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Osteomyelitis in the diabetic foot

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  #1  
Old 9th June 2006, 01:23 PM
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Default Osteomyelitis in the diabetic foot

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The diagnosis of osteomyelitis of the foot in diabetes: microbiological examination vs. magnetic resonance imaging and labelled leucocyte scanning.
Diabet Med. 2006 Jun;23(6):649-53
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Aims Foot infections and their sequelae are among the most common and severe complications of diabetes mellitus. As diabetic patients with foot infections develop osteomyelitis and may progress to amputation, early diagnosis of osteomyelitis is critical.

Methods We compared the diagnostic values of labelled leucocyte scanning with Tc(99)m, magnetic resonance imaging (MRI) and microbiological examination of bone tissue specimens with histopathology, the definitive diagnostic procedure. Thirty-one diabetic patients with foot lesions were enrolled in the study and histopathological examination was performed in all. Patients had clinically suspected foot lesions of >/= grade 3 according to the classification of Wagner.

Results Bone specimens were obtained for histopathological examination. Microbiology had a sensitivity of 92% and specificity of 60%. Labelled leucocyte scanning had a sensitivity of 91%, specificity of 67%, and MRI a sensitivity of 78%, specificity of 60%.

Conclusions Microbiological examination may be as useful as and less costly than other diagnostic procedures and is the only method which can guide the choice of antibiotic therapy.
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  #2  
Old 23rd August 2008, 08:45 AM
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Default Re: Osteomyelitis in the diabetic foot

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement.
Aragón-Sánchez FJ, Cabrera-Galván JJ, Quintana-Marrero Y, Hernández-Herrero MJ, Lázaro-Martínez JL, García-Morales E, Beneit-Montesinos JV, Armstrong DG.
Diabetologia. 2008 Aug 22. [Epub ahead of print]
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AIMS/HYPOTHESIS: We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation.

METHODS: A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death.

RESULTS: Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection.

CONCLUSIONS/INTERPRETATION: Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.
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Old 23rd August 2008, 08:47 AM
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Default Re: Osteomyelitis in the diabetic foot

Related threads:
Threads tagged with osteomyelitis
Threads tagged with diabetic foot infections
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  #4  
Old 27th December 2008, 04:04 PM
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Default Re: Osteomyelitis in the diabetic foot

Combined Clinical and Laboratory Testing Improves Diagnostic Accuracy for Osteomyelitis in the Diabetic Foot.
Fleischer AE, Didyk AA, Woods JB, Burns SE, Wrobel JS, Armstrong DG.
J Foot Ankle Surg. 2009 January - February;48(1):39-46
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The purpose of this investigation was to examine the value of using routinely available clinical and laboratory tests in combination to distinguish osteomyelitis from cellulitis in a diabetic population with mild to moderately infected forefoot ulcers. We conducted a case-control study of 54 diabetic patients with 54 locally infected ulcers admitted to a university-affiliated tertiary-care hospital over a 4.5-year period. A total of 30 clinical and laboratory characteristics obtained at admission were tested for their association with pathology-proven osteomyelitis using logistic regression techniques. Ulcer depth greater than 3 mm (univariate odds ratio 10.4, P = .001) and C-reactive protein greater than 3.2 mg/dL (univariate odds ratio 10.8, P < .001) were the most informative individual clinical and laboratory tests for differentiating osteomyelitis from cellulitis. Adding C-reactive protein also significantly improved upon the accuracy of the study's best clinical testing strategy (area under the curve improved from 0.80 to 0.88, P = .040). Strategies that combined ulcer depth with serum inflammatory markers proved most useful in detecting ulcerated patients with concomitant bone infections (sensitivity 100% [95% CI 89.7%-100%] for both ulcer depth greater than 3 mm or C-reactive protein greater than 3.2 mg/dL, and ulcer depth greater than 3 mm or erythrocyte sedimentation rate greater than 60 mm/h). We conclude that considering clinical and laboratory findings together can significantly improve our diagnostic accuracy for osteomyelitis in the diabetic foot. The specific combination of ulcer depth with serum inflammatory markers appears to be a particularly sensitive strategy that may allow for greater detection of early diabetic osteomyelitis. Level of Clinical Evidence: 3.
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  #5  
Old 2nd January 2009, 04:12 PM
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Default Re: Osteomyelitis in the diabetic foot

Risk factors for developing osteomyelitis in patients with diabetic foot wounds.
Lavery LA, Peters EJ, Armstrong DG, Wendel CS, Murdoch DP, Lipsky BA.
Diabetes Res Clin Pract. 2008 Dec 29.
Quote:
AIMS: Osteomyelitis worsens the prognosis in the diabetic foot, but predisposing factors remain largely undefined. In a prospectively followed cohort we assessed risk factors for developing osteomyelitis.

METHODS: We enrolled consecutive persons with diabetes who presented to a managed-care diabetes disease management program. The patients underwent standardized assessments. We monitored for all foot complications, defined infections by criteria consistent with International Working Group guidelines, and defined osteomyelitis as a positive culture from a bone specimen.

RESULTS: 1666 persons were enrolled, 50% male, mean age 69 years. Over a mean of 27.2 months of follow-up, 151 patients developed foot infections, 30 (19.9%) of which involved bone. Independent risk factors for osteomyelitis were: wounds that extended to bone or joint (relative risk [RR]=23.1), previous history of a wound prior to enrollment (RR=2.2), and recurrent or multiple wounds during the study period (RR=1.9).

CONCLUSIONS: In this study population, managed in a specialized diabetic foot care center, the results suggest that independent risk factors for developing osteomyelitis are deep, recurrent and multiple wounds. These results may help clinicians target their efforts at diagnosing foot osteomyelitis to the highest risk patients.
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Old 10th September 2010, 01:23 PM
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Default Re: Osteomyelitis in the diabetic foot

Treatment of osteomyelitis in the feet of diabetic patients by photodynamic antimicrobial chemotherapy.
Tardivo JP, Baptista MS.
Photomed Laser Surg. 2009 Feb;27(1):145-50.
Quote:
OBJECTIVE: This article describes two inexpensive photodynamic antimicrobial chemotherapy (PACT) protocols to provide intensive local care on ulcerated feet of diabetic patients with osteomyelitis.

