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A diabetic infected foot with erythema and fluctuation can suspect that the infection has passed the fascial compartmental, a condition that requires surgical drainage. Elective amputation may be considered for patients who have recurrent ulcers, irreversible loss of function or injuries that require long-term treatment in the hospital. If the diabetic infected foot appears ischemic it requires a treatment of revascularization. The outcome of revascularization is related with the extension of the damaged artery. The debridement removes the bacterial colonies, promotes granulation tissue and its reepithelialization, also facilitates the collection of samples for microbiological analyses. This procedure can be performed with the classic sharp instruments or with advanced autolytic dressings, maggots or ultrasonic equipment. The use of hyperbaric oxygen therapy in the treatment of infected diabetic foot is controversial because studies in this area are few and methodologically questionable. The same conclusion was reached also for the use of growth factors and skin substitutes.

Infection of diabetic foot represents one of the most serious complications of diabetes. Deep infections of the foot, due to the compartment structure of the foot, can cause severe infective compartment syndromes that pose the diabetic patient to very high risk of major amputation and sepsis. The treatment of choice of this severe infective condition is represented by an aggressive surgical debridement with the aim to drainage pus and to remove infective and non vital tissue. Surgical debridement has to be performed as soon as possible since any delay corresponds to an increase of the risk of major amputation and death for sepsis. In case of concomitant severe peripheral vascular disease any revascularisation procedures, surgical or endoluminal, have to be performer once the local and systemic infection has been controlled.

Purpose: Magnetic resonance angiography (MRA) has recently become instrumental in the diagnosis of arterial disease in various body districts and is gaining an increasingly important role in the study of peripheral vascularisation. The aim of our study was to evaluate the reliability of MRA using digital subtraction angiography (DSA) as the reference standard., Materials and Methods: Between November 2003 and August 2004, 30 patients with known peripheral arterial disease were studied by MRA and DSA. MRA was performed with a Philips Intera 1.5 T, with acquisitions from the coeliac trunk to the feet. For acquisitions of the feet and ankles we used unenhanced time-of-flight (TOF) sequences with a head coil. The angiographic sequence was acquired in three volumes of 40-45 cm after administration of paramagnetic contrast material., Results: In the patients with peripheral arterial disease, the technique provided a precise evaluation of the stenosis (mild, moderate, severe) or obstruction of the peripheral district as well as the detection of other diseases, such as stenosis of the renal arteries or aneurysms., Conclusions: Total-body three-dimensional (3D) MRA allows a fast, safe, and accurate assessment of the arterial system in patients with arteriosclerosis and can be considered an alternative to DSA in the management of patients with steno-obstructive disease of the peripheral arteries.

The author reports a case of isolated thrombosis of plantar veins, a rare finding in the international medical literature, in a patient who had a previous knee arthrocentesis and a strict localized bandage. The clinical aspect of perimalleolar-podalic (mainly plantar) oedema, with localized pain, was followed by colour flow duplex investigation, which is considered the fundamental and most useful means to achieve the diagnosis and to perform an adequate follow-up. Pharmacological therapy of such kinds thrombosis may be of an antithrombotic or anticoagulant nature, always associating elastic compression. Aethiopathogenesis of this localized thrombosis is still uncertain, but probably in situ mechanical compressions may play an important role.

Background: Diabetic foot revascularization by popliteal-to-distal bypass is a procedure for limb salvage spread in the last decade., Methods: The authors report their experience with a consecutive series of 15 ischemic feet (mean transcutaneous oxygen 5.3 +/- 4.1 mmHg) with gangrenous lesions due to extensive tibial arteries occlusive disease beginning at the popliteal artery trifurcation (9 cases) or involving the distal popliteal artery (6 cases). Limb salvage was achieved by popliteal-to-distal bypass with autogenous inverted saphenous vein., Results: No operative death was observed. At a mean follow-up of 35 +/- 23 months (range 3-84 months) 4 bypasses were occluded and two were surgically revised after 4 and 50 months from surgery and subsequently remained patent. One patient was submitted to a major amputation. By life table analysis the cumulative primary and secondary patency and limb salvage rates for this group of diabetic patients were at 2 years 79.3%, 86.2% and 93.1% respectively (SE < 10%)., Conclusions: This small experience and a review of the literature confirm the validity of the popliteal-to-distal bypass and the need for a more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

Background: In this study the circadian skin flux pattern was evaluated in 10 normal reference subjects and in 35 patients (mean age 68 +/- 11) subdivided in groups (10 with intermittent claudication (200-400 m of walking distance), 10 diabetics with claudication, 7 patients with rest pain and 8 with localised gangrene)., Methods: A laser Doppler flowmeter was used to monitor skin flux for 24 hours. In patients with intermittent claudication the circadian pattern was comparable to normal subjects. In diabetics the daily curve showed several irregular peaks mostly dissociated from activity or rest., Results: In patients with critical ischaemia severe alterations of the circadian pattern were observed (the daily curve was flattened and dissociated from activity or rest) particularly in gangrene. PGE1 alpha-ciclodestrina treatment (60 micrograms/day) partially restored the circadian pattern and increased the average values of the 24-hour curve. In rest pain and gangrene the infusion of PGE1 alpha-ciclodestrina in the late evening increased the average night flux (which tended to fall to very low levels causing pain) and prevented or abolished night rest pain.

