Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations

A research-based, current approach to diabetes-related acute foot infections and chronic osteomyelitis

INTRODUCTION

Diabetic foot infections (DFIs) and diabetic foot osteomyelitis (DFO) are common and serious complications in patients with diabetes, often leading to severe morbidity (including amputation) and even mortality. Professional footcare, prompt diagnosis and appropriate treatment are crucial to preventing limb loss and improving outcomes in infections.

AREAS COVERED

This narrative review addresses the management of all DFIs, including the approach to clinical evaluation, appropriate diagnostic methods, and optimal therapeutic strategies. We specifically address key areas in antibiotic therapy, and surgical interventions and techniques. Based on our literature review and extensive, multidisciplinary experience, we developed a novel treatment flowchart specifically for the management of DFO.

EXPERT OPINION

Managing DFIs, including DFO, requires a multidisciplinary approach tailored to each patient's clinical presentation. While antibiotics, surgery, and wound care each play a crucial role, the decision-making process should always consider the infection's severity and chronicity. Our proposed flowchart for DFO management emphasizes the importance of logically-sequenced, easy to apply and tailored interventions to prevent unnecessary amputations and improve outcomes. Further research is needed to further refine this flowchart in clinical practice and demonstrate its effectiveness.

Diabetic foot infections: Questions for an infectious disease consultant

Diabetic foot infection can lead to limb amputation in approximately 17% of affected patients. Given the complex pathophysiology associated with diabetic foot infection, the goal of limb preservation is best achieved with a multidisciplinary approach and a team of providers including infectious disease consultants. However, these infections often affect populations living in nonmetropolitan areas, where access to an infectious disease physician may be limited. It may fall on the surgeons and primary care providers to not only diagnose infections early, including osteomyelitis, but also facilitate prompt, appropriate antibiotic management. The decision to treat with antibiotics alone versus surgery, choice of antibiotic, route of administration, and duration of treatment are complicated concepts that require a patient-specific approach. In addition, use of oral antibiotics and long-acting lipoglycopeptides has gained prominence and offers an alternate solution to the tedious, resource-intense process of outpatient intravenous antibiotic treatment. The goal of this article is to outline and address diagnostic and management questions that would be posed to an infectious disease consultant. The responses would include a literature review of current management concepts and highlights from the 2023 Infectious Disease Society of America and International Working Group on the Diabetic Foot guidelines.

Determining the Best Noninvasive Test for Peripheral Arterial Disease Diagnosis to Predict Diabetic Foot Ulcer Healing in Patients Following Endovascular Revascularization

BACKGROUND/OBJECTIVES

To analyze the best noninvasive tests prognosis marker in patients with diabetic foot ulcer (DFU) who underwent endovascular revascularization based on clinical outcomes, such as healing rate, time to heal, and free amputation survival after at least a six-month follow-up.

METHODS

A multicentric prospective observational study was performed with 28 participants with ischemic or neuroischemic DFU who came to the participant centers and underwent endovascular revascularization between January 2022 and March 2023. Toe systolic pressure (TP), ankle systolic pressure (AP), the ankle brachial pressure index (ABPI), the toe brachial pressure index (TBPI), transcutaneous pressure of oxygen (TcPO2), and skin perfusion pressure (SPP) were evaluated using PeriFlux 6000 System, Perimed, Sweden, before (Visit 0) and four weeks after revascularization (Visit 1). The primary clinical outcome was an evaluation of the clinical evolution of noninvasive tests comparing Visit 0 and Visit 1, estimating the sensitivity for predicting wound healing of noninvasive tests at six months following initial recruitment.

RESULTS

After six months, 71.43% (n = 20) of DFU healed, four patients (14.3%) received major amputations, and one (3.5%) died. The two tests that best predicted wound healing after revascularization according to the ROC curve were TcPO2 and TP with sensitivities of 0.89 and 0.70 for the cut-off points of 24 mmHg and 46 mmHg, respectively.

CONCLUSIONS

TcPO2 and TP were the two tests that best predicted wound healing in patients who underwent endovascular revascularization. Clinicians should consider the importance of the evaluation of microcirculation in the healing prognosis of patients with diabetic foot ulcers.

Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF

In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.

Percutaneous Partial Bone Excision in the Management of Diabetic Toe Osteomyelitis

BACKGROUND

Diabetic foot osteomyelitis affecting the toes is associated with several complications including amputation. Management is variable and include medical therapy alone or coupled with surgery. Removal of infected tissues is a common therapeutic option. However, limited source data are available. This study determines the outcome and complications of percutaneous partial bone excision (PPBE) of infected bone among diabetic patients with toe osteomyelitis.

METHODS

This is an uncontrolled experimental prospective study in diabetic patients who underwent PPBE of infected pieces of bone for toe osteomyelitis in the outpatient setting at a single foot clinic. All participants were followed up until the occurrence of wound healing or amputation.

RESULTS

Forty-seven patients (mean ± SD age was 62.8 ± 11.6 years) participated. Forty-four patients (93.6%) had complete healing and 3 (6.4%) required toe amputation. The mean (±SD) wound healing time was 11 (±4.6) (range, 7-22) weeks. Diabetes mellitus type 1 and younger age were significantly associated with increased risk for amputation.

CONCLUSION

PPBE of infected toes in diabetic patients can be performed successfully and safely in the outpatient clinic. It can also improve healing and avoids inpatient stay.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Analysis of the Influence of Diabetic Nephropathy in Patients with Diabetic Foot Osteomyelitis

This study analyzed the influence of diabetic nephropathy on the healing prognosis after conservative surgery in diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between January 2021 and December 2022 and involved 278 outpatients with a diagnosis of DFO at a specialized diabetic foot unit, including 74 (26.62%) patients with DN (group 2) and 204 (73.38%) patients without DN (group 1). There were 266 (95.70%) ulcers on the forefoot, 8 (2.90%) on the midfoot, and 4 (1.45%) on the hindfoot (p = 0.992). The healing rates were 85.1% (n = 63) for group 2 and 81.3% (n = 165) for group 1 (p = 0.457). When exploring the influence of DN on the risk of delayed ulcer healing, the results did not show a significant effect [12 (6; 28) weeks among patients with DN vs. 12 (6; 21) weeks among patients without DN; p = 0.576]. No significant differences were observed in complications, with one (2.59%) death occurring in group 1 (p = 0.296) and three minor amputations being performed in both groups [two (5.13%) amputations in group 1 vs. one amputation (9.09%) in group 2; p = 0.217]. Bone cultures were performed for a total of 190 patients (133 in group 1 and 57 in group 2). Of these, 176 positive bone cultures were isolated: 71 positive bone cultures (57.7%) were monomicrobial cultures in group 1, with 30 (56.6%) in group 2. There were 52 (42.3%) that had at least two microorganisms in group 1, and 23 (43.4%) in group 2 (p = 0.890). The most frequently prescribed oral antibiotic was amoxicillin/clavulanate (43.89%), followed by levofloxacin (28.4%), and trimethoprim/sulfamethoxazole (14.7%). This study shows that DN does not have a significant influence on the healing prognosis of patients with DFO after conservative surgery.

A Novel Classification for Diabetic Foot Ulcers of the First Ray

OBJECTIVE

Diabetic foot ulcers of the first ray result from several distinct biomechanical mechanisms related to anatomical deformities, which must be addressed if surgical offloading is contemplated. The objective of this study was to create a classification of the anatomical deformities of first-ray ulcers that could lead to better standardization of treatment and reporting.

METHODS

The authors performed a file review of patients with diabetic neuropathy diagnosed with first-ray ulcers over a period of 3 years in an outpatient setting. Anatomical deformities were diagnosed clinically and reported with ulcer location. The primary classification was the metatarsophalangeal joint, the interphalangeal joint, and the distal phalanx.

RESULTS

Records for 59 patients (mean age, 62 years) with University of Texas A1 and A2 ulcers were reviewed. Mean ulcer duration was 2 months. The more common deformities were hallux valgus (41%), hallux valgus interphalangeus (14%), and hallux malleus (20%), and these were primarily associated with metatarsophalangeal, interphalangeal joint, and tip-of-toe ulcers, respectively (P < .0001).

