Histopathology is More Reliable Than Microbiology for Detecting Residual Osteomyelitis After Conservative Surgery for Diabetic Foot: The Pitfall of False-Positive Cultures and the Role of Pseudomonas aeruginosa

The optimal method for assessing residual osteomyelitis after conservative surgery for diabetic foot infection remains controversial. Microbiological cultures are frequently used due to their rapid turnaround and utility in guiding antibiotic therapy, but their diagnostic reliability is uncertain. This study compared microbiological cultures and histopathology in evaluating bone resection margins, using histopathology as the gold standard. We included 93 patients undergoing conservative surgery for diabetic foot osteomyelitis. Bone samples were obtained from the proximal resection margin for both microbiology and histopathology. A microbiological result was considered contamination when cultures were positive but histopathology was negative. Microbiological cultures at bone resection margins yielded 52 true positives, 23 false positives (contamination), 10 false negatives, and 8 true negatives when compared to histopathology. This resulted in a sensitivity of 83.9%, specificity of 25.8%, positive predictive value of 69.3%, and negative predictive value of 44.4%. Contamination was not associated with the severity of infection, presence of soft tissue involvement, inflammatory markers, or glycemic control. No association was found between contamination and polymicrobial flora in the primary surgical specimen. However, Pseudomonas aeruginosa was the only species significantly associated with contamination (p = .008), suggesting species-specific factors may contribute to microbiological false positives. These findings emphasize that microbiology, while sensitive, is not a specific method for assessing residual bone infection and should not be used in isolation. Histopathology remains the more reliable diagnostic tool. Future research should explore biofilm-targeted strategies and intraoperative antiseptic protocols to reduce contamination of bone biopsy specimens obtained from resection margins.

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.

Comparative Analysis of Bone Resection Versus Bone Curettage in Diabetic Foot Osteomyelitis

This study aims to describe the healing times of patients who underwent bone resection compared to bone curettage for managing diabetic foot osteomyelitis and to compare short- and long-term complications. This analytical retrospective observational cohort study collected clinical records of patients from a specialized diabetic foot clinic who underwent resection or bone curettage between January 2017 and January 2022. After surgery, a 1-year follow-up was conducted to record healing times and short- and long-term complications. The study included thirty-one patients, with 19 (61.29%) undergoing resections and 11 (38.71%) undergoing bone curettages. The resection cohort had a mean healing time of 5.70 ± 6.05 weeks, whereas the curettage cohort had a mean healing time of 14.45 ± 11.78 weeks, showing a statistically significant difference (P = 0.011). No significant differences were observed in terms of short- and long-term complications. In the resection cohort, 12 (63.20%) experienced short-term complications, compared to eight (66.70%) in the curettage cohort (P = 0.842, χ2 = 0.40, OR = 1.16). In the resection cohort, n = 6 (31.60%) had long-term complications, while n = 3 (25.00%) in the curettage cohort experienced long-term complications (P = 0.694, χ2 = 0.155, OR = 0.72). Although there were no significant differences in short- and long-term complications between resection and curettage, the resection group showed shorter healing times.

The impact of residual diabetic toe osteomyelitis at the conservative surgical resection margins on prognosis

AIMS

The study is to investigate how residual osteomyelitis at conservative surgical resection margins affects the prognosis of diabetic toe osteomyelitis.

METHODS

In this retrospective study, 67 participants with diabetic toe osteomyelitis who underwent conservative surgery were evaluated. The diagnosis of osteomyelitis was based on histopathology, and bone histopathology was done on the resection bone. After discharge, a 16-week follow-up was conducted, focusing on the wound healing time as the primary outcome. Cox regression analysis was employed as the primary method to analyse the risk factors that influence wound healing.

RESULTS

Among the 67 participants, 48 (71.6%) had positive bone margins, while 19 (28.4%) had negative bone margins. Participants with positive bone margins experienced an average healing time of 60.78 ± 18.50 days, whereas those with negative bone margins had an average healing time of 55.19 ± 14.60 days (p = 0.285). Bone margins (positive vs. negative) did not have an impact on wound healing (HR, 1.195 [95% CI, 0.668-2.136]; p = 0.549). Ankle-brachial index was identified as a factor influencing wound healing (HR, 5.399 [95% CI, 1.145-25.455]; p = 0.033). There was no statistical difference between the two groups in terms of wound healing rates (40 of 48 [83.3%] vs. 16 of 19 [84.2%], p = 0.93), inpatient days (19.48 ± 5.25 vs. 18.26 ± 4.79 days, p = 0.385) and duration of antibiotics (32.33 ± 5.64 vs. 30.53 ± 6.93 days, p = 0.272).

CONCLUSION

The residual osteomyelitis in diabetic toe osteomyelitis post-conservative surgery does not impact the wound healing.

Diagnostic Performance of Atherogenic Index of Plasma for Predicting Diabetic Foot Osteomyelitis with Peripheral Artery Disease

Background: This study aims to assess the atherogenic index of plasma (AIP) diagnostic value in detecting diabetic foot osteomyelitis (DFO) among patients with diabetic foot ulcers (DFUs). Methods: A prospective cohort study was conducted on 80 patients with DFUs and suspected DFO between January 2022 and December 2023. The primary outcome measures included the diagnosis of DFO, determined by positive microbiological analysis results from bone samples and its correlation with the AIP. Receiver operating characteristic (ROC) curves were utilized to select the optimal diagnostic cut-off points for AIP and post hoc analysis was performed to evaluate the difference in the AIP for diagnosing DFO in patients with and without peripheral arterial disease (PAD). Results: The diagnostic potential for DFO in PAD patients of AIP-1 (Log TC/HDL) showed an AUC of 0.914 (p < 0.001 [0.832-0.996]), leading to a sensitivity of 83% and a specificity of 85%. By contrast, AIP-2 (Log TG/HDL) demonstrated a slightly lower AUC of 0.841 (p < 0.001 [0.716-0.967]), leading to a sensitivity of 76% and a specificity of 74%. Conclusions: The AIP tool, with its ideal blend of sensitivity and specificity, aids in predicting DFO effectively. Therefore, clinicians should consider using AIP for patients suffering from PAD and associated DFO.

