)

Instruct to self-monitor foot skin temperatures

Advise to perform foot and mobility-related exercises

*Limited Joint Mobility

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How to Perform Vascular Assessment in a Person with Diabetes and a Foot Ulcer?

Palpation of foot pulses § Pedal Doppler arterial waveforms§ Ankle systolic pressure and ankle brachial index§ Toe systolic pressure and toe brachial index

CONSULTATION WITH VASCULAR SPECIALIST

§ Triphasic Doppler waveforms§ Ankle brachial index 0.9-1.3§ Toe brachial index ≥ 0.75

Severe ischemia:§ Ankle systolic pressure <50mmHg or§ Ankle brachial index < 0.5 or§ Toe pressure <30mmHg

PAD is less likely

Presence of foot pulses does not

reliably exclude PAD

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Abnormal values but not severe ischemia:Is there infection or ulcer deeper than skin?

Irrespective of the results of

bedside tests, when the ulcer is not

healing within 4-6 weeks:

Yes

No

Posterior tibial arteryDorsalis pedis artery Ankle systolic pressure Toe systolic pressure

How to Classify Diabetic Foot Infection?

Infection severity

Antibiotics *

Clinical presentation

Characteristics

MILD INFECTION (IDSAa)-PEDISb 2 MODERATE INFECTION (IDSA)-PEDIS 3/3osteomyelitis

Presence of at least two of:

§ Local swelling or induration§ Erythema > 0.5 cm § Local tenderness or pain§ Local increased warmth§ Purulent discharge

Oral agents Oral or initial parenteral agents Parenteral agents

§ Local infection with erythema >2 cmOR

§ Involvement structures deeper thanskin and subcutaneous tissue

§ No signs of systemic inflammatoryresponse

SEVERE INFECTION (IDSA)/PEDIS 4/4osteomyelitis

§ Temperature >38 °C or <36 °C § Heart rate >90 beats/minute § Respiratory rate >20 breaths/minute

or PaCO2 <4.3 kPa (32 mmHg) § White blood cell count

>12,000/mm3, or <4,000/mm3, or >10% immature (band) forms

* See recommendations of Infection Guideline for empirical antibiotic regimenfor diabetic foot infection

a IDSA: Infectious Disease Society of Americab PEDIS: Perfusion, Extent, Depth, Infection and Sensation

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