BACKGROUND DATA: Patients with this condition generally have poor quality of life. The usual treatment consists of the administration of a cocktail of drugs including anti-inflammatories, promoters of blood circulation, and systemic antibiotics. However, depending on the conditions of the tissues, amputation may be required. Consequently, it is important to develop PACT protocols that can help avoid amputation.

MATERIALS AND METHODS: Two PACT protocols were applied to two diabetic patients with osteomyelitis. These protocols were based on several PACT sessions that consisted of: (1) local injection of mixtures of phenothiazines (2% in water) and Hypericum perforatum extract (10% in propylene glycol), and (2) illumination, lasting 10 min, applied to the lesion's interior and exterior using, respectively, an optical fiber and a non-coherent light source. The frequency of PACT was daily or every other day in the beginning, and weekly after tissue recovery begun. The patients were followed clinically and by radiographic testing.

RESULTS: Both PACT protocols helped cure these patients who were about to have amputation of their feet. Radiograms showed that bone had healed and that the bone's texture had improved.

CONCLUSION: Here we have described efficient and affordable PACT protocols to treat osteomyelitis in the feet of diabetic patients. This treatment modality should be considered by vascular surgeons and by orthopedists to treat osteomyelitis that is resistant to conventional treatments.
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  #7  
Old 16th August 2011, 05:35 AM
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Default Re: Osteomyelitis in the diabetic foot

Outcome of patients with diabetes with negative percutaneous bone biopsy performed for suspicion of osteomyelitis of the foot.
Senneville E, Gaworowska D, Topolinski H, Devemy F, Nguyen S, Singer B, Beltrand E, Legout L, Caillaux M, Descamps D, Canonne JP, Yazdanpanah Y.
Diabet Med. 2011 Aug 12.

Quote:
Aims:  To assess the outcome of patients with diabetes with suspicion of osteomyelitis of the foot who had undergone a percutaneous bone biopsy that yielded negative microbiological results, with focus on the occurrence of osteomyelitis at the biopsied site.

Methods  Medical charts of adult patients with diabetes with a negative percutaneous bone biopsy were reviewed. Patients' outcome was evaluated at least 2 years after the initial bone biopsy according to wound healing, the results of a new bone biopsy and bone imaging evaluation when applicable.

Results:  From January 2001 to January 2008, 41 patients with diabetes (30 men/11 women; mean age 58.1 ± 9.6 years; mean diabetes duration 15.8 ± 6.7 years) met study criteria. Osteomyelitis was suspected based on combined clinical and imaging diagnostic criteria. On follow-up at a mean duration of 41.2 ± 22.5 months post-bone biopsy, 16 patients had complete wound healing (39.0%). Of the 25 other patients, 15 had a new bone biopsy performed, six of which yielded positive microbiological results, and among the 10 patients who neither healed nor underwent bone biopsy, comparative radiography of the foot showed a stable aspect of the biopsied site in six of them, for whom the data were available. Finally, osteomyelitis of the foot at the site where the initial bone biopsy had been performed was confirmed during follow-up in six patients (14.6%) and was suspected in four additional patients (9.7%).

Conclusions:  The results of the present study suggest that, of patients with diabetes with the suspicion of osteomylelitis and a negative percutaneous bone biopsy, only one out of four will develop osteomylelitis within 2 years of the biopsy.
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  #8  
Old 13th December 2011, 01:08 PM
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Default Re: Osteomyelitis in the diabetic foot

Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series
J. Aragón-Sánchez et al
Diabetic Medicine (in press)
Quote:
Aims/hypothesis:  The aim of this study was to determine the rate of recurrence, reulceration and new episodes of osteomyelitis and the duration of postoperative antibiotic treatment in a prospective cohort of patients with diabetes who underwent conservative surgery for osteomyelitis.

Methods:  The prospective cohort included patients with diabetes and a definitive diagnosis of osteomyelitis who were admitted to the Diabetic Foot Unit (Surgery Department, La Paloma Hospital, Las Palmas de Gran Canaria, Spain) and underwent surgical treatment from 1 November 2007 to 30 May 2010.

Results:  Eighty-one patients were operated on for osteomyelitis during the study period. Seven patients were lost to follow-up at different stages of the study. The median duration of follow-up was 101.8 weeks (quartile 1 = 56.6, quartile 3 = 126.7). Forty-eight patients (59.3%) underwent conservative surgery, 32 (39.5%) had minor amputations and there was one (1.2%) major amputation. Twenty patients (24.7%) required reoperation because of persistent infection. Postoperative antibiotic treatment over a median period of 36 days was necessary to achieve wound healing by secondary intention for a median of 8 weeks. Sixty-five patients were available for follow-up after healing. The percentage of recurrence, reulceration, and new episodes of osteomyelitis was 4.6% (3/65), 43% (28/65) and 17% (11/65), respectively. Mortality during follow-up (excluding in-hospital deaths and patients lost to follow-up) was 13% (9/69).