Controversial Issues Regarding Positive Bone Margins in Surgery for Diabetic Foot Osteomyelitis: A Pilot Study

Obtaining clean margins in patients who undergo surgical treatment for diabetic foot osteomyelitis (DFO) is recommended. We hypothesize that the rate of recurrence of the infection is not associated with positive margins, even when using a short-term duration of postoperative antibiotic treatment. We conducted a retrospective pilot study of patients who underwent surgery for DFO confirmed by histopathological analysis of the resected bone from August 1, 2020, to December 1, 2020. Bone samples were taken from the proximal margins to be studied by microbiology and histopathology. Twenty-five (89.3%) patients underwent conservative surgery, and 3 (10.7%) patients underwent a minor amputation. After surgery, the antibiotics were stopped in 19 (67.9%) patients and continued in 9 (32.1%) patients for a median period of 4 days. The microbiology of the bone margins was positive in 20 (71.4%) cases, but the histopathology of the bone margins was positive in just 7 (25%) cases. Recurrence of the infection was detected in 3 (10.7%) patients. Seventeen (68%) patients with microbiological-positive margins did not have a recurrence of infection, while 3 (100%) patients had a recurrence of infection (P = .53). Six (24%) patients among those with histopathological-positive margins did not have a recurrence of infection, and1 (33.3%) patient had a recurrence of infection (P = 1). The recurrence of infection was low and always detected in soft tissues, including the cases with a histopathological-positive bone margin. Postoperative antibiotics were administered for a short period of time and not based on the analysis of bone margins.

Residual osteomyelitis at the resection margin after conservative surgery is not associated with the recurrence of diabetic foot infection and may successfully be treated without postoperative antibiotic therapy

AIMS

We hypothesize that microbiology- and pathology-confirmed positive bone margins after the resection of diabetes-related foot osteomyelitis are associated with worse outcomes.

METHODS

We conducted a prospective study consisting of a cohort of 93 patients with diabetes-related foot osteomyelitis (histopathology confirmed) who underwent bone resection and where an additional bone biopsy was taken at the resection margin. The primary outcome was the recurrence of the infection.

RESULTS

Pathology-confirmed positive margins were detected in 62 cases (66.7%), microbiology-confirmed positive margins were detected in 75 cases (80.6%) and recurrence was detected in 19 patients (20.4%). Chi-squared test failed to show the presence of an association between the recurrence of the infection with pathology-confirmed positive margins (p = 0.82), with microbiology-confirmed positive margins, (p = 0.34) and with the use of postoperative antibiotics (p = 0.70). Healing in patients with pathology-confirmed positive margins was achieved in a median of 12 weeks (95% CI 9.2-18) and those with pathology-confirmed negative margins in 14.9 weeks (95% CI 10.2-21.9), Log-rank test, p = 0.74. Thirty-four patients out of 61 available for follow-up (55.7%) with pathology-confirmed positive margins were treated without postoperative antibiotics. In that group, Chi-squared test failed to show the presence of an association between the recurrence of the infection with the use of postoperative antibiotics (p = 0.47).

CONCLUSIONS

A positive margin was neither associated with the recurrence of the infection nor with the time to healing. More than half of patients with pathology-confirmed positive margins were treated without postoperative antibiotics and this approach was not associated with the recurrence of the infection.

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.

Conservative Surgery for Diabetic Foot Osteomyelitis is not Associated With Longer Survival Time Without Recurrence of Foot Ulcer When Compared With Amputation

Conservative surgery of diabetic foot osteomyelitis (DFO) in which bone infection is removed without amputation could minimize the biomechanical changes associated with foot surgery. We hypothesize that patients who undergo conservative surgery will have a longer survival time without recurrence of foot ulcers and further amputations than those who undergo any type of amputation to treat DFO. We assessed a retrospective cohort of 108 patients who underwent surgery for DFO from January 2011 to December 2012. Patients were followed-up until May 2020. Reulceration and reamputation-free survival times were plotted using the Kaplan-Meier method and were calculated from the date of first surgery to recurrence, new amputation, or end of the study. A stratified log rank was used to study differences among groups. Cumulative survival without recurrences at 1, 5, and 8 years was 95%, 36%, and 29%, respectively, in patients who underwent conservative surgery and 95%, 43%, and 30%, respectively, in those undergoing amputation. Cumulative survival without a new amputation at 1, 5, and 8 years was 100%, 80%, and 80%, respectively, in patients who underwent conservative surgery and 98%, 82%, and 69%, respectively, in those undergoing amputation. No differences were found regarding either recurrence (log rank, P = .98) or new amputations (log rank, P = .64). In conclusion, conservative surgery is as safe as amputation to arrest bone infection in the feet of patients with diabetes. Conservative surgery was not associated with a lower rate of recurrence and new amputations than those patients who underwent amputations.

Surgical Diabetic Foot Infections: Is Osteomyelitis Associated With a Worse Prognosis?

It has been reported that patients with diabetes and foot ulcers complicated with osteomyelitis (OM) have a worse prognosis than those complicated with soft tissue infections (STI). Our study aimed to determine whether OM is associated with a worse prognosis in cases of moderate and severe diabetic foot infections requiring surgery. A retrospective series consisted of 150 patients who underwent surgery for diabetic foot infections. We studied the differences between OM versus STI. Furthermore, diabetic foot infections were reclassified into four groups: moderate STI (M-STI), moderate OM (M-OM), severe STI (S-STI), and severe OM (S-OM). The variables associated with prognosis were limb loss, length of hospital stay, duration of antibiotic treatment, recurrence of the infection, and time to healing (both the initial ulcer and the postoperative wound). No differences in limb salvage, hospital stay, duration of antibiotic treatment, recurrence of the infection, and time to healing were found when comparing OM with STI. Patients with M-O had a higher rate of recurrences after initial treatment and a longer time to healing when comparing with M-STI. We didn't find any differences between severe infections with or without OM. In conclusion, we have found in our surgical series of diabetic foot infections that OM is not associated with worse prognosis when comparing with STI regarding limb loss rate, length of hospital stays, duration of antibiotic treatment, recurrence of the infection, and time to healing. The results of the present series should further be confirmed by other authors.

Bacterial Diversity and Antibiotic Resistance in Patients with Diabetic Foot Osteomyelitis

This study analysed the bacterial diversity, antibiotic susceptibility, and resistance in patients with complications of diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between September 2019 and September 2022 and involved 215 outpatients with a diagnosis of DFO at a specialized diabetic foot unit. A total of 204 positive bone cultures were isolated, including 62.7% monomicrobial cultures, and 37.3% were formed with at least two microorganisms. We observed that Proteus spp., Coagulase-negative staphylococci (CoNS), Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Corynebacterium were the most frequently isolated microorganisms and accounted for more than 10% of the DFO cases. With stratification by Gram-positive (GP) and Gram-negative (GN) bacteria, we observed that 91.6% of cultures presented at least one GP bacteria species, and 50.4% presented at least one GN bacteria species. The most common GP species were CoNS (29%), S. aureus (25.8%), and Corynebacterium spp. (14%). The most frequent GN species consisted of Proteus spp. (32%), P. aeruginosa (23.3%), and E. coli (17.5%). The main antibiotics with resistance to GP-dominated infections were penicillins without β-lactamase inhibitor, and those in GN-dominated infections were sulfonamides and penicillins without β-lactamase. Significant differences were not observed in mean healing time in DFU with acute osteomyelitis (12.76 weeks (4.50;18)) compared to chronic osteomyelitis (15.31 weeks (7;18.25); p = 0.101) and when comparing cases with soft tissue infection (15.95 (6;20)) and those without such an infection (16.59 (7.25;19.75), p = 0.618). This study shows that when treatment of DFO is based on early surgical treatment, the type of DFO and the presence of soft infection are not associated with different or worse prognoses.

