Prevalence of osteomyelitis in non-healing diabetic foot ulcers: usefulness of radiologic and scintigraphic findings

Balsells, Montserrat; Viadé, Jordi; Millan, Montserrat; García, J.R. March; García-Pascual, Luis; Pozo, C. del; Anglada, J

doi:10.1016/s0168-8227(97)00100-9

Cited by 28 publications

(10 citation statements)

References 13 publications

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“…They diagnosed osteomyelitis in 19 (24%) of their patients, a prevalence similar to that in our study (20%). Balsells et al (55) performed a PTB test in a series of 33 episodes of foot ulceration (on 28 diabetic patients) that required the patient to be hospitalized. Among the 21 who had osteomyelitis (defined by either positive nuclear medicine scans or characteristic X-ray changes associated with a foot ulcer), only 7 (33%) had a positive PTB.…”

Section: Resultsmentioning

confidence: 99%

Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis

et al. 2007

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OBJECTIVE -We sought to assess the accuracy of the probe-to-bone (PTB) test in diagnosing foot osteomyelitis in a cohort of diabetic patients with bone culture proven disease.RESEARCH DESIGN AND METHODS -In this 2-year longitudinal cohort study, we enrolled 1,666 consecutive diabetic individuals who underwent an initial standardized detailed foot assessment, followed by examinations at regular intervals. Patients were instructed to immediately come to the foot clinic if they developed a lower-extremity complication. For all patients with a lower-extremity wound, we compared the results of the PTB test with those of a culture of the affected bone. We called PTB positive if the bone or joint was palpable and defined osteomyelitis as a positive bone culture.RESULTS -Over a mean of 27.2 months of follow-up, 247 patients developed a foot wound and 151 developed 199 foot infections. Osteomyelitis was found in 30 patients: 12% of those with a foot wound and 20% in those with a foot infection. When all wounds were considered, the PTB test was highly sensitive (0.87) and specific (0.91); the positive predictive value was only 0.57, but the negative predictive value was 0.98.CONCLUSIONS -The PTB test, when used in a population of diabetic patients with a foot wound among whom the prevalence of osteomyelitis was 12%, had a relatively low positive predictive value, but a negative test may exclude the diagnosis. Diabetes Care 30:270 -274, 2007I ndividuals with diabetes have an ϳ25% lifetime risk of developing a foot complication (1), the most common of which is skin ulceration. Over half of these foot wounds may eventually become infected, which greatly increases the risk of lower-extremity amputation (2-5). While most diabetic foot infections involve only the soft tissue, bone involvement occurs in 20 -66% of cases (6 -8). Furthermore, foot infections complicated by osteomyelitis generally have a worse outcome and often require surgical resection and prolonged antibiotic therapy (6,7).While diagnosing osteomyelitis is important, it is unfortunately also difficult. Clinical and laboratory signs and symptoms are generally unhelpful (6,7). Bone infection may not show up on plain radiographs in the first 2 weeks, and any X-ray abnormalities detected may be caused by the neuropathic bone disorders that frequently occur in diabetes. More accurate imaging studies, such as radionuclide scans or magnetic resonance imaging, are expensive and not universally available (9 -21). In 1995, Grayson et al. (22) described a clinical technique they used in diabetic patients with a foot infection consisting of exploring the wound for palpable bone with a sterile blunt metal probe. Their most important finding was that the probe-to-bone (PTB) test had a positive predictive value of 89%, leading them to conclude that a positive test usually made imaging studies for diagnosing osteomyelitis unnecessary (22). Since then, many have considered a positive PTB sufficient evidence for osteomyelitis. In the study by Grayson et al., however, the prevalen...