Conclusion:  A low rate of recurrence of osteomyelitis after surgical treatment for osteomyelitis was achieved. Despite new episodes, our approach to managing this cohort of patients with diabetes and foot osteomyelitis achieved 98.6% limb salvage.
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Old 27th December 2011, 01:25 PM
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Default Re: Osteomyelitis in the diabetic foot

Prognostic difference between soft tissue abscess and osteomyelitis of the foot in patients with diabetes: data from a consecutive series of 452 hospitalized patients.
Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F.
J Foot Ankle Surg. 2012 Jan;51(1):34-8.
Quote:
From January 2008 to December 2010, 452 patients with diabetes were admitted to our diabetic foot unit because of deep soft tissue abscess (group A: n = 210) or chronic osteomyelitis (group B: n = 242). Patients from group A underwent emergency debridement in the operating room. Patients from group B underwent elective surgery. Twenty-six (5.8%) major amputations were performed: of these, 18 (8.57%) were performed in patients from group A and 8 (3.31%) were performed in patients from group B (p = .024). Multivariate analysis showed the independent role on amputation outcome of the abscess (odds ratio, 2.64; p = .029; confidence interval [CI] 1.11 to 6.28), dialysis treatment (odds ratio, 3.17; p = .039, CI 1.06-9.51), and C-reactive protein > 0.5 mg/dL (odds ratio, 3.75; p = .022, CI 1.21-11.64). In group A, 43 (22.6%) patients healed only with drainage, and 147 (70.0%) minor amputations were performed: 53 (36.1%) at the level of the forefoot and 94 (63.9%) at the level of the midfoot. In group B, 234 (96.7%) minor amputations were performed, 208 (88.9%) at the forefoot and 26 (11.1%) at the midfoot level (p < .001). Fourteen postoperative complications occurred in patients from group A and 2 in patients from group B (p < .001). In group A, 3 patients died during hospitalization, 1 from septic shock and 2 from sudden death. None of the group B patients died. This study demonstrates that the severity of a foot soft tissue abscess is not comparable with that of a chronic osteomyelitis not only because of a higher rate of major amputation, but also because of a much more proximal level of minor amputation.
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Old 10th January 2012, 03:25 PM
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Default Re: Osteomyelitis in the diabetic foot

Limb salvage for spreading midfoot osteomyelitis following diabetic foot surgery.
Aragón-Sánchez J, Lázaro-Martínez JL, Cecilia-Matilla A, Quintana-Marrero Y, Hernández-Herrero MJ.
J Tissue Viability. 2012 Jan 6.
Quote:
Osteomyelitis is a challenging problem when it appears in the feet of patients with diabetes. Although the most frequent port of entry for bacteria is an ulcer, surgical wounds also permit entry of bacteria into the foot. This surgical complication may become limb-threatening, and treatment is a challenge. Here we present two cases of patients with neuropathic feet and palpable distal pulses, who were previously treated with surgery, and who presented with spreading bone infection in the midfoot. Pictures and radiological studies are shown. In both cases, bone infection caused severe destruction of the architecture of the midfoot, and the limbs of both patients were threatened. Midfoot osteomyelitis is associated with a higher rate of major amputations than osteomyelitis of the forefoot. Furthermore, meticillin-resistant Staphylococcus aureus was isolated in one of the cases. Our successful limb salvage approach was based on three steps: 1) removing the infected bone; 2) culture-guided antibiotic treatment; and 3) stabilizing the infected foot by means of total contact casting with openings resulting in a stable foot. To the best of our knowledge, there are no reports of the use of a total contact cast to stabilize an unstable and infected foot. Eight years (Case 1) and four years (Case 2) after complete healing, there were no recurrences of infection.
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Old 27th April 2012, 12:13 AM
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Default Re: Osteomyelitis in the diabetic foot

Evidences and Controversies About Recurrence of Diabetic Foot Osteomyelitis: A Personal View and an Illustrated Guide for Understanding
Javier Aragón-Sánchez,
International Journal of Lower Extremity Wounds April 26, 2012 1534734612445204
Quote:
Recurrence is one of the most worrying issues when dealing with diabetic foot osteomyelitis (DFO). In accordance with expert opinion in other areas of bone infection, it is accepted that very late relapse of apparently successfully treated osteomyelitis is not uncommon. However, the physiopathology of infections in large bones secondary to hematogenous osteomyelitis, infected prostheses, and open fractures is quite different from what is seen in the feet of patients with diabetes. The anatomy of the bones, the mechanism of infection and alterations in host defenses that are frequently seen in patients with diabetes may condition the onset, clinical course, and outcomes. Apparent eradication, disappearance of inflammatory signs, wound healing, bone healing based on image studies, and no recurrences during follow-up are common terms used for defining the success of therapy for DFO. Failure of initial surgical treatment, readmission to hospital, and new episodes of infection at the same or a contiguous site are considered as recurrence of osteomyelitis. Theoretically, bacteria living in the bone could be the source of clinical recurrence, but is it possible to obtain complete healing while bacteria remain alive in the bone in the feet of patients with diabetes? Can these bacteria grow and spread from the bone to the skin after years of healing? In the author’s opinion, this type of long-term recurrence of DFO has not been well documented in the medical literature. It is the aim of this illustrated guide to review the evidence and controversies regarding the recurrence of DFO.
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Old 1st May 2012, 12:24 PM
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Default Re: Osteomyelitis in the diabetic foot

Diabetic foot osteomyelitis: Bone markers and treatment outcomes.
Nyazee HA, Finney KM, Sarikonda M, Towler DA, Johnson JE, Babcock HM.
Diabetes Res Clin Pract. 2012 Apr 27.
Quote:
AIMS:
Novel bone turnover markers could help with the diagnosis and monitoring of osteomyelitis patients. We compared levels of two bone turnover markers, serum amino-terminal telopeptides (NTx) and bone alkaline phosphatase (BAP), in diabetic patients with and without osteomyelitis.

METHODS:
Matched case-control study was conducted with diabetic patients with and without osteomyelitis. Cases not undergoing immediate amputation were followed with repeat measurements after osteomyelitis treatment and for outcome determination.

RESULTS:
Analysis included 54 subjects, 27 cases and 27 controls. Median BAP levels were similar between cases and controls at enrollment (p=.55) as were median NTx levels (p=.43). Cases with follow-up data (n=18) had similar bone marker levels at enrollment and 6 weeks. No significant differences in BAP or NTx levels at enrollment or follow-up were seen between cases with poor versus favorable outcomes.