Variables That Could Influence Healing Time in Patients with Diabetic Foot Osteomyelitis

AIM

To compare the healing time in patients with diabetic foot osteomyelitis according to the presence or absence of clinical signs of infection, variation of blood parameters, the presence of different radiological signs, and the treatment received for the management of osteomyelitis.

METHODS

A prospective observational study was carried out in a specialised Diabetic Foot Unit between November 2014 and November 2018. A total of 116 patients with osteomyelitis were included in the study (treated by either a surgical or medical approach). During the baseline visit, we assessed the diagnosis of osteomyelitis, demographic characteristics and medical history, vascular and neurological examination, clinical signs of infection, increased blood parameters, radiological signs of osteomyelitis, and the treatment to manage osteomyelitis. We analysed the association between the presence of clinical signs of infection, variation of blood parameters, presence of radiological signs, and treatment received for management of osteomyelitis with the healing time.

RESULTS

The mean time to ulcer healing was 15.8 ± 9.7 weeks. Concerning healing times, we did not find an association with the presence of clinical signs of infection or with the increase in blood parameters, except in the case of eosinophils, which with higher values appear to increase the healing time (U = 66, z = -2.880, p = 0.004). Likewise, no relationship has been found between healing time and the appearance of the different radiological signs of osteomyelitis, nor depending on the treatment administered for the management of osteomyelitis.

CONCLUSION

High levels of eosinophils are associated with a longer healing time of diabetic foot ulcers complicated with osteomyelitis, finding no other factors related to increased healing time.

Prospective Validation of the Value of Adding Osteomyelitis to Moderate and Severe Categories of Diabetic Foot Infections

We aimed to validate the value of adding osteomyelitis (OM) to moderate and severe categories of diabetic foot infections (DFIs) classification. We conducted a prospective study of a cohort of 200 patients with moderate and severe infections. Variables associated with prognosis were need for any amputation, major amputation, need for hospitalization, length of hospitalization, length of antibiotic therapy, reinfection rate and infection-related mortality. Infections were moderate in 111 cases (55.5%) and severe in 89 (44.5%). OM was diagnosed in 114 cases (57%), 73 presented as moderate (36.5%) and 41 as severe (20.5%). Overall, 129 patients (64.5%) were admitted for a median of 15 days (IQR 13) and 71 (35.5%) were treated as outpatients (day-surgery). Ninety-four patients (47%) were exclusively treated with intravenous antibiotics, 35 (17.5%) with intravenous and then shifting to oral, 16 (8%) exclusively with oral antibiotics, and 55 (27.5%) without antibiotics. Definitive surgery that led to the arrest of the infection was as follows: 117 patients (58.5%) underwent surgical debridement without amputation, and 69 (34.5%) underwent minor and 14 (7%) major amputation. Patients with OM presented as severe had a higher rate of amputations, major amputations, hospitalizations and need for antibiotic therapy when compared with OM presented as moderate. OM is strongly recommended to be added to the moderate and severe categories of the Infectious Diseases Society of America/International Working Group on Diabetic Foot severity system, as recommended by the International Working Group on Diabetic Foot 2019 guidelines.

Could X-ray Predict Long-term Complications in Patients with Diabetic Foot Osteomyelitis?

OBJECTIVE

To analyze the association between radiologic changes on plain X-rays in patients with diabetic foot osteomyelitis and the development of complications at the 1-year follow-up.

METHODS

A prospective, observational study was conducted involving 115 patients with diabetic foot osteomyelitis. X-ray features that were evaluated during 1-year follow-up visits included affected bone marrow, active periosteal reaction, sequestrum, cortical disruption, and other types of signs. Researchers analyzed the association between the presence of X-ray changes and complication development, such as bone or soft tissue infections, ulcer recurrence, reulceration, amputation, death, and other diabetic foot disease-related events.

RESULTS

During follow-up, of 115 patients included in the study, 33 patients (28.7%) showed radiologic changes, and 85 (73.9%) developed complications. The presence of radiologic changes after ulcer healing had a significant association with complication development during the 1-year follow-up in addition to those found at different follow-up visits. Patients who showed radiologic changes had higher percentages of complications during the 1-year follow-up, and patients without radiologic changes had lower percentages of complications.

CONCLUSIONS

The presence of radiologic changes is related to the development of complications in patients who suffer from diabetic foot osteomyelitis.

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.

Bioactive Glass in a Multi Drug Resistance Osteomyelitis in Diabetic Foot: Case Report

Diabetic foot osteomyelitis (DFO) is a clinical problem with high risk of amputation. The treatment of DFO is still an unsolved challenge. Surgical therapy, antibiotic therapy or conservative treatment are still debated for the timing and the consequences. Long antibiotic therapies expose the selection of multidrug-resistant bacteria. Nowadays the use of new bone substitutes aims to support the load of the bone segments and to ensure the eradication of the infectious process after surgical treatment. A case report of digital osteomyelitis due to a multidrug resistant bacteria was treated with a conservative treatment and use of bioglass (Bonalive) that has the ability to inhibit bacterial growth. A long follow-up shows the resolution of infectious process, no ulcer recurrence and persistent recovery of its ability to walk. Our results agree with literature data and suggest that bioglass may be considered a useful option to manage DFO and achieve healing with a very conservative approach.

Pilot study of the diagnostic value of CRP:albumin ratio for osteomyelitis in patients with diabetic foot ulcers

OBJECTIVE

Osteomyelitis may complicate diabetic foot ulcers (DFUs). As a new inflammation-based prognostic factor, CRP:albumin ratio's significance is not known in osteomyelitis among patients with or without diabetes.

METHOD

Patients with type 2 diabetes and DFUs were divided into two groups: group 1 (n=47) comprised patients without osteomyelitis, and group 2 (n=50) comprised patients with osteomyelitis.

RESULTS

Erythrocyte sedimentation rate (ESR) (88.5±23.0 versus 42.0±22.2), white blood cell count (WBC) (14.7±6.9x10³ versus 10.0±4.4x10³), C-reactive protein (CRP) level (15.6±9.9 versus 2.4±3.3) and CRP:albumin ratio (6.6±4.9 versus 0.7±1.0) were significantly higher, and albumin level was significantly lower in group 2 compared to group 1 (p<0.001 for all). The presence of osteomyelitis was significantly and positively correlated with ESR (r=0.721; p<0.001), WBC (r=0.380; p<0.001), CRP (r=0.667; p<0.001) and CRP:albumin ratio (r=0.638; p<0.001), and negatively correlated with albumin (r=-0.590; p<0.001). A CRP:albumin ratio of 1.74 or above could predict osteomyelitis with 92.0% sensitivity, 80.9% specificity, and the best area under the curve (AUC) score (AUC=0.957; 95% CI: 0.924-0.991). ESR (odds ratio (OR): 1.071 (1.025-1.119); p=0.02) and CRP:albumin ratio (OR: 2.65 (1.437-4.885); p=0.002) were independent predictors in the final model for stepwise linear regression analyses for the estimation of osteomyelitis.