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Section: Resultsmentioning

confidence: 99%

Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis

et al. 2007

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“…In diabetic patients, the depressed immune system exposes wounds to resistant and recalcitrant infections, especially in bony structures. 5,6 Osteomyelitis in these patients requires more aggressive treatment than in nondiabetic patients. In addition, whatever the etiopathogenesis, adequate therapy requires complete resection of necrotic and infected tissues, decompression of all suspected compartments, and filling in of all potential dead spaces with appropriate tissues as well as the simultaneous administration of appropriate antibiotic therapy.…”

Section: Discussionmentioning

confidence: 99%

“…In diabetic patients, wounds are susceptible to serious and recalcitrant infections, and in many cases, this problem may become of major importance. 5,6 Local wound care, including serial and sometimes vigorous debridement of infected and nonviable tissues with an appropriate antibiotic regimen, may be needed. Under favorable circumstances, conservative treatment may overcome the wound problem.…”

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confidence: 99%

Reliability of free-flap coverage in diabetic foot ulcers

2005

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As microsurgery advances, microsurgical free-tissue transfers have become the reconstructive method of choice over staged or primary amputation, and enabling independent ambulation in difficult lower-extremity wounds. In this report, we present our experiences with free-tissue transfer for the reconstruction of soft-tissue defects in 13 diabetic foot ulcers. Following radical debridement, soft-tissue reconstruction was achieved in the following ways: anterolateral thigh fasciocutaneous flap in 5 patients, radial forearm fasciocutaneous flap in 3 patients, lateral arm fasciocutaneous flap in 1 patient, gracilis musculocutaneous flap in 1 patient, tensor fascia latae flap in 1 patient, deep inferior epigastric perforator flap in 1 patient, and a parascapular flap in the remaining patient. In 8 cases, diabetic wounds were in the foot, while wounds were at the level of the lower leg in the remaining patients. In all patients, vascular patency was confirmed by the Doppler technique. In suspicious cases, arteriography was then performed. While all flaps survived well in the postoperative period, one patient died from cardiopulmonary problems on postoperative day 16 in an intensive care unit. Amputation was necessary in the early postoperative period because of healing problems. In the remaining 10 cases, all flaps survived intact. In one case, arterial revision was performed successfully. The ultimate limb salvage rate was 83% for the 12 patients. Independent ambulation was achieved in these cases. During the follow-up period of 8 months to 2 years, no ulcer recurrence was noted, and no revascularization or vascular bypass surgery was needed before or after the free-tissue transfers. The authors conclude that free-tissue transfer for diabetic foot ulcers is a reliable procedure, despite pessimistic opinions regarding the flap survival and low limb salvage rates. It should be considered a useful reconstructive option for serious defects in well-selected cases.

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“…Osteomyelitis should be considered if bone is visible or palpable in the base of an ulcer [39], or when a nonischemic ulcer has not healed after six weeks of adequate offloading. A so-called 'sausage toe', a red swollen digit, frequently indicates osteomyelitis [40].…”

Section: Diagnostic Approaches Clinicalmentioning

confidence: 99%

Diagnosing and treating diabetic foot infections

Lipsky

Berendt

Embil

et al. 2004

Diabetes Metab. Res. Rev.

112

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Foot infections are a common, complex and costly complication of diabetes. We have made considerable progress in establishing consensus definitions for defining infection. Similarly, we have learned much about the appropriate ways to diagnose both soft tissue and bone infections. Accompanying these advances have been improvements in our knowledge of the proper approaches to antibiotic (and surgical) therapy for diabetic foot infections. Furthermore, investigators have explored the value of various adjunctive therapies, especially granulocyte colony stimulating factors and hyperbaric oxygen, for improving outcomes. This paper presents a summary of a minisymposium on infection of the diabetic foot that was held at the fourth International Symposium on the Diabetic Foot, in Noordwijkerhout, The Netherlands.

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Prevalence of osteomyelitis in non-healing diabetic foot ulcers: usefulness of radiologic and scintigraphic findings

Cited by 28 publications

References 13 publications

Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis

Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis

Reliability of free-flap coverage in diabetic foot ulcers

Diagnosing and treating diabetic foot infections

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