Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis
- 0 Comments
- 6689 reads
With the advent of newer broad-spectrum antibiotics and the understanding of the basics of diabetic foot wound care, clinicians around the world have been attempting a treatment based on local care and potent antibiotic regimens to allow conservation of bony architecture and better long-term outcomes.
Bamberger, et al., in 1987 reported success in eradicating osteomyelitis in 27 out of 51 patients (53%), with failures being those with swelling, necrosis, or gangrene.6 The use of intravenous antibiotics against isolated pathogens for at least four weeks improved the likelihood of cure. Subsequently, Peterson, et al., showed that oral antibiotic therapy in chronic osteomyelitis may be useful, successfully treating 19 out of 29 patients (66%) with oral ciprofloxacin.7
Since then, other retrospective studies primarily from Europe have demonstrated reasonable efficacy to a conservative approach. Eneroth, et al., demonstrated healing deep foot infections, including osteomyelitis, without amputation in 39 percent of their large series of 223 patients. The authors emphasize aggressive initial soft tissue surgical debridement.8 Conservative therapy by another multidisciplinary diabetic foot clinic and long-term oral antibiotics resulted in resolution of bone infection in 17 out of 21 patients without bone resection.9 In another larger retrospective study, Pittet, et al., reported successful conservative treatment of diabetic osteomyelitis. In this series, 35 out of 50 (70%) patients were cured of osteomyelitis with long-term antibiotics without any significant surgical intervention.10 The analysis was made, however, after the exclusion of 14 patients who initially underwent amputation. The studies do suggest, however, that cure of osteomyelitis without significant bone resection is possible with long-term antibiotics.
A more defined analysis on the value of surgical intervention was a retrospective study by Ha Van, et al., which showed that patients who had a conservative surgical procedure faired better than those who were managed only medically with antibiotics.11 Similarly, Tan and colleagues showed the value of early surgical intervention in a retrospective post-hoc analysis of pooled data from several clinical trials for antibiotic therapy of osteomyelitis. It was found that those that had prompt surgical intervention had significantly less amputations than those treated by medical therapy alone.12 Thus, there is some validation to the clinical approach to osteomyelitis in the diabetic foot that advocates long-term systemic antibiotics in concert with early conservative surgical intervention.
Our findings support this conservative management, especially as an initial intervention. Only three of our series of fifty-eight patients required major amputation on their first admission. Patients collectively fared well with either debridement, excision of involved bone, or partial amputation. The outcomes were comparable in all subgroups, but the size of the subgroups was not large enough for analysis to detect significant differences. Furthermore, the choice of the initial procedure was by the treating practitioners’ clinical judgment, interjecting selection bias into the analysis. We can only conclude that achievement of nearly 80-percent cure overall makes several treatment options viable. This contrasts with a prevailing surgical view that osteomyelitis should be treated with surgical resection.13
Another striking observation of this series is the success of empiric antibiotic therapy for ulcers complicated by osteomyelitis.
1. Mokdad AH, Bowman BA, Ford ES, et al. The continuing epidemics of obesity and diabetes in the United States. J Am Med Assoc 2001;286(10):1195–200.
2. Reiber GE, Boyko E, Smith DG. Lower-extremity ulcers and amputations in individuals with diabetes. In: Harris MI, Cowie CC, Stern MP, et al. (eds). Diabetes in America, Second Edition. Washington, DC: US Govt. Printing Office, 1995;409–27 (NIH publ. No. 95-1468).
3. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999;22(3):382–7.
4. Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes: The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 1999;22(7):1029–35.
5. Grayson ML, Gibbons GW, Balogh K, et al. Probing to bone in infected pedal ulcers: A clinical sign of underlying osteomyelitis in diabetic patients. J Am Med Assoc 1995;273(9):721–3.
6. Bamberger DM, Daus GP, Gerding DN. Osteomyelitis in the feet of diabetic patients: Long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med 1987;83(4):653–60.
7. Peterson LR, Lissack LM, Canter K, et al. Therapy of lower-extremity infections with ciprofloxacin in patients with diabetes mellitus, peripheral vascular disease, or both. Am J Med 1989;86(6 Pt 2):801–8.
8. Eneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int 1997;18(11):716–22.
9. Venkatesan P, Lawn S, Macfarlane RM, et al. Conservative management of osteomyelitis in the feet of diabetic patients. Diabetic Med 1997;14(6):487–90.
10. Pittet D, Wyssa B, Herter-Clavel C, et al. Outcome of diabetic foot infections treated conservatively: A retrospective cohort study with long-term follow-up. Arch Intern Med 1999;159(8):851–6.
11. Ha Van G, Siney H, Danan JP, et al. Treatment of osteomyelitis in the diabetic foot: Contribution of conservative surgery. Diabetes Care 1996;19(11):1257–60.
12. Tan JS, Friedman NM, Hazelton-Miller C, et al. Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation? Clin Infect Dis 1996;23(2):286–91.
13. Kerstein MD, Welter V, Gahtan V, Roberts AB. Toe amputation in the diabetic patient. Surgery 1997;122(3):546–7.
14. Caputo GM, Cavanagh PR, Ulbrecht JS, et al. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;331(13):854–60.
15. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997;25(6):1318–26.
16. Edmonds ME, Blundell MP, Morris ME, et al. Improved survival of the diabetic foot: The role of a specialized foot clinic. Q J Med 1986;60(232):763–71.