CONCLUSION

CRP:albumin ratio is a cheap and repeatable inflammatory marker and can successfully detect osteomyelitis in patients with DFU.

Amputation versus Primary Nonoperative Management of Chronic Osteomyelitis Involving a Pedal Digit in Diabetic Patients

BACKGROUND

The preferred primary treatment of toe osteomyelitis in diabetic patients is controversial. We compared the outcome of primary nonoperative antibiotic treatment versus digital amputation in patients with diabetes-related chronic digital osteomyelitis.

METHODS

We conducted a retrospective medical record review of patients treated for digital osteomyelitis at a single center. Patients were divided into two groups according to initial treatment: 1) nonoperative treatment with intravenous antibiotics and 2) amputation of the involved toe or ray. Duration of hospitalization, number of rehospitalizations, and rate of below- or above-the-knee major amputations were evaluated.

RESULTS

The nonoperative group comprised 39 patients and the operative group included 21 patients. The mean ± SD total duration of hospitalization was 24.05 ± 15.43 and 20.67 ± 15.97 days, respectively (P = .43). The mean ± SD number of rehospitalizations after infection recurrence was 2.62 ± 1.63 and 1.67 ± 1.24, respectively (P = .02). During follow-up, the involved digit was eventually amputated in 13 of the 39 nonoperatively treated patients (33.3%). The rate of major amputation (above- or below-knee amputation was four of 39 (10.3%) and three of 21 (14.3%), respectively (P = .69).

CONCLUSIONS

Despite a higher rate of rehospitalizations and a high failure rate, in patients with mild and limited digital foot osteomyelitis in the absence of sepsis it may be reasonable to offer a primary nonoperative treatment for digital osteomyelitis of the foot.

The Influence of Arterial Calcification on Clinical Outcomes in Patients with Diabetic Foot Ulcer Complicated by Osteomyelitis Treated by Surgery

The aim of our study was to analyze the influence of radiographic arterial calcification (RAC) on clinical outcomes and wound healing in patients with diabetic foot ulcers complicated by osteomyelitis treated by surgery. We analyzed retrospectively the clinical records of 102 patients with diabetic foot osteomyelitis who underwent surgery at a specialized diabetic foot unit between January 2014 and December 2016. The clinical data of evolution until its complete epithelialization and a follow-up 1 year were reviewed, and after reviewing the radiological images, patients were classified into 2 groups: those with RAC and those without RAC. We analyzed several clinical features in both groups. The presence of RAC was associated with a greater time of healing (10.68 ± 7.24 vs 8.11 ± 4.50 weeks; P = .029) and shorter time to recurrence and reulceration (13.30 ± 9.25 vs 18.81 ± 11.63 weeks; P = .036). However, this association was not found for patients with mild and moderate peripheral artery disease (PAD), whose time of healing was 8.97 ± 4.51 weeks compared to 9.16 ± 6.39 weeks for patients without PAD; P = .864. The time of healing of diabetic foot ulcers complicated by osteomyelitis treated by surgery can be negatively affected by the presence of RAC even more than by the presence of mild and moderate ischemia. The presence of RAC may offer clinical guidance at the level of primary care though this would need thorough validation in future studies.

Long-Term Complications after Surgical or Medical Treatment of Predominantly Forefoot Diabetic Foot Osteomyelitis: 1 Year Follow Up

AIM

To compare long-term complications according to the treatment received for management of diabetic foot osteomyelitis (surgical or medical) at 1 year follow up.

DESIGN AND PARTICIPANTS

A prospective observational study was conducted involving 116 patients with diabetic foot osteomyelitis. The patients received surgical or medical treatment based on the principles described in the literature. To register the development of a complication, both groups of treatments were followed-up 1 year after the ulcer had healed.

RESULTS

Ninety-six (82.8%) patients received surgical treatment and 20 (17.2%) medical treatment. No differences were found in the time to healing between both groups of treatment, 15.7 ± 9.2 weeks in the surgical group versus 16.4 ± 12.1 weeks in the medical group; p = 0.103. During follow up, 85 (73.3%) patients developed complications without differences between both groups, 68 (70.8%) in the surgical group versus 17 (85%) in the medical group (p = 0.193). The most common complication in both groups was re-ulceration. We did not observe significant differences comparing complication-free time survival between both treatments (p = 0.665).

CONCLUSION

The onset of complications after healing in patients who suffered from diabetic foot osteomyelitis was not associated with the treatment received. Surgical and medical approaches to the management of diabetic foot osteomyelitis produced similar results in long-term follow up.

Diagnostic Accuracy of Bone Culture Versus Biopsy in Diabetic Foot Osteomyelitis

OBJECTIVE

To compare the diagnostic accuracy of bone culture (microbiology) and biopsy (histology) in patients with acute or chronic diabetic foot osteomyelitis (DFO).

METHODS

This cross-sectional study involved patients for whom providers had a clinical suspicion of DFO. Two bone samples were taken: one for microbiologic testing and another for histologic testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio were calculated for bone culture results in relation to the probability of DFO diagnosis.

RESULTS

Fifty-two patients were included; 69% had positive bone culture results, and 90.4% had positive histology results (P = .013), and of those 90.4%, 25.5% had acute and 74.5% had chronic DFO. The sensitivity of the microbiologic bone culture result was 0.70, the specificity was 0.40, the positive predictive value was 0.92, and the negative predictive value was 0.13.

CONCLUSIONS

Histology provides more accurate diagnosis of DFO than microbiology, especially for patients with chronic DFO. These patients could be underdiagnosed because of false-negative results provided by bone culture. Providers should perform both tests to confirm the presence of DFO.

Medical Versus Surgical Treatment for the Management of Diabetic Foot Osteomyelitis: A Systematic Review

A systematic review and quality assessment was performed to assess the management of diabetic foot osteomyelitis by medical or surgical treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used. All selected studies were evaluated using the Cochrane Risk of Bias Tool to assess the risk of bias for randomized controlled trials. The literature was revised using PubMed (Medline) and Embase (Elsevier) up to September 2020 to identify clinical trials assessing medical or surgical treatment to manage diabetic foot osteomyelitis. A total of six clinical trials that met our inclusion criteria, with a total of 308 participants. Healing rate, complete closure of the wound, and type of complications were the outcomes evaluated. Risk of bias assessment showed that only two of the six clinical trials included in the systematic review had a low risk of bias. Based on our findings, we believe that the management of diabetic foot osteomyelitis remains challenging. There are few high-quality clinical trials that both stratify clinical presentations and compare these treatments. We conclude that the available evidence is insufficient to identify the best option to cure diabetic foot osteomyelitis.

Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations

Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU. Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications. A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot. Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection. When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures. Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.

Role of inflammatory markers in the healing time of diabetic foot osteomyelitis treated by surgery or antibiotics

OBJECTIVE

To analyse the predictive role of inflammatory markers in the healing time of diabetic foot osteomyelitis treated by surgery or antibiotics.

METHODS

An observational study of patients with diabetic foot ulcers (DFU) and clinically suspected osteomyelitis. The patients underwent surgical or antibiotic treatment for bone infection in a specialised diabetic foot unit. Blood samples were taken from each patient to analyse biomarkers. The main outcome was the number of weeks until healing occurred.

RESULTS

A total of 116 patients took part in the study. The number of weeks until healing was similar for both groups (surgical n=96 and antiobiotic n=20, treatments). No association was observed among biomarkers as predictors of time-to-healing.

CONCLUSION

There is not enough evidence to define the prognostic role of inflammatory markers in the healing time of DFUs complicated with diabetic foot osteomyelitis, regardless of the treatment administered.

Surgical techniques for Bone Biopsy in Diabetic Foot Infection, and association between results and treatment duration

Surgery is an important part of the management of patients diagnosed with DFO. It consists in some selected patients, to remove all or part of the infected bone(s) or even to amputate all or part of the foot. Despite the use of sophisticated imaging techniques, it is however difficult to remove all the infected tissue while respecting the principles of an economical surgery. Bone biopsy performed at the margins of the resection permits to identify residual osteomyelitis and to adjust the post-surgical antibiotic treatment. Some recent studies have reported the way to perform bone margin biopsies and have assessed the impact of the bone results on the patient's outcome. However, the real impact of a residual osteomyelitis on the risk of recurrent DFO is still debated and questions regarding the interpretation of the results remain to be solved. Similarly, the consequences in terms of choice and duration of the antimicrobial treatment to use in case of positive bone margin are not clearly established.

A Meta-analysis of the Types and Outcomes of Conservative Excisional Surgery for Recalcitrant or Infected Diabetic Toe Ulcers

Although they occur frequently, diabetic toe ulcers (DTUs) are poorly investigated. Long-term antibiotics or toe amputation are the usual indications for complicated DTU treatment. Some authors reported good to excellent results following conservative surgery (CS) for recalcitrant or infected wounds; yet no systematic review has been published. Seven studies, comprising 290 patients with 317 ulcers, met the inclusion criteria of this meta-analysis. Three types of CS were found: resection arthroplasty of the interphalangeal joint, toe-sparing bone excision (internal pedal amputation), and distal Symes amputation. The meta-analytical results were as follows: healing rate of 98.3%, healing time of 6.8 ± 3.9 weeks, recurrence rate of 2.3%, wound dehiscence/recurrent infection rate of 6.4%, skin necrosis rate of 2.8%, and revision surgery rate of 7.4%. Subgroup analyses showed no significant differences in outcomes between recalcitrant ulcers and infected ulcers nor between surgery types. Significance was found in relation to ulcer location; when compared with the hallux, DTU on the lesser toes demonstrated better outcomes. Compared with the reported overall results of standard of care associated with antibiotics or toe amputation of complicated DTUs in the literature, CS seems to be a better option for the treatment of recalcitrant or infected DTUs. Levels of Evidence: Level III.

An evidence based narrative review on treatment of diabetic foot osteomyelitis

OBJECTIVE

The diagnosis of diabetic food infection is usually clinical, and its severity is related to location and depth of the lesion, and the presence of necrosis or gangrene. Osteomyelitis of the foot and ankle can be extremely debilitating, and, in the preantibiotic era acute staphylococcal osteomyelitis carried a mortality rate of 50%. The microbiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial. Indeed, gram-negative and gram-positive bacilli can be identified using molecular techniques applied to bone biopsies compared to conventional techniques. The aim of the present study is to report a complete overview regarding medical and surgical management of diabetic foot osteomyelitis (DFO) in combination or alone.

MATERIALS AND METHODS

We performed a search in PubMed and Scopus electronic databases (up to January 2019) of articles assessing the epidemiology, diagnostic strategy and pharmacological treatment of diabetic foot infection. In the search strategy, we used various combinations of the following key terms: infection, orthopaedic, diabetic foot, management, DFO.

RESULTS

This article discusses the definition, epidemiology, microbiological assessment, clinical evaluation, pharmacological and surgical management and a comparison between them, of DFO. After the initial literature search and removal of duplicate records, a total of 756 potentially relevant citations were identified. After a further screening and according to the inclusion criteria, a total of 65 articles were included in the present review.

CONCLUSION

The association of antibiotic and surgical therapy seems to be more effective compared to each one alone. The lack of comparison studies and randomized controlled trials makes it difficult to give information about the efficacy of the different management therapies.

Assessment of the Risk Factors of Multidrug-Resistant Organism Infection in Adults With Type 1 or Type 2 Diabetes and Diabetic Foot Ulcer

OBJECTIVES

To our knowledge, this is the first review to analyze the literature identifying risk factors for multidrug-resistant organism (MDRO) infection in patients with diabetic foot ulcer. The purpose of this study was to collect the currently published data to determine the most commonly and consistently identified risk factors for MDRO infection.

METHODS

PubMed, MEDLINE, BIOSIS, Web of Science and the Cochrane Library electronic databases were searched. The last search updated was in September 2019. The evaluated outcomes included age, male sex, type of diabetes, diabetes duration, level of glycated hemoglobin, ulcer type, wound duration, ulcer size, ulcer grade, osteomyelitis, previous antibiotic therapy and previous hospitalization. The standard mean difference or the odds ratio (OR) was calculated for continuous or dichotomous data, respectively. The quality of the studies was assessed, and meta-analyses were performed with Cochrane Collaboration's RevMan 5.0 software.

RESULTS

A total of 11 studies, including 1,229 patients provided evidence for 6 possible risk factors for MDRO infection. Ischemic ulcer (OR, 0.50; 95% confidence interval [CI], 0.35 to 0.71), ulcer size (standard mean difference, -0.27; 95% CI, -0.46 to -0.08), ulcer grade (OR, 0.36; 95% CI, 0.15 to 0.83), osteomyelitis (OR, 0.33; 95% CI, 0.25 to 0.45), previous antibiotic therapy (OR, 0.08; 95% CI, 0.04 to 0.14) and previous hospitalization (OR, 0.15; 95% CI, 0.08 to 0.28) were identified as risk factors for MDRO infection in patients with diabetic foot ulcer.

