Abstract:
:EXECUTIVE SUMMARY: 1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic Gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with Gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture before starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic Gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 12 weeks usually suffices, but some require an additional 12 weeks; for moderate and severe infections, usually 24 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 46 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to 1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from noninfectious osteoarthropathy. Clinical examination and imaging tests may suffice, but bone biopsy is valuable for establishing the diagnosis of osteomyelitis, for defining the pathogenic organism(s), and for determining the antibiotic susceptibilities of such organisms (B-II). 19. Although this field has matured, further research is much needed. The committee especially recommends that adequately powered prospective studies be undertaken to elucidate and validate systems for classifying infection, diagnosing osteomyelitis, defining optimal antibiotic regimens in various situations, and clarifying the role of surgery in treating osteomyelitis (A-III).
journal_name
Plast Reconstr Surgjournal_title
Plastic and reconstructive surgeryauthors
Lipsky BA,Berendt AR,Deery HG,Embil JM,Joseph WS,Karchmer AW,LeFrock JL,Lew DP,Mader JT,Norden C,Tan JS,Infectious Diseases Society of America.doi
10.1097/01.prs.0000222737.09322.77subject
Has Abstractpub_date
2006-06-01 00:00:00pages
212S-238Sissue
7 Suppleissn
0032-1052issn
1529-4242pii
00006534-200606001-00023journal_volume
117pub_type
杂志文章abstract:BACKGROUND:Beside botulinum-toxin injections and hyaluronic acid fillers, thread lifts have established themselves as the third column of minimally invasive facial rejuvenation. Most commonly, barbed threads for this approach are made out of polydioxanone, a material known for decades from application in resorbable sut...
journal_title:Plastic and reconstructive surgery
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abstract::Many patients of rhytidectomy age have had previous rhinoplasty or nasal injury and have dorsal irregularities or saddle-nose deformities. SMAS tissue ordinarily discarded at rhytidectomy may be used for nasal dorsal augmentation and padding. Six patients undergoing rhytidectomy who also had prior nasal surgery or def...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199605000-00025
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abstract::The possibility of raising the cutaneous island of the latissimus dorsi musculocutaneous flap without muscle based on only one cutaneous perforator is presented in this paper. An anatomic study performed in 40 fresh cadaver specimens injected with colored latex demonstrated that the vertical intramuscular branch of th...
journal_title:Plastic and reconstructive surgery
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doi:10.1097/00006534-199512000-00014
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abstract::On the basis of over 100 endoscopic forehead lifts, we present an in-depth view of the current operative technique. The critical components are the following: (1) a subgaleal resection of muscle insertions rather than a subperiosteal approach to muscle origins, (2) a complete periosteal release along the lateral orbit...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199612000-00003
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abstract::We have studied the chemomigration activity of an epithelial carcinoma cell line using a modified 96-well Boyden chamber apparatus consisting of upper and lower wells separated by an 8-microns pore polycarbonate filter. Cells from the malignant squamous carcinoma cell line A-431 were plated in the upper wells over a c...
journal_title:Plastic and reconstructive surgery
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doi:10.1097/00006534-199512000-00024
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abstract::Since the 1970s, anecdotal reports have described a relatively small number of women who received silicone gel breast implants and later developed either a recognized rheumatologic disease or unexplained symptoms suggestive of an autoimmune disorder. The study reported here examined whether there is any association be...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:
更新日期:1995-12-01 00:00:00
abstract:BACKGROUND:Predicting outcomes based on a variety of fixation techniques remains problematic in the treatment of mandible fractures. There is inherent difficulty in comparing the hundreds of published articles on the subject because of the large number of variables, including injury patterns, assessment techniques, tre...
