Objective: To describe the characteristics, the management and the outcome of a consecutive series of patients with diabetic foot lesions (DF) and no-option critical limb ischemia (CLI) treated with a multidimensional, interdisciplinary approach in a dedicated center. Research Design and Methods: The prospective database of the Diabetic Foot Unit of the Maria Cecilia Hospital (Cotignola, Italy) collects medical history, risk factors, chemistry values, angiographic data, characteristic of foot lesions, medical and surgical therapies of all patients admitted with a diagnosis of DF and CLI. All patients were followed-up for at least 1 year and/or total recovery. The primary endpoint was 1-year amputation-free survival (AFS), secondary endpoints were limb salvage and survival. Results: Between October 2014 and October 2017, 1024 patients with DF and CLI were admitted to the center. Eighty-four of them (8.2%) fulfilled the criteria for no-option CLI. At 1 year, AFS, limb salvage, and survival rates were 34%, 34%, and 83%, respectively. Lesions located proximal to the Lisfranc joint were associated with major amputation (HR 2.1 [1.2-3.6]). One-year survival of patients treated with minor procedures was significantly higher compared to patients treated with major amputation (96% vs 76%, log-rank p = 0.019). Major amputation was independently associated with mortality (HR 7.83 [1.02-59.89]). Conclusions: The application of dedicated and standardized strategies permitted limb salvage in one-third of patients with no-option CLI. Patients with stable lesions limited to the forefoot and without ischaemic pain had a greater probability to successfully receive conservative treatments. Limb salvage was associated with subsequent higher one-year survival.
Background: Foot complications such as ulceration and neuropathy are common complications of diabetes mellitus (DM). Previous reports have demonstrated a possible increased risk of these complications in diabetic patients with low levels of serum vitamin D.Objectctive: The purpose of this study is to compare serum vitamin D levels in diabetic patients with and without Charcot neuroarthropathy (CN), peripheral arterial disease (PAD), infection (DFI), ulceration (DFU), and peripheral neuropathy (DPN). Design: A retrospective chart review of all patients undergoing foot and ankle surgery with a history of DM over a 13 month period was performed. From this cohort, fifty subjects with CN were matched with 50 without CN and preoperative lab values were compared. A secondary evaluation was performed on the subjects' other comorbidities including PAD, DFI, DFU, and DPN. Results: Seventy-eight percent of our patients had vitamin D deficiency or insufficiency. Preoperative serum vitamin D levels were not significantly different between diabetic patients with and without CN (p = 0.55). Diabetic patients with PAD (p = 0.03), DFI (p = 0.0006), and DFU (p = 0.04) were all found to have significantly lower serum vitamin D levels than diabetic patients without these complications. Lower levels of serum albumin and higher serum creatinine were also noted with subjects with PAD, DFI, DPN, and DFU. While seasonal serum vitamin D level fluctuation was noted, this difference did not reach statistical significance with the numbers available. Conclusion: We found various lower extremity complications to be associated with low serum vitamin D including PAD, DFI, and DFU. While other studies have questioned the role of vitamin D and CN, we were unable to identify any significant difference between diabetic patients with and without Charcot neuroarthropathy. Level of evidence: Level 2.
Background: One of the complications of the diabetes mellitus is the amputation of the lower limbs. This complication may be developed after an insidious ulcer, that may be raised by the peripheral neuropathy or the ischaemic limb, and that the ulcer get infected. That is, to develop an ulcer, in the diabetic patient, three factors should be taken into the account, the autonomic nervous system, the blood supply and the inmune system. Methods: In this work, the thermogram is used to identify regions on the plantar skin with blood supply deficiencies and the behaviour of the thermoregulation process. Within the thermogram of the plantar skin, it can be identify local regions with low and high temperatures that corresponds to ischemic or inflammatory process on that part of the skin. Results: The findings within the 186 thermograms of diabetic patients, obtained from three hospitals and from INAOE facilities, showed, first, the thermograms of the plantar skin of two diabetic patients, acquired in two different times show that the temperature distribution and the average temperatures, vary slightly for a period of weeks. Second, the thermograms of two patients, who both developed insidious ulcers which evolved favourable, demonstrated the importance of the immune system and the drug therapy. These patients are, one who has a Charcot foot, and in the second one, the patient had loss the sensibility of the feet. Finally, the thermograms of two patients, showing abrupt temperature change within small regions in the plantar skin, are discussed. Conclusion: A diabetic patient, with an asymmetric thermogram, as physiological interpretation of the thermoregulation, may indicate a decrease of the blood supply, which may be corroborated by vascular ultrasound. The regions of abrupt temperature change, cold or hot spots, may correspond to ischaemic or inflammatory processes.