CONCLUSIONS:
No differences in NTx or BAP levels were seen between cases and controls. Cases with follow-up data had similar levels at enrollment and 6 weeks. Lack of difference may be due to small sample size, small areas of bone involved in foot osteomyelitis, or limitations of these specific markers. More research is needed.
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Old 12th May 2012, 02:45 AM
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Default Re: Osteomyelitis in the diabetic foot

Clinical–Pathological Characterization of Diabetic Foot Infections: Grading the Severity of Osteomyelitis
Javier Aragón-Sánchez,
International Journal of Lower Extremity Wounds May 10, 2012
Quote:
The present study has 3 aims: (a) to characterize the clinical and pathological features of diabetic foot infections, (b) to show the range of clinical presentations of moderate infections, and (c) to analyze the different behavior of diabetic foot osteomyelitis regarding to its clinical presentation. A definitive diagnosis of the type of infection was made based on intraoperative findings and histopathology. Diabetic foot infections were classified into 2 types: soft tissue and bone infections. Mild infections were always superficial. Severe infections included 75% of necrotizing soft tissue infections. Moderate infections showed ample range of clinical presentations. Eighty-one patients presented osteomyelitis. Osteomyelitis was further classified as follows: osteomyelitis without ischemia and without soft tissue involvement (class 1), osteomyelitis with ischemia without soft tissue involvement (class 2), osteomyelitis with soft tissue involvement (class 3), and osteomyelitis with ischemia and soft tissue involvement (class 4). Forty-eight patients (59.3%) with osteomyelitis underwent conservative surgery, 32 (39.5%) had minor amputations including 9 open transmetatarsal amputations, and there was 1 (1.2%) major amputation. The characterization of osteomyelitis into 4 classes showed a statistically significant trend toward increased severity and increased amputation rate and mortality. In conclusion, the clinical presentation of foot infections in diabetic patients is very heterogeneous and can be classified into soft tissue infections (cellulitis, superficial and deep abscesses, and necrotizing soft tissue infections) and osteomyelitis, which was the most frequent type of infection found in the author’s series. Their division into 4 classes showed a statistically significant trend toward increased severity, amputation rate, and mortality. The diagnosis of deep soft tissue infections associated with osteomyelitis may be difficult to achieve before surgery.
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Old 4th June 2012, 12:19 PM
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Default Re: Osteomyelitis in the diabetic foot

Evidences and Controversies About Recurrence of Diabetic Foot Osteomyelitis
A Personal View and an Illustrated Guide for Understanding

Javier Aragón-Sánchez
Extremity Wounds June 2012 vol. 11 no. 2 88-106
Quote:
Recurrence is one of the most worrying issues when dealing with diabetic foot osteomyelitis (DFO). In accordance with expert opinion in other areas of bone infection, it is accepted that very late relapse of apparently successfully treated osteomyelitis is not uncommon. However, the physiopathology of infections in large bones secondary to hematogenous osteomyelitis, infected prostheses, and open fractures is quite different from what is seen in the feet of patients with diabetes. The anatomy of the bones, the mechanism of infection and alterations in host defenses that are frequently seen in patients with diabetes may condition the onset, clinical course, and outcomes. Apparent eradication, disappearance of inflammatory signs, wound healing, bone healing based on image studies, and no recurrences during follow-up are common terms used for defining the success of therapy for DFO. Failure of initial surgical treatment, readmission to hospital, and new episodes of infection at the same or a contiguous site are considered as recurrence of osteomyelitis. Theoretically, bacteria living in the bone could be the source of clinical recurrence, but is it possible to obtain complete healing while bacteria remain alive in the bone in the feet of patients with diabetes? Can these bacteria grow and spread from the bone to the skin after years of healing? In the author’s opinion, this type of long-term recurrence of DFO has not been well documented in the medical literature. It is the aim of this illustrated guide to review the evidence and controversies regarding the recurrence of DFO.
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Old 4th June 2012, 12:20 PM
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Default Re: Osteomyelitis in the diabetic foot

Clinical–Pathological Characterization of Diabetic Foot Infections
Grading the Severity of Osteomyelitis

Javier Aragón-Sánchez
International Journal of Lower Extremity Wounds June 2012 vol. 11 no. 2 107-112
Quote:
The present study has 3 aims: (a) to characterize the clinical and pathological features of diabetic foot infections, (b) to show the range of clinical presentations of moderate infections, and (c) to analyze the different behavior of diabetic foot osteomyelitis regarding to its clinical presentation. A definitive diagnosis of the type of infection was made based on intraoperative findings and histopathology. Diabetic foot infections were classified into 2 types: soft tissue and bone infections. Mild infections were always superficial. Severe infections included 75% of necrotizing soft tissue infections. Moderate infections showed ample range of clinical presentations. Eighty-one patients presented osteomyelitis. Osteomyelitis was further classified as follows: osteomyelitis without ischemia and without soft tissue involvement (class 1), osteomyelitis with ischemia without soft tissue involvement (class 2), osteomyelitis with soft tissue involvement (class 3), and osteomyelitis with ischemia and soft tissue involvement (class 4). Forty-eight patients (59.3%) with osteomyelitis underwent conservative surgery, 32 (39.5%) had minor amputations including 9 open transmetatarsal amputations, and there was 1 (1.2%) major amputation. The characterization of osteomyelitis into 4 classes showed a statistically significant trend toward increased severity and increased amputation rate and mortality. In conclusion, the clinical presentation of foot infections in diabetic patients is very heterogeneous and can be classified into soft tissue infections (cellulitis, superficial and deep abscesses, and necrotizing soft tissue infections) and osteomyelitis, which was the most frequent type of infection found in the author’s series. Their division into 4 classes showed a statistically significant trend toward increased severity, amputation rate, and mortality. The diagnosis of deep soft tissue infections associated with osteomyelitis may be difficult to achieve before surgery.
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Old 14th July 2012, 12:34 PM
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Default Re: Osteomyelitis in the diabetic foot