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doi:10.1097/01.prs.0000297646.86919.b7
更新日期:2008-02-01 00:00:00
abstract::A follow-up study was made of 77 hands for 6 months or more after operation for bifid thumb. Repair of detached thenar muscles and capsule is the most important procedure at the initial ablation of the extra digit. After reinsertion of the thenar muscles, the remaining problems are deformity of bones themselves, adduc...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-198203000-00012
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abstract::Chemosurgical peel is a technique that has been used widely by plastic surgeons and dermatologists to remove fine and deep wrinkles of the skin. However, the reaction of elastic tissue to the cutaneous application of commonly used chemical peeling agents has not been defined. This study comparatively assessed the alte...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199708000-00035
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journal_title:Plastic and reconstructive surgery
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pub_type: 杂志文章,多中心研究
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journal_title:Plastic and reconstructive surgery
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doi:10.1097/00006534-200007000-00019
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journal_title:Plastic and reconstructive surgery
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journal_title:Plastic and reconstructive surgery
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更新日期:1985-10-01 00:00:00
abstract:BACKGROUND:The lymph system plays important roles in maintaining fluid balances, the immune system, and lipid metabolism. After tissue replantation or transfer, some cases suffer long-lasting edema or lymphedema caused by interruption of main lymph flows; however, this mechanism has yet to be clarified. METHODS:The me...
journal_title:Plastic and reconstructive surgery
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doi:10.1097/PRS.0000000000004694
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journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199606000-00009
更新日期:1996-06-01 00:00:00
abstract::The purpose of this article is to introduce plastic surgeons to a theory of adult education. Most surgeons have been hired by their parent institution because of their clinical skills, and rightly so. At the same time, these same surgeons choose or are expected to be involved to varying degrees in the surgical educati...
journal_title:Plastic and reconstructive surgery
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doi:10.1097/PRS.0b013e318252f19d
更新日期:2012-05-01 00:00:00
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journal_title:Plastic and reconstructive surgery
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doi:10.1097/01.PRS.0000055731.22839.74
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journal_title:Plastic and reconstructive surgery
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journal_title:Plastic and reconstructive surgery
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journal_title:Plastic and reconstructive surgery
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更新日期:1991-09-01 00:00:00
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journal_title:Plastic and reconstructive surgery
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abstract::To develop new types of surgical flaps that utilize portions of the skin and subcutaneous tissue (e.g., a thin flap or an adipofascial flap), three-dimensional investigation of the vasculature in the skin and subcutaneous tissue has been anticipated. In the present study, total-body arterial injection and three-dimens...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199809030-00020
更新日期:1998-09-01 00:00:00
abstract::This article introduces a new surgical method for one-stage reconstruction of the penis. It is applied to the reconstruction of the microphallus as well as to traumatic cases with the residual stump of the amputated penis not less than 3 cm long. By transferring the original glans or the residual penile stump to the a...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199701000-00012
更新日期:1997-01-01 00:00:00
abstract::In spite of adequate preoperative evaluation, lagophthalmos may appear during a brow lift procedure if the patient has had a prior upper lid blepharoplasty. Relief of this condition may be obtained by incising the upper lid scar and spreading the wound. Subsequent granulation results in an acceptable scar. ...
journal_title:Plastic and reconstructive surgery
pub_type: 杂志文章
doi:10.1097/00006534-199511000-00037
更新日期:1995-11-01 00:00:00
abstract:BACKGROUND:Patients with Apert, Crouzon, and Pfeiffer syndromes who have severe midfacial hypoplasia are treated by Le Fort III midface advancement. The purpose of this study was to examine long-term (10-year) midface skeletal stability and growth following Le Fort III midface advancement in growing children. METHODS:...
journal_title:Plastic and reconstructive surgery
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更新日期:2010-09-01 00:00:00
abstract::The aims of this anatomic investigation were to examine the levator veli palatini, tensor veli palatini, and salpingopharyngeus muscles in relation to normal eustachian tube function and to analyze the clinical implications of these data for tubal physiology in cleft palate individuals. Detailed dissections under 3.2x...
journal_title:Plastic and reconstructive surgery
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更新日期:1997-09-01 00:00:00