Introduction: Diabetic foot ulcers are one of the most frequent complications of diabetes; such ulcers cause an increase in the costs of the health care of the diabetic patient and can even cause disability due to amputation in the patient. Although a proportion of patients achieve a spontaneous closure of ulcers, others require medical or surgical treatment.Objective: To determine the cost-effectiveness of the intra- and perilesional application of recombinant human epidermal growth factor (rhEGF), as opposed to conventional therapy for the management of patients diagnosed with Wagner's 3 or 4 diabetic foot ulcer in Colombia.Methodology: Using a Markov model, the process of care of a diabetic patient with diagnosis of Wagner's 3 or 4 ulcer receiving conventional treatment, or intra- and perilesional rhEGF, is configured. The evaluation cycles of the treatments are weekly over a 5-year horizon and the outcomes evaluated are quality-adjusted life years (QALYs) and the number of amputations avoided by each treatment scheme, in addition to the total costs for treatments.Results: For the analysed base case, in the outcome of amputations, it was found that the factor presents 39 fewer amputations, in a cohort of 100 patients, compared with conventional treatment. Likewise, QALYs are 0.65 more with the use of rhEGF in an average patient. The estimated cost-utility ratio for the base case would be below the threshold established for Colombia.Conclusions: The intra- and perilesional application of rhEGF is a more effective therapeutic option than conventional therapy in the treatment of patients with Wagner's 3 or 4 diabetic foot ulcers and is cost-effective, taking as an outcome the QALYs for Colombia from the perspective of the health system.
Background: Diabetic foot remains a challenge in most low-middle-income countries (LMICs). A severe deficit in data exists on them in sub-Saharan Africa (SSA). Up-to-date data on the longitudinal trajectories and determinants can provide a benchmark for reducing diabetic foot complications in SSA.Objective: The primary objective of this study was to estimate trends in the incidence of diabetic foot and determine predictors in an adult Ghanaian diabetes cohort.Design: The study is a retrospective longitudinal study over a 12 year period.Methods: We applied Poisson regression analysis and Cox proportional hazard models to demographic and clinical information obtained from patients who enrolled in a diabetes specialist clinic in Ghana from 2005 to 2016 to identify longitudinal trends in incidence and predictors of diabetic foot.Results: The study comprised 7383 patients (63.8% female, mean follow-up duration: 8.6years). The mean incidence of foot disorders was 8.39% (5.27% males and 3.12% females). An increase in the incidence of diabetic foot ranging from 3.25% in 2005 to 12.57% in 2016, p<0.001, was determined. Diabetic foot, with adjusted hazard ratio (HR; 95% confidence interval (CI)), was predicted by disease duration, that is, for every 5-year increase in diabetes duration: 2.56 (1.41-3.06); male gender: 3.51 (1.41-3.06); increased body mass index (BMI), that is, for every 5kg/m(2): 3.20 (2.51-7.52); poor glycaemic control, that is, for every percentage increase in HbA1c: 1.11 (1.05-2.25), hypertension: 1.14 (1.12-3.21); nephropathy: 1.15 (1.12-3.21); and previous foot disorders: 3.24 (2.12-7.21).Conclusions: We have found a trend towards an increased incidence of diabetic foot in an outpatient tertiary diabetes setting in Ghana. Systemic and individual-level factors aimed at preventive foot screening as well as vascular risk factor control should be intensified in diabetic patients in Ghana and other LMICs.Abbreviations: BMI: Body Mass Index, BP: Blood Pressure, CI: Confidence Interval, HR: Hazard Ratio, HbA1c: Glycated Hemoglobin, PAD: Peripheral Arterial Disease, NCDs: Non Communicable Disease, SSA: Sub Saharan Africa.
Over the past generation, limb preservation programs and diabetic foot services have begun to proliferate within academic health science centers as well as within health-care systems in general. We describe four key components for a successful program that, developed sequentially with temporal overlap, can allow the program to scale. The first component includes establishment of a 'hot foot line' for urgent emergency department/inpatient referral. The second includes development of a wound-healing clinic to address outpatient care through to remission. The third component focuses on the diabetic foot in remission to maximize ulcer-free days following healing. The fourth and final component focuses on implementation of local and widespread screening clinics to identify and triage patients into appropriate therapeutic and surveillance programs for healing, remission, and primary prevention. Along with developing each of these components, we describe discrete methods to quantify success.
