Controversies in Diagnosing and Managing Osteomyelitis of the Foot in Diabetes

Abstract

The optimal approach to diagnosing and managing osteomyelitis of the foot in diabetes is unclear. Diagnosis is based on clinical signs, supplemented by a variety of imaging tests. Bone biopsy is the accepted criterion standard for diagnosis but is not used by many. Management traditionally involves surgical removal of infected bone, combined with antibiotic therapy. However, recent studies have shown that antibiotics alone may apparently eliminate bone infection in many cases. There is also evidence that early amputation of infected digits is frequently noncurative. Agreement on criteria for diagnosing osteomyelitis is required, and randomized trials are urgently needed, to determine the relative benefits of various surgical interventions and the optimal deployment of antibiotics. We review the microbiology of osteomyelitis of the foot in diabetes, the benefits and limitations of various diagnostic procedures, and the evidence for the effectiveness of both surgical and nonsurgical approaches to management.

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement

“…The studies which support a surgical approach likewise did not report histopathological confirmation [15] and the results of the different surgical working groups are not well evidenced [2]. Like other authors, our group believes that osteomyelitis of the diabetic foot is, once diagnosed, predominantly a surgical disease [15,16].…”

“…In this study, osteomyelitis was present in 72.2% of the patients with foot infection, which is by far the most frequent type of infection treated in our unit. There is currently a tendency to consider that, with the new medication options, treatment by antibiotics is more feasible [2], but a review of the literature seems to indicate that antibiotics alone may not be enough. The series in which osteomyelitis was not confirmed by histopathology [7][8][9][10][11][12] show healing rates of 53-88% with antibiotic treatment, although in some cases 'limited' debridement was also performed.…”

Application of white blood cell SPECT/CT to predict remission after a 6 or 12 week course of antibiotic treatment for diabetic foot osteomyelitis

“…Despite controversies in the management of DFO, the purely medical approach based on antibiotic therapy alone is efficient [2,3]. Indeed, the remission rate of DFO in those treated medically is reported to range from 53% to 82% [4][5][6][7][8][9][10][11][12][13][14].…”

Primarily non-surgical management of osteomyelitis of the foot in diabetes

“…In support of a more conservative approach is the evidence from over 500 reported cases in whom the initial management was primarily non-surgical and in whom there was a mean rate of eradication of infection of over 60% [6]. A recent series reported from a single centre [7] reported apparent cure or remission in 80% of cases managed in this way.…”