CONCLUSIONS

By classifying ulcer locations, the relevant corrective surgery may be chosen. Although some prophylactic procedures may be safe and effective, prophylactic hallux valgus correction in the diabetic foot requires further study.

Safety and Efficacy of Several Versus Isolated Prophylactic Flexor Tenotomies in Diabetes Patients: A 1-Year Prospective Study

Background: To assess long-term clinical outcomes of patients who underwent isolated versus several percutaneous flexor tenotomies for the treatment of toe deformities and previous diabetic foot ulcers; Methods: Twenty-three patients (mean age 66.26 ± 11.20, years) who underwent prophylactic percutaneous flexor tenotomies secondary to tip-toe ulcers participated in this 1-year prospective study. The study was stratified into two groups for analyses: (1) isolated tenotomies patients, and (2) several tenotomies patients (two or more tenotomies). Outcome measures were toe reulceration and recurrence, minor lesions, digital deformities, and peak plantar pressure (PPP—N/cm2) and pressure/time Integral (PTI—N/cm2/s) in the hallux and minor toes after a 1-year follow-up period; Results: Patients with isolated tenotomies (n = 11, 35.48%) showed a higher rate of reulceration (n = 8, 72.7%, p < 0.001) in the adjacent toes, additionally, we found more prevalence of hyperkeratosis (n = 11, 100%), minor lesions (n = 9, 81%), and claw toes (n = 11, 100%) (p < 0.001). In several tenotomies patients (n = 20, 64.52%), we found a higher rate of floating toes (n = 16, 80%) in comparison with isolated tenotomies patients (p < 0.001). PPP and PTI in the non-tenotomy toes were higher in the group of patients who underwent isolated tenotomies (p < 0.001); Conclusions: Patients who underwent several tenotomies had better clinical outcomes after a 1-year follow-up period compared to isolated tenotomies.

Are Digital Arthroplasty and Arthrodesis Useful and Safe Surgical Techniques for the Management of Patients with Diabetic Foot?

OBJECTIVE

To analyze and compare the development of short- and long-term complications in patients with diabetic foot after digital arthroplasty or arthrodesis.

METHODS

The authors reviewed patient records from January 2017 to March 2020. Patients were treated by digital arthroplasty or arthrodesis to correct toe deformity (elective or prophylactic surgery), achieve ulcer healing in toes (curative surgery), or manage toe infection (emergent surgery). During 1-year follow-up, researchers registered short- and long-term complications. Researchers analyzed the association between the type of surgery and the development of short- and long-term complications.

RESULTS

Forty-four patients (83.0%) received arthroplasty, and nine (17.0%) received arthrodesis. The mean time to heal from ulcers was 5.2 ± 5.2 weeks. A significant association was observed between arthrodesis and the development of long-term complications (P = .044; odds ratio, 5.1; 95% confidence interval, 0.9-27.2). No differences were observed between type of surgery and short- or long-term complications. Moreover, both short- and long-term complications were related to longer time to heal (respectively, 7.6 ± 6.0 vs 2.1 ± 0.5 weeks, P < .001; and 6.3 ± 6.2 vs 4.2 ± 4.0 weeks, P = .039).

CONCLUSIONS

Digital arthroplasty or arthrodesis are good options for managing patients with diabetic foot who require digital deformity correction to achieve digital ulcer healing or management of diabetic foot infection in phalanges.

Conservative surgical treatment for metatarsal osteomyelitis in diabetic foot: experience of two French centres

AIMS

Conservative surgery (CS) for diabetic foot osteomyelitis (DFO) consists in removing all or part of the infected bone tissues without amputation, in complement with antibiotic therapy. Data on CS for DFO therapy are scarce.

MATERIAL AND METHODS

We performed a retrospective analysis of all DFO episodes treated with CS between 06/2007 and 12/2017. Remission was defined by the absence of soft-tissue infection, complete sustained (i.e. > 1 month) healing of the foot ulcer, favourable (i.e., stabilisation or improvement) radiological outcome, and no need for additional surgery during a 1-year follow-up.