Objective: This single-centred study aims to evaluate the incidence, risk factors and treatment outcomes of a podiatry led, evidence-based diabetic foot ulcer (DFU) clinic.Research design and methods: Data from the DFU database and patient electronic health records were retrospectively collected from patients with new DFUs who were referred for treatment to the Department of Podiatry, Dasman Diabetes Institute, Kuwait, from 1 October 2014, to 31 December 2016. Patients were followed-up until healing occurred or until 6months after the study end date, whichever came first.Results: All data were analysed using IBM SPSS version 24 software. Data were collected from 230 patients with 335 DFUs. Most DFUs (67%) were present for <3months from the time of the first podiatry appointment. A total of 56% of DFUs were classified as neuropathic. Most (72%) DFUs healed, with a median healing time of 52.0days. Chronic kidney disease (p=0.001), retinopathy (p=0.03), smoking (p=0.02), ulcer location (p=0.03), peripheral arterial disease (PAD) (p=0.004) and osteomyelitis (p=0.05) were found to have a meaningful association with DFU outcome. The number of days to heal was associated with ulcer classification (p=0.005), bacterial infection (p=0.002), osteomyelitis (p=<0.001) and PAD (p=<0.001).Conclusions: The incidence of new DFUs in our tertiary clinic is 3.4%. The incidence of diabetic foot ulceration, days to heal, healing rate and the risk factors influencing healing are in accordance with other multidisciplinary facilities with podiatry input.
ABSTRACT Background: Ill-defined areas of water-like signal on bone magnetic resonance imaging (MRI), characterized as bone marrow edema or edema-equivalent signal-changes (EESC), is a hallmark of active-stage pedal neuro-osteoarthropathy (Charcot foot) in painless diabetic neuropathy, and is accompanied by local soft-tissue edema and hyperthermia. The longitudinal effects on EESC of treating the foot in a walking cast were elucidated by reviewing consecutive cases of a diabetic foot clinic. Study design: Retrospective observational study, chart review Material and methods: Cases with active-stage Charcot foot were considered, in whom written reports on baseline and follow-up MRI studies were available for assessment. Only cases without concomitant infection or skin ulcer were chosen, in whom both was documented, onset of symptomatic foot swelling and patient compliance with cast treatment. Results: From 1994 to 2017, 45 consecutive cases in 37 patients were retrieved, with 95 MRI follow-up studies (1–6 per case, average interval between studies 13 weeks). Decreasing EESC was documented in 66/95 (69%) follow-up studies. However, 29/95 (31%) studies revealed temporarily increasing, migrating or stagnating EESC. Conclusion: EESC on MRI disappear in response to prolonged offloading and immobilizing treatment; however, physiologic as well as pathologic fluctuations of posttraumatic EESC have to be considered when interpreting the MR images. Conventional MRI is useful for surveillance of active-stage Charcot foot recovery.
Background: The objective of this study was to determine the clinical and surgical characteristics of diabetic foot ulcers in a tertiary level hospital in Mexico. Methods: We performed a longitudinal, descriptive study from July, 2012 to August, 2015 on a sample composed of 100 patients with type 2 diabetes mellitus and infected diabetic foot ulcers. We analyzed socio-demographic variables, comorbidities, characteristics of ulcers, and the applied treatment. Results: We found that the most affected areas were the forefoot (48%) and the plantar region (55%) of the foot. Also, most of the patients arrived with advanced stages of diabetic foot ulcers, since 93% of the lesions were of grades III-V according to the Wagner classification. Moreover, lesions usually present with advanced states of infection, since 60% of the lesions were of grades 3-4 in the PEDIS scale. In addition, the great majority of the patients are prone to complications because we found that 43% of the patients suffered from hypertension, 47% of the patients had chronic kidney disease, and 45% reported smoking. In fact, 45% of the patients eventually suffered an amputation. We also found that the situation is more difficult because the great majority of the patients (96%) have a low level of education and very low income and they do not have any health insurance. Nevertheless, we also found that an efficient treatment can help in avoiding amputations, since 53% of grade IV and 25% of grade V lesions according to the Wagner system did not suffer an amputation. Conclusions: Therefore, an effective antibiotic treatment and an education of the patient on the adequate care of their lesions are essential in increasing the welfare of patients, especially when they have a low level of education.
