Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis
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Historically, these infections are often polymicrobial with gram-positive (most commonly Staphylococcal), gram-negative, and anaerobic species represented.14 The treatment approach of empirically treating all three bacterial groups—unless the infection did not respond or the culture grew obvious pathogens that were resistant—was utilized in over 80 percent of the cases. This also avoids the pitfall of too narrow an antibiotic spectrum when antibiotics are targeted against a single isolate, rather than the polymicrobial flora that is historically known to be present in such complicated ulcers.15
The high rates of healing osteomyelitis could also reflect the impact of having a comprehensive center providing interdisciplinary care, which has been held up as a model for management of complex diabetic foot disorders.16 The high rate of new ulcerations, in face of a low rate of persistent or recurrent ulcers, probably reflects the morbidity of the patient population rather than the quality of care.
The interpretive difficulties of this series reside largely in the limitations of retrospective analysis. In addition, many eligible patients were not captured or were lost to follow up. We only assessed patients with whom we had continued contact, selecting out some treatment failures and noncompliant individuals. This may also explain why there may have been a higher success rate than prior published series.
In conclusion, our series supports an approach to diabetic foot ulcers complicated by osteomyelitis that is based on early conservative surgery and long-term empiric antibiotic therapy. When this is complimented by good foot ulcer care and suitable offloading, satisfactory healing rates may be achieved. Although early surgical intervention seems beneficial, the extent of the necessary debridement and/or bone excision is not yet clear. A conservative, foot-sparing approach, however, appears safe in selected patients and may be an alternative to early amputation, especially as an initial intervention. A well-defined prospective study with intent-to-treat analysis is needed to guide clinicians with more certainty.
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