Abstract
Although osteomyelitis occurs in approximately 10−20% of patients with diabetes-related foot ulcers, no widely accepted guideline is available for its treatment. In particular, little consensus exists on the place of surgery. A number of experts claim that early surgical excision of all infected or necrotic bone is essential. Others suggest that surgery should not be performed routinely, but instead only in patients who do not respond to antibiotic treatment or in case of particular clinical indications. Unfortunately, no studies have directly compared the two approaches. Over 500 cases of conservative (that is, nonsurgical) management with resolution rates of 60−80% have been described previously. Most patients in these series, however, received prolonged courses of broad-spectrum antibiotics, which increase the risk of diarrhea caused by Clostridium difficile or the emergence of multidrug-resistant organisms. By contrast, relatively few series of primarily surgical management have been published, with widely differing outcomes, and some of them also reported high recurrence rates. Further research is required to establish the relative importance of each approach, but the available data clearly indicate that a combined assessment and treatment by surgeons and physicians together is essential for many patients.
Key Points
-
Currently, no consensus exists on the optimal management of osteomyelitis of the foot in diabetes mellitus
-
Observational data suggest that antibiotics use alone is associated with apparent eradication of infection in >60% of cases, although this predisposes patients to the adverse effects of prolonged antibiotic administration
-
One study of early removal of infected bone revealed a high incidence of apparent eradication when combined with antibiotic treatment, but other data suggest poor outcomes following surgery alone
-
Bone biopsy for both the diagnosis and the selection of antibiotic therapy may prove a key way forward, but its role has yet to be substantiated in prospective studies
-
Cases should be managed by a multidisciplinary team and the role of surgery decided on the basis of the nature of the infection, clinical circumstances and the patient's opinion
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$209.00 per year
only $17.42 per issue
Buy this article
- Purchase on Springer Link
- Instant access to full article PDF
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Shone, A., Burnside, J., Chipchase, S., Game, F. & Jeffcoate, W. Probing the validity of the probe-to-bone test in the diagnosis of osteomyelitis of the foot in diabetes. Diabetes Care 29, 945 (2006).
Lavery, L. A., Armstrong, D. G., Peters, E. J. & Lipsky, B. A. Probe-to-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic? Diabetes Care 30, 270–274 (2007).
Newman, L. G. et al. Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline. JAMA 266, 1246–1251 (1991).
Lipsky, B. A. Osteomyelitis of the foot in diabetic patients. Clin. Infect. Dis. 25, 1318–1326 (1997).
Lavery, L. A. et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care 29, 1288–1293 (2006).
Berendt, A. R. et al. Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment. Diabetes Metab. Res. Rev. 24 (Suppl. 1), S145–S161 (2008).
Gadepalli, R. et al. A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital. Diabetes Care 29, 1727–1732 (2006).
Lipsky, B. A. Osteomyelitis of the foot in diabetic patients. Clin. Infect. Dis. 25, 1318–1326 (1997).
Berendt, A. R. et al. Specific guidelines for treatment of diabetic foot osteomyelitis. Diabetes Metab. Res. Rev. 24 (Suppl. 1), S190–S191 (2008).
Lipsky, B. A. et al. Diagnosis and treatment of diabetic foot infections. Plast. Reconstr. Surg. 117 (7 Suppl.), S212–S238 (2006).
Lipsky, B. A. & Berendt, A. R. Principles and practice of antibiotic therapy of diabetic foot infections. Diabetes Metab. Res. Rev. 16 (Suppl. 1), S42–S46 (2000).
Henke, P. K. et al. Osteomyelitis of the foot and toe in adults is a surgical disease conservative management worsens lower extremity salvage. Ann. Surg. 241, 885–894 (2005).
Jeffcoate, W. J. & Lipsky, B. A. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin. Infect Dis. 39, S115–S122 (2004).
Embil, J. M. et al. Oral antimicrobial therapy for diabetic foot osteomyelitis. Foot Ankle Int. 27, 771–779 (2006).
Game, F. L. & Jeffcoate, W. J. Primarily non-surgical management of osteomyelitis of the foot in diabetes. Diabetologia 51, 962–967 (2008).
Valabhji, J. et al. Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging. Diabet. Med. doi:10.1111/j.1464–54912009.02828.x.