External neurolysis of the nerve at fibro-osseous tunnels has been proprosed to treat or prevent signs, symptoms, and complications in the lower extremity of diabetes patients with sensorimotor polyneuropathy. Nerve decompression is justified in the presence of symptomatic compressed nerves in the several fibro-osseous tunnels of the extremities, which are known to be frequent in diabetes. Quite a body of literature has accumulated reporting results after such nerve decompression in the leg, describing pain relief and sensibility improvement, as well as balance recovery, diabetic foot ulcer prevention, curtailed ulcer recurrence risk, and amputation avoidance.Historical academic hesitance to endorse surgical treatments for pain and numbness in diabetes was based primarily on the early retrospective reports’ potential for bias and placebo effects, and that the hypothetical basis for surgery lies outside the traditional etiology paradigm of length-dependent axonopathy. This reticence is here critiqued in view of recent studies using objective, measured outcome protocols which nullify such potential confounders. Pain relief is now confirmed with Level 1 studies, and Level 2 prospective information suggests protection from initial diabetic foot ulceration and most neuropathic ulcer recurrences. In view of the potential for nerve decompression to be useful in addressing some of the more difficult, expensive, and life altering complications of diabetic neuropathy, this secondary compression thesis and operative treatment methodology may deserve reassessment.
Background: Diabetic foot (DF) disease causes severe suffering around the world, and appropriate self-care activities are needed to prevent and treat this condition. However, all too often, self-care activities are less than optimal and clinicians find themselves unable to influence them in a positive direction. Clinicians' and researchers' mental models of the DF tend to be dichotomous: either the patient has or does not have an active ulcer or other DF disease. This mode of thinking hides the long-term perspective of DF disease, where patients' previous experiences and expectations for the future influence their current behavior. Thus, there is a need for a different perspective on DF disease to better understand patients' perspectives and thereby improve self-care, leading to more effective prevention and treatment. Objective: To present a novel framework, the process perspective on the DF, which can explain inadequate self-care behaviors not easily understood with a dichotomous perspective, and how they can be changed. Results: Three fictive clinical examples are used to illustrate how the process perspective on the DF can be used to understand how patients' previous experiences and expectations for the future influence their current behavior. In particular, this process perspective is used to understand how patients' beliefs and behaviors are sometimes self-reinforcing, resulting in stable behavior patterns, here referred to as 'DF cycles'. These cycles are quite common in clinical practice but are difficult to analyze using a dichotomous perspective on DF disease. The process perspective on the DF is used to analyze specific 'vicious' DF cycles of inadequate patient behavior and to find ways to transform them into 'virtuous' DF cycles, resulting in effective prevention and treatment. Conclusions: The process perspective on the DF seems suitable for understanding inadequate patient behaviors not easily understood with a dichotomous perspective on DF disease, opening up new avenues for clinical practice and research to help patients live a life with long remission phases, few relapses, and a high quality of life.
The aim of this case report was to describe a successful diabetic limb salvage procedure in the treatment of an infected diabetic foot ulcer through a multidisciplinary team approach and complex surgical reconstruction involving a femoral head bone allograft and musculocutaneous latissimus dorsi free flap. The decision to proceed with aggressive staged efforts at diabetic limb salvage should be made only after careful consultation with the patient, his or her family, and the rest of the multidisciplinary healthcare team.
Background: Non-removable knee-high devices are the gold standard to treat diabetic foot ulcers located on the plantar forefoot, but they immobilize the ankle, which restricts daily life activities and has negative effects on joint functioning. Objective: To investigate the feasibility of sealing a therapeutic shoe to off-load and heal diabetic forefoot ulcers. Design: A case series of seven men with type 2 diabetes and a metatarsal head ulcer were prescribed therapeutic shoes and custom-made insoles. The shoe was sealed with a plastic band. Off-loading was assessed with the F-scan pressure measurement system. Adherence to wearing the shoe was assessed with a temperature sensor and by documenting the status of the seal. Results: The off-loading was effective and all ulcers healed. Median time to healing was 56 days (range 8-160). Complications were secondary ulcer (n = 1) and plantar hematoma (n = 1). Five of seven participants did not disturb the seal. Conclusions: Sealing a therapeutic shoe is a feasible way to off-load and heal forefoot ulcers. A controlled trial is needed to compare the effectiveness and safety of a sealed shoe to other non-removable devices.
