Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis

NG Yadlapalli, MD, Anand Vaishnav, MD, and Peter Sheehan, MD

Disclosures

Wounds. 2002;14(1) 

In This Article

Abstract and Introduction

Osteomyelitis of the diabetic foot remains a difficult clinical infection, often resulting in disability and amputation. Standard management consists of thorough removal of all infected bone in conjunction with antimicrobial therapy. This may have an untoward effect on foot mechanics and may increase risk of future ulcer events. In order to evaluate the efficacy of a more conservative approach, we retrospectively assessed the outcomes patients managed by an interdisciplinary team of comprehensive inpatient and outpatient care. Over a three-year period, 160 patients were identified by a discharge database with osteomyelitis; of these, 58 had outpatient follow-up records for at least 12 months. The treatment regimen consisted of conservative debridement or surgery, four to six weeks of empiric intravenous antibiotics, and biomechanical offloading of pressure impediments to wound healing. Initial procedures were debridement (34 patients), excision of bone (13 patients), toe or ray amputation (8 patients), and major amputation (3 patients). The mean duration of antibiotic therapy was 40.3 days. At twelve-months follow up, twelve patients (20.7%) failed treatment, with nine patients having persistent ulcers, and three patients requiring amputation. The remaining 46 patients healed (79.3%). Three patients had ulcer recurrence and 21 patients had new ulcer episodes in the follow-up observation period. In conclusion, an approach to osteomyelitis in the diabetic foot that is based on conservative surgical intervention, long-term empiric antibiotics, and interdisciplinary wound care and offloading may be a safe and effective alternative to amputation in selected patients.

Foot ulcers in patients with diabetes constitute a growing and costly public health concern. Diabetes is increasing in prevalence, especially in developed nations. In the United States, the prevalence is estimated to be 7.3 percent of adults.[1] Foot ulcers in these individuals arise at an incidence of 2.5 percent each year and, unfortunately, may initiate a pathway to amputation and limb loss.[2]

One adverse consequence of foot ulceration is infection, which becomes limb threatening when there is bone involvement. Repetitive pressures on an ulcer often are rapidly converted to tissue-disruptive inflammation close to an underlying bony prominence; the consequence is that approximately 15 percent of foot ulcers are complicated by osteomyelitis.[3] The customary management of osteomyelitis from contiguous foot ulceration is thorough surgical removal of all infected bone and often involves resection of relatively noninfected adjacent soft tissue and bone. Along with concurrent use of appropriate antimicrobials, this aggressive approach may lead to successful eradication of the infection; however, it may also result in the untoward outcome of altered biomechanics, foot instability, and increased residual plantar pressures -- placing the patient at greater risk of future ulcerations. Indeed, one of the risk factors for amputation is prior amputation.[4]

In the past decade, there has been a growing clinical interest in an approach to osteomyelitis in the diabetic foot that is more foot sparing with less aggressive surgical ablation, favoring instead more reliance on conservative surgery and long-term antimicrobials. Besides reducing the number of major amputations as first-line treatment, the advantage to such an approach would be in the maintenance of some biomechanical stability to allow easier accommodation of the foot and prevention of new ulcer events.

In order to evaluate the efficacy of a conservative approach, we retrospectively evaluated a series of patients with diabetes and foot ulcers complicated by osteomyelitis that were managed by an interdisciplinary team. Patients were evaluable only if they had at least 12-months follow up for the assessment of healing and recurrence.

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