Feasibility and Effectiveness of Internal Pedal Amputation of Phalanx or Metatarsal Head in Diabetic Patients with Forefoot Osteomyelitis.
Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F.
J Foot Ankle Surg. 2012 Jul 11
Quote:
From January 2007 to December 2009, 207 diabetic patients were consecutively admitted to our foot center because of osteomyelitis of a phalanx or metatarsal head. The removal of infected bone was performed by internal bone resection in 110 patients (group A) and amputation in 97 patients (46.9%; group B). Dehiscence occurred in 15 patients (13.6%) patients in group A and 10 patients (10.3%) in group B (p = 0.464). A total of 206 patients (99.5%) were followed up from January 1, 2007 to December 31, 2011. Ulcer relapse occurred in 12 patients (12.4%) in group A and 18 patients (16.4%) in group B (p = .437). A contralateral ulcer occurred in 10 group A patients (10.3%) and 14 group B patients (12.7%; p = .667). The results of the present study have demonstrated that bone resection with preservation of the soft tissue envelope is feasible in approximately one half of diabetic patients with forefoot osteomyelitis and does not result in any risk of major dehiscence or ulcer recurrence compared with ray or toe amputation.
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Old 23rd July 2012, 02:38 PM
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Default Re: Osteomyelitis in the diabetic foot

Successful Limb-sparing Treatment Strategy for Diabetic Foot Osteomyelitis
Alison M. Beieler et al
JAPMA July/August 2012 vol. 102 no. 4 273-277
Quote:
Background: Diabetic foot osteomyelitis is common and causes substantial morbidity, including major amputations, yet the optimal treatment approach is unclear. We evaluated an approach to limb salvage that combines early surgical debridement or limited amputation with antimicrobial therapy.

Methods: We conducted a retrospective cohort study of patients treated between May 1, 2005, and May 31, 2007. The primary end point was cure, defined as not requiring further treatment for osteomyelitis of the affected limb. The secondary end point was limb salvage, defined as not requiring a below-the-knee amputation or a more proximal amputation.

Results: Fifty patients with diabetic foot osteomyelitis met the study criteria. Initial surgical management included local amputation in 43 patients (86%) and debridement without amputation in seven (14%). Most infections (n = 30; 60%) were polymicrobial, and Staphylococcus aureus was the most common pathogen (n = 23; 46%). Parenteral antibiotics were used in 45 patients (90%). Patients who had pathologic evidence of osteomyelitis at the surgical margin received therapy for a median of 43 days (interquartile range [IQR], 36–56 days), whereas those without evidence of residual osteomyelitis received therapy for a median of 19 days (IQR, 13–40 days). Overall, 32 patients (64%) were considered cured after a median follow-up of 26 months (IQR, 12–38 months). Fifteen of 18 patients (83%) who failed initial therapy were treated again with limb-sparing surgery. Limb salvage was achieved in 47 patients (94%), with only three patients (6%) requiring below-the-knee amputation.

Conclusions: In patients with diabetic foot osteomyelitis, surgical debridement or limited amputation plus antimicrobial therapy is effective at achieving clinical cure and limb salvage.
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Old 15th August 2012, 04:59 AM
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Default Re: Osteomyelitis in the diabetic foot

Antibiotic impregnated cement spacer for salvage of diabetic osteomyelitis.
Melamed EA, Peled E.
Foot Ankle Int. 2012 Mar;33(3):213-9.
Quote:
BACKGROUND:
Florid infection and osteomyelitis of the forefoot in patients with diabetic neuropathy often requires minor amputation, with risk of subsequent reulceration, reamputation, and patient dissatisfaction. We investigated use of an antibiotic-impregnated cement spacer (ACS) to release antibiotic locally to resolve residual infection and to fill the cavity created by debridement.

METHODS:
We report 23 cases of osteomyelitis and associated severe infection of forefoot joints in 20 consecutive patients, age 60.3 +/- 13.4 years. Antibiotic-impregnated cement, extensive meticulous debridement, and ACS placement to fill the gap were employed in all cases. Deep cultures were taken routinely. Fixation with Kirschner wires was used as necessary. Mean followup was 21.2 +/- 10.2 months. A successful result was resolution of infection and wound healing to full skin closure without amputation.

RESULTS:
Of 23 cases, 21 (91.3%) healed and two required toe amputation. ACS was left permanently in 10 patients, removed with arthrodesis in six, and removed without arthrodesis in five. One patient recovered but subsequently underwent transtibial amputation due to infection of a different site.

CONCLUSION:
Severe infection associated with osteomyelitis of the foot in diabetic patients was successfully treated with extensive debridement and use of ACS, which filled the void created by debridement. Amputation was avoided in most patients. This procedure allowed extensive debridement through filling large voids with ACS, with prolonged antibiotic release.
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Old 11th October 2012, 12:17 PM
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Default Re: Osteomyelitis in the diabetic foot

Surgical complications associated with primary closure in patients with diabetic foot osteomyelitis.
García-Morales E, Lázaro-Martínez JL, Aragón-Sánchez J, Cecilia-Matilla A, García-Álvarez Y, Beneit-Montesinos JV.
Diabet Foot Ankle. 2012;3.
Quote:
BACKGROUND:
The aim of this study was to determine the incidence of complications associated with primary closure in surgical procedures performed for diabetic foot osteomyelitis compared to those healed by secondary intention. In addition, further evaluation of the surgical digital debridement for osteomyelitis with primary closure as an alternative to patients with digital amputation was also examined in our study.

METHODS:
Comparative study that included 46 patients with diabetic foot ulcerations. Surgical debridement of the infected bone was performed on all patients. Depending on the surgical technique used, primary surgical closure was performed on 34 patients (73.9%, Group 1) while the rest of the 12 patients were allowed to heal by secondary intention (26.1%, Group 2). During surgical intervention, bone samples were collected for both microbiological and histopathological analyses. Post-surgical complications were recorded in both groups during the recovery period.