Background: Diabetic patients are susceptible to developing foot ulcers with serious complications such as osteomyelitis and amputations. Treatment approaches are still empirical and the benefit of usual procedures such as surgical debridement has not been properly evaluated. Photodynamic Therapy (PDT) is a non-invasive and highly efficient method for the treatment of the diabetic foot, being able to eradicate the infection and to stimulate healing, decreasing considerably the amputation risk. In the day-to-day practice of our service, we have been faced with the question whether debridement is necessary before PDT. In here, we designed a study to answer that question. Methods: Patients were divided in two groups: In one of the groups (n = 17), debridement was performed before PDT and in the other (n = 40) only PDT treatment was performed. PDT sessions were performed once a week in all patients until healing was achieved, as indicated by visual inspection as well as by radiographic and laboratory exams. At the start of the study, the two groups had no statistical differences concerning their clinical features: average age, gender, insulin use, diabetes mellitus onset time and previous amputations. Results: PDT was effective in the treatment of 100% of the patients showing no relapses after one year of follow up. The group submitted to PDT without previous debridement had a statistically significant (p = 0.036, Mann-Whitney) shorter cure time (29 days, ~27%). Conclusion: Our data indicates that debridement is not necessary in the treatment of diabetic foot in patients that have enough peripheral arterial perfusion. In addition, we reproduced previous studies confirming that PDT is an efficient, safe, simple and affordable treatment method for the diabetic foot.
Background: This study attempted to determine the disease burden in terms of clinical profile and outcome of diabetic foot ulcer (DFU) admissions at a tertiary care hospital in a developing country. Methods: In this descriptive study, the data were collected from the medical record of diabetic patients with foot ulcer who were treated in Dr. Kariadi General Hospital during a 3-year period. The demographic characteristic, type of foot lesion, etiology, isolated microorganism, treatment, and outcome were reviewed. Results: Foot problems accounted for 16.2% of total diabetic admission (n = 1429). All patients had type 2 diabetes with no gender predominance. The mean age was 54.3 ± 8.6 years and diabetes control was very poor. Before admission, the ulcers had already developed for 4.7 ± 2.9 weeks; however, the majority of patients were unaware of the preceding causes. Ulcers were neuropathic in 42.2% of cases, neuroischemic in 29.9%, and pure ischemic at lesser percentage. More than 70% of ulcers were in Wagner grade ≥3 with infection event in nearly all patients. The most common isolates from culture were Gram-negative bacteria. A total of 98 (36.3%) lower extremity amputations (LEAs) at various level of the foot were carried out, including major LEA in 24 patients and multiple amputations in seven patients. Mortality rate due to DFU reached 10.7%. Conclusions: Diabetic foot problems constitute a source of morbidity, a reason for LEA surgery as well as being a cause of death among patients with diabetes mellitus.
Background: Thermoregulation is a complex autonomic process to keep or to dissipate heat in the human body. Methods: In this work, by means of the thermogram of the plantar skin, the thermoregulation of healthy individuals, overweight-obese, and diabetic is discussed. Results: The thermograms of the plantar skin, for the healthy individuals, are: (1) symmetrical, the temperature distribution of the right foot being a mirror image of that of the left foot ; (2) the thermograms of women, on average, are 3°C colder than those of the men; and (3) the temperature distributions decrease distally from the medial longitudinal arch. The plantar skin thermograms of overweight-obese individuals show: (1) increased average temperature of both feet and for both genders; (2) no symmetry between the left and right feet thermograms; and (3) the temperature distribution is still decreasing from the medial longitudinal arch to the periphery of the foot. However, the standard deviation, for each averaged temperature of the angiosomes, shows greater uncertainty. Most thermograms of diabetic individuals show temperature increase on the plantar skin, and are mostly symmetric between left and right feet. Conclusions: An asymmetric thermogram of the plantar skin of diabetic individuals, where one foot is hotter than the other, may mean that the coldest foot is losing the capacity to communicate properly with the central nervous system and/or that vasoconstriction/vasodilatation is having problems in regulating the passing of blood through the vessels. Thus, the asymmetric thermograms of diabetic patients, and particularly those coldest regions of foot are of interest, because of the reduction of the local autonomic sensing and the lack of achieving properly the passing of the blood.