CONCLUSIONS

Our meta-analysis indicated that ischemic ulcer, ulcer size, ulcer grade, osteomyelitis, previous antibiotic therapy and previous hospitalization were associated with MDRO infection in patients with diabetic foot ulcer.

Evidence mapping of recommendations on diagnosis and therapeutic strategies for diabetes foot: an international review of 22 guidelines

To systematically review clinical practice guidelines (CPGs) on diabetes foot and assess the consistency of recommendations, quality of CPGs and to present an evidence-map for explicating research trends and gaps. We performed a literature search on PubMed, Embase, and Web of Science, guideline databases and websites of diabetes society to include the diabetic CPGs. The basic information, recommendations for the diabetic foot, methodological quality and reporting quality of diabetic CPGs were exacted by the Excel. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE II instrument and RIGHT checklist. R3.5.1 software was used to create all bubble plots. A total of 22 diabetic CPGs were included, eight CPGs were from different professional diabetes societies. Recommendations on diabetic foot complications involve Diabetic foot ulcer (DFU), Charcot neuropathy (CN) and Osteomyelitis (OM). Eight DFU diagnostic systems presented in 22 CPGs. According to the recommendations of diabetic CPGs, the treatment of DFU can be summarized in four major items; six recommendations on CN diagnosis and six recommendations on treatment of CN were consistent among studies. However, there were inconsistencies in three OM diagnosis recommendations and four OM treatment recommendations. Some recommendations in CPGs were not very specific and clear, and hence they were not reliable for OM diagnosis and treatment. Once these inconsistencies are resolved, validated, accurate and effective diagnosis and treatment of diabetes foot will lead to reduced costs and adverse complications. The results of this review add to our knowledge and promote the development of trustworthy CPGs on diabetes.

Correlation between Empirical Antibiotic Therapy and Bone Culture Results in Patients with Osteomyelitis

OBJECTIVE

To analyze the correlation between empirical antibiotic therapies prescribed in primary care centers by general practitioners and the microbiology results of bone culture in patients with diabetic foot-related osteomyelitis.

METHODS

This observational study involved 80 patients with diabetic foot ulcers and clinically suspected osteomyelitis. The patients were taking antibiotics prescribed by general practitioners to treat diabetic foot infections. Bone samples were taken from every patient for microbiology analysis in a specialized diabetic foot unit.

MAIN OUTCOME MEASURE

The sensitivity of the bone cultures to antibiotics was compared with the patient's previous antibiotic therapy, and antibiotic and bacterial resistance were analyzed.

MAIN RESULTS

The bone cultures from only 16 patients (22.3%) showed sensitivity to the antibiotics that the patient had been prescribed. Fifty-six patients (77.8%) displayed bacterial resistance to the antibiotic that they were taking.

CONCLUSIONS

Awareness and implementation of international antibiotic stewardship guidelines are poor in primary care centers. It is important to establish strategies that foster a better understanding of treatment management standards and ensure the proper implementation of guidelines.

Adjuvant antibiotic loaded bio composite in the management of diabetic foot osteomyelitis - A multicentre study

BACKGROUND

Diabetic foot ulcers are associated with a high morbidity and are common cause of non-traumatic lower limb amputations. The effect of debridement and the use of an adjuvant local antibiotic carrier in the treatment of diabetic foot ulcers with osteomyelitis was evaluated.

METHODS

A retrospective review of patients with diabetic foot ulceration and osteomyelitis treated by debridement with adjuvant local antibiotic was performed. Seventy patients with Texas Grade 3B & 3D lesions were included, with a mean age of 68 years. Cerament G, an antibiotic-loaded absorbable calcium sulphate/hydroxyapatite bio-composite was used along with intraoperative multiple bone sampling and culture-specific systemic antibiotics.

RESULTS

Patients were followed up until infection eradication or ulcer healing. Mean follow up was 10 months (4-28months). Nine patients had Charcot foot deformity, 14 had peripheral vascular disease. 62% of patients had forefoot, 5% midfoot and 33% hind foot involvement. Fifty-three patients (87%) had polymicrobial infection. Staphylococcus aureus was the most common microorganism isolated. Infection was eradicated in 63 patients (90%) with mean time to ulcer healing of 12 weeks. Seven patients were not cured and required further treatment. Five patients had below knee amputation.

CONCLUSIONS

Adjuvant, local antibiotic therapy with an absorbable bio-composite can help achieve up to 90% cure rates in diabetic foot ulceration with osteomyelitis. Cerament G can act as effective void filler allowing dead space management after excision and preventing reinfection and the need for multiple surgical procedures.

LEVEL OF EVIDENCE

Level IV- case series.

Optimal management of diabetic foot osteomyelitis: challenges and solutions

Purpose: Diabetic foot osteomyelitis (DFO) is the most frequent infection associated with diabetic foot ulcers, occurs in >20% of moderate infections and 50%-60% of severe infections, and is associated with high rates of amputation. DFO represents a challenge in both diagnosis and therapy, and many consequences of its condition are related to late diagnosis, delayed referral, or ill-indicated treatment. This review aimed to analyze the current evidence on DFO management and to discuss advantages and disadvantages of different treatment options. Methods: A narrative review of the evidence was begun by searching Medline and PubMed databases for studies using the keywords "management", "diabetic foot", "osteomyelitis", and "diabetic foot osteomyelitis" from 2008 to 2018. Results: We found a great variety of studies focusing on both medical and surgical therapies showing a similar rate of effectiveness and outcomes; however, the main factors in choosing one over the other seem to be associated with the presence of soft-tissue infection or ischemia and the clinical presentation of DFO. Conclusion: Further randomized controlled trials with large samples and long-term follow-up are necessary to demonstrate secondary outcomes, such as recurrence, recurrent ulceration, and reinfection associated with both medical and surgical options.

Modern management of diabetic foot osteomyelitis. The when, how and why of conservative approaches

INTRODUCTION

Diabetic foot osteomyelitis (DFO) has long been considered a complex infection that is both difficult to diagnose and treat, and is associated with a high rate of relapse and limb loss. Areas covered: DFO can usually be diagnosed by a combination of clinical evaluation, serum inflammatory markers and plain X-ray. When the results of these procedures are negative or contradictory, advanced imaging tests or bone biopsy may be necessary. Staphylococcus aureus remains the most frequent microorganism isolated from bone specimens, but infection is often polymicrobial. Antibiotic therapy, preferably with oral agents guided by results of bone culture, for a duration of no more than six weeks, appears to be as safe and effective as surgery in cases of uncomplicated forefoot DFO. Surgery (which should be limb-sparing when possible) is always required for DFO accompanied by necrotizing fasciitis, deep abscess, gangrene or in cases not responding (either clinically or radiographically) to apparently appropriate antibiotic treatment. Expert commentary: Research in the past decade has improved diagnosis and treatment of DFO, and most cases can now be managed with a 'conservative' approach, defined as treatment either exclusively with antibiotics or with surgery removing as little bone and soft tissue as necessary.