RESULTS:
The average healing time was 9.9±SD 8.4 weeks in Group 1 and 19.1±SD 16.9 weeks in Group 2 (p=0.008). The percentage of complications was 61.8% in Group 1 and 58.3% in Group 2 (p=0.834). In all patients with digital ulcerations that were necessary for an amputation, a primary surgical closure was performed with successful outcomes.

DISCUSSION:
Primary surgical closure was not associated with a greater number of complications. Patients who received primary surgical closure had faster healing rates and experienced a lower percentage of exudation (p=0.05), edema (p<0.001) and reinfection, factors that determine the delay in wound healing and affect the prognosis of the surgical outcome. Further research with a greater number of patients is required to better define the cases for which primary surgical closure may be indicated at different levels of the diabetic foot.
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Old 25th October 2012, 09:53 PM
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Default Re: Osteomyelitis in the diabetic foot

Controversies regarding radiological changes and variables predicting amputation in a surgical series of diabetic foot osteomyelitis.
Aragón-Sánchez J, Lázaro-Martínez JL, Campillo-Vilorio N, Quintana-Marrero Y, Hernández-Herrero MJ.
Foot Ankle Surg. 2012 Dec;18(4):233-6.
Quote:
BACKGROUND:
To investigate if radiological changes have any influence on the outcomes of surgical treatment of diabetic foot osteomyelitis.

METHODS:
Data of patients included in a prospective cohort who underwent surgical treatment for definitive osteomyelitis were analyzed. Cases were classified according to radiological changes as "early osteomyelitis" when no radiological changes were found or in cases showing periosteal elevation and/or subcortical demineralization and/or cortical disruption. Cases showing sequestra and/or gross bone destruction were classified as "advanced osteomyelitis".

RESULTS:
Early osteomyelitis was defined according to radiological findings in 37 cases (45.7%) and advanced in 44 (54.3%). Advanced osteomyelitis was not associated with the risk of undergoing amputation.

CONCLUSIONS:
The bone changes seen in simple X-rays in cases of osteomyelitis do not have any prognostic value when surgical treatment is undertaken. The outcomes are more related to soft tissue involvement than bone destruction seen in simple X-rays.
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Old 17th January 2013, 04:22 PM
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Default Re: Osteomyelitis in the diabetic foot

Histopathologic Characteristics of Bone Infection Complicating Foot Ulcers in Diabetic Patients
Almudena Cecilia-Matilla, José Luis Lázaro-Martínez, Javier Aragón-Sánchez, Esther García-Morales, Yolanda García-Álvarez, Juan Vicente Beneit-Montesinos, MD, PhD*
JAPMA January/February 2013 vol. 103 no. 1 24-31
Quote:
Background: A universally accepted histopathologic classification of diabetic foot osteomyelitis does not currently exist. We sought to evaluate the histopathologic characteristics of bone infection found in the feet of diabetic patients and to analyze the clinical variables related to each type of bone infection.

Methods: We conducted an observational prospective study of 165 diabetic patients with foot ulcers who underwent surgery for bone infection. Samples for microbiological and histopathologic analyses were collected in the operating room under sterile conditions.

Results: We found four histopathologic types of osteomyelitis: acute osteomyelitis (n = 46; 27.9%), chronic osteomyelitis (n = 73; 44.2%), chronic acute osteomyelitis (n = 14; 8.5%), and fibrosis (n =32; 19.4%). The mean ± SD time between the initial detection of ulcer and surgery was 15.4 ± 23 weeks for acute osteomyelitis, 28.6 ± 22.4 weeks for chronic osteomyelitis, 35 ± 31.3 weeks for chronic acute osteomyelitis, and 27.5 ± 27.3 weeks for the fibrosis stage (analysis of variance: P = .03). Bacteria were isolated and identified in 40 of 46 patients (87.0%) with acute osteomyelitis, 61 of 73 (83.5%) with chronic osteomyelitis, 11 of 14 (78.6%) with chronic acute osteomyelitis, and 25 of 32 (78.1%) with fibrosis.

Conclusions: Histopathologic categorization of bone infections in the feet of diabetic patients should include four groups: acute, chronic, chronic acute, and fibrosis. We suggest that new studies should identify cases of fibrosis to allow comparison with the present results.
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Old 17th January 2013, 04:29 PM
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Default Re: Osteomyelitis in the diabetic foot

The role of cytokines in diabetic foot osteomyelitis.
Aragón-Sánchez J, Cabrera-Galván JJ.
Diabet Med. 2013 Jan 15.
Quote:
Some experimental data in well-established rat models suggest that elevated tumour necrosis factor (TNF)-α levels may be directly related to histopathological changes during osteomyelitis. Local release of interleukin-6 (IL-6) is also increased in bacterial osteomyelitis. However, no data about local release of IL-6 and TNF-α in cases of foot osteomyelitis in patients with diabetes have been reported.
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Old 7th February 2013, 04:51 PM
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Default Re: Osteomyelitis in the diabetic foot

The implications of the presence of osteomyelitis on outcomes of infected diabetic foot wounds.
Mutluoglu M, Sivrioglu AK, Eroglu M, Uzun G, Turhan V, Ay H, Lipsky BA.
Scand J Infect Dis. 2013 Feb 5
Quote:
Aim: To assess the effect of the presence of osteomyelitis in patients with a diabetic foot infection.

Methods: We reviewed the records of diabetic patients hospitalized at our medical center for a foot infection over a 2-y period. Using clinical, imaging, and microbiology results, we classified each patient as having diabetic foot osteomyelitis (DFO) or not. We then compared several outcome criteria of interest between the 2 groups.