Objective: The treatment of diabetic hindfoot ulcers is a challenging problem. In addition to serial surgical debridements, hyperbaric oxygen therapy and local wound care play important roles in the surgeon's armamentarium, for both superficial infection and gangrene of the soft tissue, often complicated by osteomyelitis of the calcaneus. The purpose of this study was to evaluate the results of an aggressive approach from diagnosis to treatment of calcaneal osteomyelitis in foot-threatening diabetic calcaneal ulcers.Methods: The study included 23 patients with diabetic hindfoot ulcers who were treated with radical excision of the necrotic tissue and application of circular external fixation. The treatment protocol was a combination of magnetic resonance imaging (MRI)-guided debridement of the necrotic tissues and application of an Ilizarov external fixator in plantarflexion to decrease the soft-tissue defect. Primary outcome measures were total cure of infection and obvious healing of the osteomyelitis at 12 weeks determined by MRI, and clinical cure through objective assessment of the appearance of the wound.Results: The wounds healed in 18 of the 23 patients (78%), partial recovery occurred and subsequent flap operation was performed in three patients (13%), and below-the-knee amputation was performed in two patients (9%).Conclusions: This surgical protocol is effective in ameliorating diabetic hindfoot ulcers with concomitant calcaneal osteomyelitis, and satisfactorily reduces the need for amputation.
Objective: Foot and ankle exercise has been advocated as a preventative approach in reducing the risk of foot ulceration. However, knowledge about the appropriate types and intensity of exercise program for diabetic foot ulcer prevention is still limited. The current study aimed to examine the effects of an eight-week mini-trampoline exercise on improving foot mobility, plantar pressure and sensation of diabetic neuropathic feet. Methods: Twenty-one people with diabetic peripheral neuropathy who had impaired sensation perception were divided into two groups. The exercise group received a foot-care education program plus an eight-week home exercise program using the mini-trampoline (n = 11); whereas a control group received a foot-care education only (n = 10). Measurements were undertaken at the beginning, at the completion of the eight-week program and at a 20-week follow-up. Results: Both groups were similar prior to the study. Subjects in the exercise group significantly increased the range of the first metatarsophalangeal joint in flexion (left: p = 0.040, right: p = 0.012) and extension (left: p = 0.013) of both feet more than controlled subjects. There was a trend for peak plantar pressure at the medial forefoot to decrease in the exercise group (p = 0.016), but not in the control group. At week 20, the number of subjects in the exercise group who improved their vibration perception in their feet notably increased when compared to the control group (left: p = 0.043; right: p = 0.004). Conclusions: This is a preliminary study to document the improvements in foot mobility, plantar pressure and sensation following weight-bearing exercise on a flexible surface in people with diabetic neuropathic feet. Mini-trampoline exercise may be used as an adjunct to other interventions to reduce risk of foot ulceration. A larger sample size is needed to verify these findings. This trial is registered with COA No. 097.2/55.
In the surgical treatment of severe diabetic foot infections, substantial soft tissue loss often accompanies partial foot amputations. These sizeable soft tissue defects require extensive care with the goal of expedited closure to inhibit further infection and to provide resilient surfaces capable of withstanding long-term ambulation. Definitive wound closure management in the diabetic population is dependent on multiple factors and can have a major impact on the risk of future diabetic foot complications. In this article, the authors provide an overview of autogenous skin grafting, including anatomical considerations, clinical conditions, surgical approach, and adjunctive treatments, for diabetic partial foot amputations.
Background: The aim of this study was to develop consensus statements that may help share or even establish 'best practices' in the surgical aspects of managing diabetic foot osteomyelitis (DFO) that can be applied in appropriate clinical situations pending the publication of more high-quality data.Methods: We asked 14 panelists with expertise in DFO management to participate. Delphi methodology was used to develop consensus statements. First, a questionnaire elicited practices and beliefs concerning various aspects of the surgical management of DFO. Thereafter, we constructed 63 statements for analysis and, using a nine-point Likert scale, asked the panelists to indicate the extent to which they agreed or disagreed with the statements. We defined consensus as a mean score of greater than 7.0.Results: The panelists reached consensus on 38 items after three rounds. Among these, seven provide guidance on initial diagnosis of DFO and selection of patients for surgical management. Another 15 statements provide guidance on specific aspects of operative management, including the timing of operations and the type of specimens to be obtained. Ten statements provide guidance on postoperative management, including wound closure and offloading, and six statements summarize the panelists' agreement on general principles for surgical management of DFO.Conclusions: Consensus statement on the perioperative management of DFO were formed with an expert panel comprised of a variety of surgical specialties. We believe these statements may serve as 'best practice' guidelines until properly performed studies provide more robust evidence to support or refute specific surgical management steps in DFO.
