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Management of osteomyelitis of the foot in diabetes mellitus

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

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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

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