Results: Among 73 eligible patients, 37 were in the DFO group (DFO group), while the other 36 were in the soft tissue infection group (STI group). In comparison to the STI group, the DFO group had a significantly longer length of stay (LOS) in the hospital (42 (28.5-51) days vs 19.5 (13.2-29.5) days, p < 0.001), longer duration of antibiotic therapy (46.6 ± 19.9 days vs 22.0 ± 14.6 days, p < 0.001), longer duration of intravenous antibiotic therapy (32.3 ± 16.3 days vs 13.6 ± 14.3 days, p < 0.001), longer duration of wound before admission (44 (31-64.5) days vs 33 (23-45.5) days, p = 0.034), and longer time to wound healing (239.8 ± 108.2 days vs 183.1 ± 73 days, p = 0.011). There were more surgical procedures in the DFO group than in the STI group (24/37 (64.8%) vs 11/36 (30.5%), p = 0.003), and during hospitalization, 22 patients in the DFO group and 5 patients in STI group underwent minor amputation (59.4% vs 13.8%, p < 0.001).

Conclusion: The presence of osteomyelitis negatively affects both the treatment and outcome of diabetic foot infections.
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Old 16th February 2013, 01:31 PM
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Default Re: Osteomyelitis in the diabetic foot

Influence of osteomyelitis location in the foot of diabetic patients with transtibial amputation.
Faglia E, Clerici G, Caminiti M, Curci V, Somalvico F.
Foot Ankle Int. 2013 Feb;34(2):222-7.
Quote:
Background: To evaluate the prevalence of osteomyelitis in different areas of the foot and the possible correlation between localization and outcome of major amputation.

Methods: From January 2008 to December 2010, a total of 350 diabetic patients were admitted to our diabetic foot unit for the surgical treatment of osteomyelitis. Osteomyelitis was diagnosed when both the probe-to-bone maneuver and plain radiography were positive. In all of these patients, osteomyelitis was confirmed by histological examination.

Results: Osteomyelitis was localized to the forefoot in 300 (85.7%) patients, to the midfoot in 27 (7.7%) patients, and to the hindfoot in the remaining 23 (6.75) patients. On average, foot lesions had developed 6.6 ± 5.6 months before admission to our unit. Transtibial amputation was performed in 1 (0.33%) patient with forefoot osteomyelitis, in 5 (18.5%) patients with midfoot osteomyelitis, and in 12 (52.2%) patients with osteomyelitis of the heel (χ(2) = 128.4, P < .001). Multivariate analysis showed the independent role that osteomyelitis in the heel region had in major amputation outcome (odds ratio 15.3; P < .001; confidence interval, 17.4-5336.0), dialysis treatment (odds ratio 6.3; P = .012; confidence interval, 2.5-1667.2), and leukocyte count greater than 10(3) mm(3) (odds ratio 2.25; P = .036; confidence interval, 1.1-76.6).

Conclusions: We found a higher rate of transtibial amputation when osteomyelitis involved the heel instead of the midfoot or forefoot in diabetic patients.
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Old 27th February 2013, 09:58 PM
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Default Re: Osteomyelitis in the diabetic foot

Gram-Negative Diabetic Foot Osteomyelitis: Risk Factors and Clinical Presentation
Javier Aragón-Sánchez, Benjamin A. Lipsky, Jose L. Lázaro-Martínez
International Journal of Lower Extremity Wounds February 26, 2013 1534734613477423
Quote:
Osteomyelitis frequently complicates infections in the feet of patients with diabetes. Gram-positive cocci, especially Staphylococcus aureus, are the most commonly isolated pathogens, but gram-negative bacteria also cause some cases of diabetic foot osteomyelitis (DFO). These gram-negatives require different antibiotic regimens than those commonly directed at gram-positives. There are, however, few data on factors related to their presence and how they influence the clinical picture. We conducted a retrospective study to determine the variables associated with the isolation of gram-negative bacteria from bone samples in cases of DFO and the clinical presentation of these infections. Among 341 cases of DFO, 150 had a gram-negative isolate (alone or combined with a gram-positive isolate) comprising 44.0% of all patients and 50.8% of those with a positive bone culture. Compared with gram-positive infections, wounds with gram-negative organisms more often had a fetid odor, necrotic tissue, signs of soft tissue infection accompanying osteomyelitis, and clinically severe infection. By multivariate analysis, the predictive variables related to an increased likelihood of isolating gram-negatives from bone samples were glycated hemoglobin <7% (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.1-3.5) and a wound caused by traumatic injury (OR = 2.0, 95% CI = 1.0-3.9). Overall, patients whose bone samples contained gram-negatives had a statistically significantly higher prevalence of leukocytosis and higher white blood cell counts than those without gram-negatives. In conclusion, gram-negative organisms were isolated in nearly half of our cases of DFO and were associated with more severe infections, higher white blood cell counts, lower glycated hemoglobin levels, and wounds of traumatic etiology.
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Old 18th March 2013, 12:11 PM
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Default Re: Osteomyelitis in the diabetic foot

Gram-Negative Diabetic Foot Osteomyelitis
Risk Factors and Clinical Presentation

Javier Aragón-Sánchez et al
International Journal of Lower Extremity Wounds March 2013 vol. 12 no. 1 22-29
Quote:
Osteomyelitis frequently complicates infections in the feet of patients with diabetes. Gram-positive cocci, especially Staphylococcus aureus, are the most commonly isolated pathogens, but gram-negative bacteria also cause some cases of diabetic foot osteomyelitis (DFO). These gram-negatives require different antibiotic regimens than those commonly directed at gram-positives. There are, however, few data on factors related to their presence and how they influence the clinical picture. We conducted a retrospective study to determine the variables associated with the isolation of gram-negative bacteria from bone samples in cases of DFO and the clinical presentation of these infections. Among 341 cases of DFO, 150 had a gram-negative isolate (alone or combined with a gram-positive isolate) comprising 44.0% of all patients and 50.8% of those with a positive bone culture. Compared with gram-positive infections, wounds with gram-negative organisms more often had a fetid odor, necrotic tissue, signs of soft tissue infection accompanying osteomyelitis, and clinically severe infection. By multivariate analysis, the predictive variables related to an increased likelihood of isolating gram-negatives from bone samples were glycated hemoglobin <7% (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.1-3.5) and a wound caused by traumatic injury (OR = 2.0, 95% CI = 1.0-3.9). Overall, patients whose bone samples contained gram-negatives had a statistically significantly higher prevalence of leukocytosis and higher white blood cell counts than those without gram-negatives. In conclusion, gram-negative organisms were isolated in nearly half of our cases of DFO and were associated with more severe infections, higher white blood cell counts, lower glycated hemoglobin levels, and wounds of traumatic etiology.
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Old 10th May 2013, 12:53 AM
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Default Re: Osteomyelitis in the diabetic foot