RESULTS

During the study period, 47 episodes (in 41 patients) were analysed. Excluding deaths (all unrelated to the DFO; n = 3) or loss to follow-up before 1 year (n = 5), the remission rate was 64.2%. Most failures occurred during the first 6 months (79%, 11/14). Patients who experienced failure had a higher rate of peripheral arterial disease with arterial stenosis than patients in remission (57% vs. 24%, P = 0.03), a higher C-reactive protein rate at admission (116 ± 112 mg/L vs. 48 ± 46 mg/L, P = 0.02), and a trend for a higher rate of abscesses (29% vs. 4%, P = 0.06). At 1-year follow-up, foot ulcers related to transfer lesion were identified in 25.5% of the cases. At the last follow-up (mean 3 ± 2 years), the remission rate was 23/25 (92%).

CONCLUSIONS

Our results suggest that CS is a therapeutic option in patients with localised but severe DFO. Clinicians should, however, consider the necessity of revascularisation, and higher risk of failure if surgery is performed in patients presenting with acute foot infections.

The Fate of Antibiotic Impregnated Cement Space in Treatment for Forefoot Osteomyelitis

Forefoot osteomyelitis can be an extremely challenging problem in orthopedic surgery. Unlike conventional methods, such as amputations, antibiotic impregnated cement space (ACS) was recently introduced and perceived as a substitute for amputation. The purpose of this study was to compare clinical features between diabetic and non-diabetic groups and to evaluate the efficacy of ACS in the treatment of forefoot osteomyelitis, by identifying the clinical characteristics of ACS. We inserted ACS into the forefoot osteomyelitis patients and regularly checked up on them, then analyzed the clinical features of the patients and failure reasons, if ACS had to be removed. Average survival rate of ACS was 60% (21 out of 35 cases) and main failure reason was recurrence of infection. There was no significant clinical difference between diabetic and non-diabetic groups. We concluded that ACS could be a possible way of avoiding amputation if infection is under control. ACS seems to be an innovative method with promising results for foot osteomyelitis, but widely accepted indications need to be agreed upon.

Dual-functional hybrid quaternized chitosan/Mg/alginate dressing with antibacterial and angiogenic potential for diabetic wound healing

BACKGROUND

Clinic treatment of diabetic foot ulcers (DFUs) is considerably challenging. Impaired wound healing may be caused by poor vascularization and dysfunction of the extracellular matrix, which leads to poor re-epithelialization and increased risk of infection. In this study, we evaluated the treatment potential of a functional dressing comprising quaternized chitosan (hydroxypropyltrimethyl ammonium chloride chitosan) and magnesium (Mg) on DFUs.

METHODS

Dressings were prepared by vacuum freeze-drying. The cellular proliferation, migration, and angiogenesis potential of the functional dressings were determined in vitro. Methicillin-resistant Staphylococcus aureus (MRSA, ATCC43300) and methicillin-resistant Staphylococcus epidermidis 287 (MRSE287) were used to evaluate the antibacterial efficiency of the dressings. Finally, a diabetic rat model with infected wounds was used to further evaluate the effects of functional dressings on the healing of DFUs.

RESULTS

Functional dressings facilitated the migration of human dermal fibroblasts and human umbilical vein endothelial cells (HUVECs), while also stimulating angiogenesis in HUVECs. Additionally, the functional dressing could effectively eradicate MRSA and MRSE, exhibiting excellent antibacterial ability against drug-resistant bacteria. The results of in vivo microbiological and histological tests demonstrated effective anti-infection ability and wound-healing potential of this functional dressing.

CONCLUSIONS

The dual-functional dressing exhibited wound-healing ability and anti-infection efficiency, demonstrating potential application prospects in DFU treatment.

TRANSLATIONAL POTENTIAL OF THIS ARTICLE

As one of the common and serious complications of diabetes, DFUs do not heal easily, causing great suffering to patients. Therefore, improvement in the prognosis of DFUs is a crucial clinical need. The dual-functional dressing prepared in this study was proven to improve the treatment of DFUs, both in vitro and in vivo. Considering its urgent clinical necessity and good biocompatibility of its raw materials, such as alginate, Mg, and chitosan derivatives, this dual-functional dressing presents good prospects for clinical translation.

Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update

Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.