The Relationship Between Osteomyelitis Complication and Drug-Resistant Infection Risk in Diabetic Foot Ulcer: A Meta-analysis

In this study, we aimed to investigate the relationship between osteomyelitis complications and drug-resistant infection risk in diabetic foot ulcer. Searches of MEDLINE and ISI databases were performed for the studies. Odds ratios (ORs) for drug-resistant infection incidence were calculated for diabetic foot ulcer patients with or without osteomyelitis complications. Eleven studies (12 cohorts) with 1526 patients were included in this study. Meta-analysis showed that the summary OR was 3.343 (95% CI = 2.355-4.745; Z = 6.75, P < .00001) when compared with osteomyelitis group and without osteomyelitis group. Significant publication bias was found. Sensitivity analysis by only pooled the adjusted ORs showed that the result was robust (the summary OR = 4.081, 95% CI = 2.471-6.739). Subgroup analysis by drug-resistant type showed that the summary OR was 4.391 (95% CI = 2.287-8.394) for methicillin-resistant infection subgroup, and 2.693 (95% CI = 1.882-3.851) for multidrug-resistant infection subgroup. The meta-regression showed that drug-resistant incidence ( t = -0.90, P = .389) and published year ( t = -0.11, P = .913) were not related with the OR changes. In conclusion, our meta-analysis indicates that osteomyelitis complications are related with drug-resistant infection risk in diabetic foot ulcer. We suggest bone culture-based narrow-spectrum antibiotic therapy for osteomyelitis for prevention drug-resistant infection in diabetic foot ulcer.

Treatment options for diabetic foot osteomyelitis

INTRODUCTION

Diabetic foot osteomyelitis therapeutical options are based on antibiotic therapy and surgical resection of the infected bone(s). Surgical and medical approaches of patients suffering from a diabetic foot osteomyelitis do not oppose but are complementary and need to be discussed as a tailored manner. Areas covered: The aim of the present article is to discuss data issued from the most recent guidelines of the Infectious Diseases Society of America and the International Working Group on the Diabetic Foot on the management of the diabetic foot infection and from a search in the current literature using the terms diabetic foot osteomyelitis and treatment/therapy/therapeutical in both PubMed and Medline, restricted to the last five years. Expert opinion: Surgical removal of the entire infected bone(s) has been considered in the past as the standard treatment but medical approach of these patients has now proven efficacy in selected situations. The current emergence of bacteria, especially among Gram negative rods, resistant to almost all the available antibiotics gradually augments the complexity of the management of these patients and is likely to decrease the place of the medical approach and to worsen the outcome of these infections in the next future.

Diagnostic and therapeutic update on diabetic foot osteomyelitis

Diabetic foot osteomyelitis (DFO) is the most common infection associated to diabetic foot ulcers (DFU). This review is designed to provide an update on the diagnosis and treatment of DFO based on an analysis of MEDLINE through PubMed using as search criterion "Diabetic Foot Osteomyelitis". Authors have included in this review the most relevant manuscripts regarding diagnosis and treatment of DFO. After review and critical analysis of publications, it may be concluded that diagnosis of DFO is not simple because of its heterogeneous presentation. Clinical inflammatory signs, probe-to-bone test, and plain X-rays are postulated as the basic tests for clinical diagnosis when DFO is suspected. Diagnosis should be supported by laboratory tests, of which ESR (>70mm/h) has been shown to be most precise. MRI is the most accurate imaging test, especially for differential diagnosis with Charcot foot. Pathogen isolation by bone culture is essential when the patient is treated with ATB only. Medical or surgical treatment should be based on the clinical characteristics of the patient and the lesion. Surgery should always be an option if medical treatment fails.

Efficacy of magnetic resonance imaging in diagnosing osteomyelitis in diabetic foot ulcers

BACKGROUND

The clinical diagnosis of osteomyelitis is difficult because of neuropathy, vascular disease, and immunodeficiency; also, with no established consensus on the diagnosis of foot osteomyelitis, the reported efficacy of magnetic resonance imaging (MRI) in detecting osteomyelitis and distinguishing it from reactive bone marrow edema is unclear. Herein, we describe a retrospective study on the efficacy of MRI for decision-making accuracy in diagnosing osteomyelitis in diabetic foot ulcers.

METHODS

Twelve diabetic patients with infected foot ulcers underwent preoperative MRI between January 1, 2008, and December 31, 2011. The findings were compared with the histopathologic features of 67 parts of 45 resected bones, the cut ends of which were also histopathologically evaluated.

RESULTS

Osteomyelitis was disclosed by MRI and histopathologically confirmed in 30 parts. In contrast, bone marrow edema diagnosed by MRI in 29 parts was confirmed in 23; the other six parts displayed osteomyelitis. Among 17 resected bones, 13 cut ends displayed bone marrow edema and four were normal. All of the wounds healed uneventfully.

CONCLUSIONS

In the diagnosis of diabetic foot ulcers, osteomyelitis is often reliably distinguished from reactive bone marrow edema, except in special cases.

Optimising the quality and outcomes of treatments for diabetic foot infections

INTRODUCTION

Infection is the commonest foot complication that arises in people with diabetes and may lead to amputation and even death. The emergence of multidrug resistant bacteria, especially in Gram negative rods, may have a negative impact on the chances of cure in these patients.

AREAS COVERED

We searched the Medline and Pubmed databases for studies using the keywords 'diabetic foot infection' and 'diabetic foot osteomyelits' from 1980 to 2016. Expert commentary: Much has been done in the field of diabetic foot infection regarding pathophysiology, diagnosis and treatment. The construction of multidisciplinary teams is probably the most efficient way to improve the patients' outcome. The rational use of antibiotics and surgical skills are essential in these potentially severe infections. Each case of diabetic infection deserves to be discussed in the light of the current guidelines and the local resources. Because of the overal poor outcome of these infections, prevention remains a priority.

Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot

Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.

Toe-Sparing Surgery for Neuropathic Toe Ulcers With Exposed Bone or Joint in an Outpatient Setting

The purpose of this study was to review the results of aggressive surgical debridement of neuropathic toe ulcers with exposed bone or joint. We identified patients with a single toe ulcer with exposed bone or joint that had been operated on in an outpatient setting. The surgery had included aggressive debridement and was performed using a small curette and rongeur, followed by oral antibiotic treatment at home. Success was defined as complete healing with no recurrence 6 months after full wound closure and epitheliazation was achieved. Twenty-five patients with neuropathic toe ulcers (72% male) had a total of 26 primary operations. Their mean age was 60 ± 12 years. In 22 patients, the neuropathy resulted from diabetes mellitus of 17 ± 9 years’ duration. The mean ulcer duration was 6 weeks (range 1-24). The mean number of visits per patient was 6.5 (range 3-20). The ulcers closed in a median of 5 weeks (8 ± 6 weeks, range 3-24 weeks, Q1-Q3 4-10 weeks). At 6 months, 3 (11.5%) patients had needed a toe amputation for infection or necrosis that could not be controlled. None needed a major amputation or hospitalization related to the ulcer. Toe-sparing surgery is feasible and in a select population can have a high success rate (88%), even though it does dictate more dedicated patient care.