The Performance of Serum Inflammatory Markers for the Diagnosis and Follow-up of Patients With Osteomyelitis
Marios Michail, et al
International Journal of Lower Extremity Wounds May 9, 2013
Quote:
Serum inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), and procalcitonin (PCT), have been used for the diagnosis of foot infections in patients with diabetes. However, little is known about their changes during treatment of patients with foot infections. The aim of this prospective study was to examine the performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft-tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scintigraphy, magnetic resonance imaging). Determination of the inflammatory markers was performed at baseline, after 1 week, after 3 weeks, and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC, and PCT were significantly higher in patients with osteomyelitis than in those with soft-tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cutoff value >14 mg/L) were 0.85 and 0.83, of ESR (cutoff value >67 mm/h) 0.84 and 0.75, of WBC (cutoff value >14 × 109/L) 0.75 and 0.79, and of PCT (cutoff value >0.30 ng/mL) 0.81 and 0.71, respectively. All values declined after initiation of treatment with antibiotics; the WBC, CRP, and PCT values returned to near-normal levels at day 7, whereas the values of ESR remained high until month 3 only in patients with bone infection. From the inflammatory markers, ESR is recommended to be used for the follow-up of patients with osteomyelitis.
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Old 15th May 2013, 02:19 PM
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Default Re: Osteomyelitis in the diabetic foot

The Performance of Serum Inflammatory Markers for the Diagnosis and Follow-up of Patients With Osteomyelitis.
Michail M, Jude E, Liaskos C, Karamagiolis S, Makrilakis K, Dimitroulis D, Michail O, Tentolouris N.
Int J Low Extrem Wounds. 2013 May 9.
Quote:
Serum inflammatory markers, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), and procalcitonin (PCT), have been used for the diagnosis of foot infections in patients with diabetes. However, little is known about their changes during treatment of patients with foot infections. The aim of this prospective study was to examine the performance of serum inflammatory markers for the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft-tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scintigraphy, magnetic resonance imaging). Determination of the inflammatory markers was performed at baseline, after 1 week, after 3 weeks, and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC, and PCT were significantly higher in patients with osteomyelitis than in those with soft-tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cutoff value >14 mg/L) were 0.85 and 0.83, of ESR (cutoff value >67 mm/h) 0.84 and 0.75, of WBC (cutoff value >14 × 109/L) 0.75 and 0.79, and of PCT (cutoff value >0.30 ng/mL) 0.81 and 0.71, respectively. All values declined after initiation of treatment with antibiotics; the WBC, CRP, and PCT values returned to near-normal levels at day 7, whereas the values of ESR remained high until month 3 only in patients with bone infection. From the inflammatory markers, ESR is recommended to be used for the follow-up of patients with osteomyelitis.
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Old 6th July 2013, 04:50 PM
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Default Re: Osteomyelitis in the diabetic foot

The Performance of Serum Inflammatory Markers for the Diagnosis and Follow-Up of Patients with Osteomyelitis
NIKOLAOS TENTOLORUIS, EDWARD B. JUDE, CHRISTOS LIASKOS, MARIOS MICHAIL, SPYROS KARAMAGKIOLIS
American Diabetes Assoication; 73rd Scientific Sessions (2013); Chicago
Quote:
Serum inflammatory markers like C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell count (WBC), and procalcitonin (PCT) have been used for the diagnosis of patients with diabetic foot infections. In the present prospective study we examined the performance of these markers in the diagnosis and follow-up of patients with osteomyelitis. A total of 61 patients (age 63.1 ± 7.0 years, 45 men and 16 women, 7 with type 1 and 54 with type 2 diabetes) with untreated foot infection (34 with soft tissue infection and 27 with osteomyelitis) were recruited. Diagnosis of osteomyelitis was based on clinical examination and was confirmed by imaging studies (X-ray, scientigraphy, MRI). Determination of the inflammatory markers was performed at baseline, after 1 and 3 weeks and after 3 months of treatment. At baseline, the values of CRP, ESR, WBC and PCT were significantly higher in patients with osteomyelitis than in those with soft tissue infections. The sensitivity and specificity for the diagnosis of osteomyelitis of CRP (cut-off value >14 mg/l) were 0.85 and 0.83, of ESR (cut-off value>67 mm/h) 0.84 and 0.75, of WBC (cut-off value >14.000/ml) 0.74 and 0.82, and of PCT (cut-off value >0.30 ng/ml) 0.81 and 0.71. All values declined after initiation of treatment with antibiotics; the WBC, CRP and PCT values returned to near-normal levels by day 21 in both groups, while the values of ESR remained high until month 3 only in patients with bone infection. In conclusion, all inflammatory markers have adequate performance for the diagnosis of osteomyelitis; ESR is the best marker for the follow-up of patients with osteomyelitis
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Old 16th July 2013, 02:49 PM
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Default Re: Osteomyelitis in the diabetic foot

Conservative management of diabetic foot osteomyelitis.
Acharya S, Soliman M, Egun A, Rajbhandari SM.
Diabetes Res Clin Pract. 2013 Jul 11.
Quote:
In this retrospective study, 130 patients with diabetic foot osteomyelitis were analysed. 66.9% of these healed with antibiotic treatment alone and 13.9% needed amputation, of which 1.5% were major. Presence of MRSA was associated with adverse outcome (53.3% vs 21.1%, p=0.04) which was defined as death, amputation and failure to heal.
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