DIABETES MELLITUS

VOLUME 20 • NUMBER 4 • OCTOBER 2003 v

CONTENTS

Foreword xiVincent J. Mandracchia

Preface xiiiGary Peter Jolly and Thomas Zgonis

Diabetes Mellitus and Pharmacological Therapy 635James Bernene, Thomas Zgonis, and Gary Peter Jolly

Diabetes mellitus can be a devastating lifelong disease if nottreated appropriately. The physician and the patient should beaware of both extremes involved with DM: hyperglycemia andhypoglycemia. Enormous advances in the treatment of diabeteshave occurred over the past decade and even greater ones canbe expected in the future. This article discusses the new drugs,insulin delivery devices, and noninvasive glucose monitoringmachines currently available for the treatment of diabetes mellitus.

Diabetic Foot Infections and Antibiotic Therapy 655Thomas Zgonis, Gary Peter Jolly, Benjamin J. Buren, and Peter Blume

Diabetic foot infections are the most common cause of lowerextremity amputations. Diabetic neuropathy, angiopathy, renaldisease, and multisystem failure are some of the factors that canlead to a limb or a life-threatening infection and subsequent ampu-tation. Soft tissue or bone infections in diabetics are usually man-aged surgically, supplemented by antibiotic therapy and vascularreconstruction when appropriate. Aggressive surgical interventionand appropriate antibiotic therapy will reduce the likelihood ofmajor amputations and the duration of hospitalization.

Medical Evaluation and Treatment of Diabetic Peripheral Neuropathy 671William A. Petit, Jr and Raghu P. Upender

Diabetes mellitus is a major health problem that is expected tobecome more prevalent over the next few decades. It causes muchmorbidity and mortality through various macro- and microvascularcomplications, including diabetic neuropathy. Because treatmentsoptions are limited, and frequently unsatisfactory, prevention ofdiabetic foot complications becomes even more imperative. Thisarticle reviews our current understanding of diabetic neuropathy.

Vascular Evaluation and Arterial Reconstruction of the Diabetic Foot 689Bauer E. Sumpio, Taeseung Lee, and Peter A. Blume

Management of the diabetic foot is often a complex clinical problem.The pathophysiologic mechanisms underlying diabetic foot diseaseinclude neuropathy, infection, and ischemia. However, the princi-ples of care are simple, including correction of systemic and localfactors. This article discusses clinical evaluation of the diabetic footand various methods of arterial reconstruction.

Diabetic Foot Ulcerations: Management and Adjunctive Therapy 709 Robert G. Frykberg

Foot ulcerations in individuals who have diabetes mellitus aremajor risk factors for infection, osteomyelitis, and gangrene. Eachof these lesions has consistently been ascertained as a significantrisk factor for subsequent lower extremity amputations. A multi-disciplinary team approach as been demonstrated as the most suc-cessful way to manage and prevent foot lesions in individualswho have diabetes. Such teams provide education, appropriatefoot care, and early intervention as key components in their pro-grams, which are focused on amputation prevention. This articlereviews the epidemiology, current understanding of the underlyingpathophysiology, and treatment rationale for diabetic foot ulcera-tions. When evidence-based concepts are incorporated into dailypractice, the incidence and morbidity of foot disease in diabetes canbe significantly reduced.

Imaging Modalities of the Diabetic Foot 729 Enzo J. Sella and Dawn M. Grosser

Charcot osteoarthropathy is a devastating process that occurs inthe diabetic foot. It may be complicated by or confused withosteomyelitis. Osteoarthropathy and osteomyelitis must be differ-entiated accurately and efficiently because each has different treat-ments and are potentially limb threatening. This article explores

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the various available radiologic modalities for distinguishing bet-ween the two processes, including plain radiographs, diphospho-nate scanning, leukocyte-labeled scans and combined scans, CT,and MR imaging. The combined leukocyte scan with bone marrowimaging is superior to a leukocyte scan alone or in combinationwith a bone scan for detecting infection in the neuropathic foot.The combined leukocyte scan and marrow imaging is the currentgold standard for diagnosis, and MR imaging is the anatomic goldstandard to define the extent of the process.

External Fixation in the Management of Charcot Neuroarthropathy 741Gary Peter Jolly, Thomas Zgonis, and Vasilios Polyzois

Charcot neuroarthropathy is a complex sequela of neuropathiesassociated with diabetes mellitus, syringomyelia, alcoholism, andother disorders. The treatment of deformities associated withCharcot neuroarthropathy is evolving from a passive approach toone in which an earlier recognition of the emergence of the eventpermits an avoidance of deformity. As the understanding of theetiology and natural history of Charcot neuroarthropathy deepens,it has become apparent that many of the deformities that do developmay be reconstructed expeditiously by the surgeon with a thor-ough understanding of the diabetic foot and experience in the useof external fixation.

Soft Tissue Reconstruction of the Diabetic Foot 757Gary Peter Jolly, Thomas Zgonis, and Peter Blume

Treatment of wounds in the diabetic foot presents a set of difficultproblems that requires “out of the box” thinking. The traditionalapproach of off-loading these wounds is often expensive, time-consuming, and in some cases seemingly never ending. The appli-cation of the principles and techniques of plastic surgery to thetreatment of the foot began in the 1980s, and the integration ofthese techniques into the armamentarium of the foot and anklesurgeon has progressed quickly. This article will provide an intro-duction to the principles and methods of soft tissue reconstructionof the diabetic foot.

Elective Surgery of the Diabetic Foot 783Lee R. Sayner, Barry I. Rosenblum, and John M. Giurini

Surgical management of the diabetic foot has been limited histori-cally to treatment of ulceration and acute infection. More practi-tioners now appreciate the role of elective surgery in the treatmentand prevention of ulceration, infection, and amputation. This arti-cle discusses various elective surgical techniques used to treat thediabetic foot.

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Amputation Considerations and Energy Expenditures in the Diabetic Patient 793Kathleen Satterfield

Amputations are not procedures of choice but are often necessaryand valuable tools for returning a patient who has diabetes to amore active lifestyle. Because of the comorbidities associated withdiabetes, this is an important consideration. A return to a moreactive existence can reduce the effect of vascular disease, hyper-glycemic states, and functional limitations. This article addressesthe many medical and mobility issues that practitioners shouldconsider before deciding whether to amputate.

Cumulative Index 2003 803

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