Analysis of Ulcer Recurrences After Metatarsal Head Resection in Patients Who Underwent Surgery to Treat Diabetic Foot Osteomyelitis

Metatarsal head resection is a common and standardized treatment used as part of the surgical routine for metatarsal head osteomyelitis. The aim of this study was to define the influence of the amount of the metatarsal resection on the development of reulceration or ulcer recurrence in patients who suffered from plantar foot ulcer and underwent metatarsal surgery. We conducted a prospective study in 35 patients who underwent metatarsal head resection surgery to treat diabetic foot osteomyelitis with no prior history of foot surgeries, and these patients were included in a prospective follow-up over the course of at least 6 months in order to record reulceration or ulcer recurrences. Anteroposterior plain X-rays were taken before and after surgery. We also measured the portion of the metatarsal head that was removed and classified the patients according the resection rate of metatarsal (RRM) in first and second quartiles. We found statistical differences between the median RRM in patients who had an ulcer recurrence and patients without recurrences (21.48 ± 3.10% vs 28.12 ± 10.8%; P = .016). Seventeen (56.7%) patients were classified in the first quartile of RRM, which had an association with ulcer recurrence (P = .032; odds ratio = 1.41; 95% confidence interval = 1.04-1.92). RRM of less than 25% is associated with the development of a recurrence after surgery in the midterm follow-up, and therefore, planning before surgery is undertaken should be considered to avoid postsurgical complications.

Local antibiotic delivery systems in diabetic foot osteomyelitis: time for one step beyond?

In patients with diabetes mellitus, osteomyelitis is a severe, difficult-to-treat form of foot infection. In the management of diabetic foot osteomyelitis, carriers for local delivery of antimicrobial agents have begun to be tried, in an attempt to provide high local antibiotic concentrations. Randomized clinical trials are now expected to clarify when this new approach should be used and how it can be integrated into the overall therapeutic strategy for diabetic foot osteomyelitis.

Staphylococcus aureus–Related Diabetic Osteomyelitis

Staphylococcus aureus is the main cause of diabetic foot osteomyelitis (DFO) and can be treated medically or by surgery. We investigated the outcome of consecutive patients with a diagnosis of S aureus DFO retrospectively in 4 hospitals according to the type of management, medical (including debridement at bedside) or surgical. The outcome was classified as either favorable or failure (relapse, impaired wound healing, or amputation). Seventy-four patients with S aureus DFO, including 26 with methicillin-resistant S aureus, were included with a mean duration of follow-up of 21 ± 1 months. As part of the initial treatment, 47% underwent bone surgery followed with a short course of antibiotic. Others were treated with antibiotic therapy alone with bedside debridement. The outcome was favorable for 84% of these patients, with similar rates in the surgical and medical groups (80% vs 87%, P > .05). Patients in the medical group were less frequently hospitalized (49% vs 94%, P < .001) and had a shorter length of hospital stay (17 ± 3 vs 50 ± 12 days, P = .004). Patients in the surgery group received a shorter course of antibiotic therapy (10 ± 2 vs 11 ± 1 weeks, P = .001) with fewer side effects (9% vs 33%, P = .01). The type of management was not associated with subsequent new episode of noncontiguous DFO, which developed in 32% of cases. In conclusion, except significant differences in duration of hospitalization and antibiotic therapy, medical and surgical management of S aureus DFO had similar outcomes with a cure rate >80%.

Difficult Situations Managing Diabetic Foot. Evidences and Personal Views

Both medical and surgical approaches have been shown to be effective in the treatment of patients with diabetic foot osteomyelitis (DFO). In patients with risk factors of bad outcome such as major bone destruction, concomitant acute infections requiring drainage, problems in limb perfusion, highly resistant bacteria, and contraindication for or patient refusal of prolonged antibiotic therapy, the choice of surgery does not require further discussion. On the contrary, modest changes of bone on imaging assessment and no limiting factors as described above make medical treatment an attractive option for patients with DFO provided the rules of antibiotic treatment of chronic osteomyelitis are respected. The key question may not be to oppose surgery and medical treatment but to identify patients who need surgery and those who do not. There is currently no classification or score system that may allow physician to decide whether medical or surgical approach is best adapted to a given patient, and so both experience and skill of the multidisciplinary team appear paramount for guiding the choice of the best adapted (“tailored”) strategy in a given patient. In this regard, it would be interesting to compare surgical and medical approaches for DFO that apparently may benefit from one or another (ie, bone lesions seen on plain radiographs of the foot but without bone fragmentation or multiple sites of osteomyelitis, no contraindication to prolonged antibiotic therapy, and location of bone involvement that may allow conservative surgery). Given the current available data on the therapeutic options of DFO, it appears that surgery for those patients is obviously not an old-fashioned option.

Conservative Surgery of Diabetic Forefoot Osteomyelitis: How Can I Operate on This Patient Without Amputation?

Surgery is necessary in many cases of diabetic foot osteomyelitis. The decision to undertake surgery should be based on the clinical presentation of diabetic foot osteomyelitis. Surgery is required when the bone is protruding through the ulcer, there is extensive bone destruction seen on x-ray or progressive bone damage on sequential x-ray while undergoing antibiotic treatment, the soft tissue envelope is destroyed, and there is gangrene or spreading soft tissue infection. Several issues should be taken into account when considering surgery for treating diabetic foot osteomyelitis. It is necessary to have a surgeon available with diabetic foot expertise. Regarding location of diabetic foot osteomyelitis, it is important to consider whether isolated bone or a joint is involved. In cases in which osteomyelitis is associated with a bone deformity, surgery should be able to correct this. The surgeon should always reflect about whether extensive/radical surgery could destabilize the foot. The forefoot is the most frequent location of diabetic foot osteomyelitis and is associated with better prognosis than midfoot and hindfoot osteomyelitis. Many surgical procedures can be performed in patients with diabetes and forefoot ulcers complicated by osteomyelitis while avoiding amputations. Performing conservative surgeries without amputations of any part of the foot is not always feasible in cases in which the infection has destroyed the soft tissue envelope. Attempting conservative surgery in such cases risks infected tissues remaining in the wound bed leading to failure. The election of different surgical options depends on the expertise of the surgeons selected for the multidisciplinary teams. It is the aim of this article to provide a sample of surgical techniques in order to remove the bone infection from the forefoot while avoiding amputations.