Foot revascularization by popliteal-to-distal by-pass is a well documented procedure for limb salvage in diabetic patients. The authors report their experience with a consecutive series of 5 ischemic feet [transcutaneous oxygen (PtO2): 6 +/- 5.6 mmHg] due to extensive tibial artery occlusive disease beginning at the popliteal artery trifurcation. Limb salvage was achieved by popliteal-to-anterior tibial bypass (1 case) and popliteal-to-dorsalis pedis artery by-pass with autogenous inverted saphenous vein. No operative death was observed. At follow-up (range 3-34 months) one patient died at 3 months after surgery because of an intestinal bleeding. All 4 remaining by-passes are well functioning [PtcO2 46 +/- 11.2 mmHg) and all patients have resumed their normal walking distance. This preliminary experience, and a review of the literature, confirm the validity of the popliteal-to-distal by-pass and the need for more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

A total of 89 diabetic patients with foot lesions were treated using amputation during the past 5 years at Niguarda-Ca' Grande Hospital. All patients suffered from gangrene which in 76% of cases was classified as Wagner's stage IV. The lesion was infected in 67 patients. Emergency surgical cleansing was performed in order to drain abscesses and remove necrotic tissue, taking care not to damage healthy tissue. An accurate multidisciplinary study was performed in all cases which included neurological, oculistic and vascular assessment. 83% of patients presented retinopathy and 62.5% were nephropathic. Angiographic tests revealed the presence of distal vascular lesions in 90% of cases. A femoro-distal by-pass was used in 17 cases and the limb was salvaged in 13 patients; ileal-femoral PTA was performed in 10 cases and the limb was salvaged in 7 patients. Amputations were limited wherever possible to distal segments: toes (55 cases), transmetatarsal (12 case), leg (12 cases), thigh (5 cases), atypical resections or ample cleansing of the foot (5 cases). This approach allowed us to record: 1) a low operative mortality (1 case); 2) higher quality of life; 3) the possibility of reoperating on more proximal portions of the limb in the event of immediate or long-term failure. This was necessary in 19 cases which can be classified as follows: reamputation of toe (11 cases), transmetatarsal (4 cases), amputation of leg (4 cases).

Sudeck's atrophy of the foot is an acute, patchy osteoporosis that, on bone scan, shows an increase in both bone blood flow and local bone uptake of bone-seeking radionuclides. The purpose of this study was to evaluate the relationship between bone uptake of 99mTc-MDP and local bone blood flow. In some patients with Sudeck's atrophy of one foot we measured local bone blood flow and bone uptake of 99mTc-MDP. External counting of radioactivity, with a count-rate of 1 second was performed for 60 minutes after i.v. injection of a known dose of 99mTc-MDP in some patients with Sudeck's atrophy of the foot. The regions of interest (ROI) were selected on the basis of a bone scan performed 24 hours earlier. We assumed that the data recorded during the first seconds (7-10) reflect local blood flow and the data at 60 minutes reflect the bone uptake. The ratio between the local blood flow in the involved and healthy foot was higher than the local bone uptake ratio. The ratio between bone uptake and local bone blood flow was higher in the normal foot than in the affected one. These results suggest that the bone avidity for bone-seeking radionuclides is lower in Sudeck's atrophy than in normal bone.

A simplified classification for clinical pratical purposes of the diabetic foot necrotic lesions is proposed. Two types are considered both possibly with infection: 1. The angiopathic foot, as a manifestation of the diabetic macro- and microangiopathy. 2. The angioneuropathic foot, as an association of the preminent diabetic neuropathy with diabetic microangiopathy and macroangiopathy. This classification proved suitable to 63 personal observations during the last 7 years. Diagnosis and treatement, planned by a diabetological-orthopedic cooperation, are specified for the two headings. The measure of systolic peripheral blood pressure by means of the ultrasonic device Doplette 10 Danica is introduced.

Taking into consideration a previous work, where we experimented the pharmacological action of different products of nitrite retard and from which resulted the absolute superiority of isosorbide dinitrate, we considered interesting to repeat the experimentation with a new form of isosorbide dinitrate characterized by an action duration more prolonged in the time owing to the particular freeing of the active principle. In 20 patients free from peripheral vasculopathy it was enregistered the rheogram with derivation back-feet-big toe in base condition and at 1st, 3rd, 5th and 10th hour from the administration of Nitrosorbide Retard 20 mg. The product action, put in evidence by the appearance of the typical pulse by nitrite, begins the first hour, it reaches the maximum at the 5th hour on average and it clearly lasts until the 10th hour. Therefore it is demonstrated the practical usefulness of this product in the daily clinical medicine considered its characteristics of action rapidity, duration and steadfastness.