Couret, G. et al. Emergence of monomicrobial methicillin-resistant Staphylococcus aureus infections in diabetic foot osteomyelitis [French]. Presse Med. 36, 851–858 (2007).
Dang, C., Prasad, Y. D., Boulton, A. J. M. & Jude, E. Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem. Diabet. Med. 20, 159–161 (2003).
Johnstone, B. L. & Conly, J. M. Osteomyelitis management: More art than science? Can. J. Infect. Dis. Med. Microbiol. 18, 115–118 (2007).
Lipsky, B. A., Itani, K. & Norden, C. Treating foot infections in diabetic patients: a randomized, multicenter, open-label trial of linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate. Clin. Infect. Dis. 38, 17–24 (2004).
Lipsky, B. A. et al. Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, randomised, controlled, double-blinded, multicentre trial. Lancet 366, 1695–1703 (2005).
Tan, J. S., Friedman, N. M., Hazelton-Miller, C., Flanagan, J. P. & File T. M. Jr. Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation? Clin. Infect. Dis. 23, 286–291 (1996).
Ha Van, G., Siney, H., Danan, J. P., Sachon, C. & Grimaldi, A. Treatment of osteomyelitis in the diabetic foot. Contribution of conservative surgery. Diabetes Care 19, 1257–1260 (1996).
Aragón-Sánchez, F. J. et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia 51, 1962–1970 (2008).
Murdoch, D. P. et al. The natural history of great toe amputations. J. Foot Ankle Surg. 36, 204–208 (1997).
Nehler, M. R. et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J. Vasc. Surg. 30, 509–517 (1999).
Hachmöller, A. Outcome of minor amputations at the diabetic foot in relation to bone histopathology: a clinical audit [German]. Zentralbl Chir. 132, 491–496 (2007).
Eneroth, M., Larsson, J. & Apelqvist, J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. J. Diabetes Complications 13, 254–263 (1999).
Tomas, M. B., Patel, M., Marwin, S. E. & Palestro, C. J. The diabetic foot. Br. J. Radiol. 73, 443–450 (2000).
Becker, W. Imaging osteomyelitis and the diabetic foot. Q. J. Nucl. Med. 43, 9–20 (1999).
Croll, S. D., Nicholas, G. G., Osborne, M. A., Wasser, T. E. & Jones, S. Role of magnetic resonance imaging in the diagnosis of osteomyelitis in diabetic foot infections. J. Vasc. Surg. 24, 266–270 (1996).
Rajbhandari, S. M, Jenkins, R. C., Davies, C. & Tesfaye, S. Charcot neuroarthropathy in diabetes mellitus. Diabetologia 45, 1085–1096 (2002).
Enderle, M. D. et al. Correlation of imaging techniques to histopathology in patients with diabetic foot syndrome and clinical suspicion of chronic osteomyelitis. The role of high resolution ultrasound. Diabetes Care 22, 294–299 (1999).
Senneville, E. et al. Outcome of diabetic foot osteomyelitis treated nonsurgically: a retrospective cohort study. Diabetes Care 31, 637–642 (2008).
Senneville, E. et al. Needle puncture and transcutaneous bone biopsy cultures are inconsistent in patients with diabetes and suspected osteomyelitis of the foot. Clin. Infect. Dis. 48, 888–893 (2009).
Diabetes UK. Putting feet first: Commissioning specialist services for the management and prevention of diabetic foot disease in hospitals [online]. (2009).
Author information
Authors and Affiliations
Ethics declarations
Competing interests
The author declares no competing financial interests.
Rights and permissions
About this article
Cite this article
Game, F. Management of osteomyelitis of the foot in diabetes mellitus. Nat Rev Endocrinol 6, 43–47 (2010). https://doi.org/10.1038/nrendo.2009.243
Issue Date:
DOI: https://doi.org/10.1038/nrendo.2009.243
This article is cited by
-
Application of white blood cell SPECT/CT to predict remission after a 6 or 12 week course of antibiotic treatment for diabetic foot osteomyelitis
Diabetologia (2017)
-
The association between chronic osteomyelitis and increased risk of diabetes mellitus: a population-based cohort study
European Journal of Clinical Microbiology & Infectious Diseases (2014)