Conservative Management of Diabetic Foot Ulcers Complicated by Osteomyelitis

Author(s): 
NG Yadlapalli, MD;1 Anand Vaishnav, MD;1 Peter Sheehan, MD2

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.

Conclusion

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.

References: 

References

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.



Post new comment

  • Lines and paragraphs break automatically.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.