Efficacy and Safety of Bioactive Glass S53P4 as a Treatment for Diabetic Foot Osteomyelitis

Osteomyelitis represents a challenging condition in the diabetic foot with an associated high risk of major amputation. S53P4 Bioactive Glass (BG) has bacterial inhibiting properties on the market and indicated to be used in osteomyelitis. The objective of the study was to test the efficacy and safety of BG in treating diabetic foot osteomyelitis. This was an observational, retrospective, single-centre study involving subjects with diabetes affected by osteomyelitis of the foot who underwent surgical debridement from 01/2016 to 10/2018. Overall, 44 diabetic patients (14 [31.8%] female, aged 68.0 ± 10.2 years, diabetes duration 26.8 ± 11.9 years) were studied: 22 (50%) treated with surgical debridement and a local application of BG; 22 (50%) treated by means of surgical debridement. The primary outcome was the osteomyelitis resolution. Revascularization was performed before surgical procedure in 31 (70.5%) of patients. Systemic antibiotics were used in both groups. The osteomyelitis resolution rate was significantly higher in subjects treated with BG than in subjects treated with traditional procedure (18 [90%] vs 13 [61.9%], respectively p = .03). The odds of BG to reach osteomyelitis resolution was 5.54 times greater than for traditional treatment (odds ratio 5.54, 95% confidence interval 1.10-30.5). The use of BG was associated with an 81% lower probability to need additional antibiotic therapy compared to subjects treated with traditional procedure (odds ratio 0.19, 95% confidence interval 0.04-0.87). The debridement of osteomyelitis followed by application of BG could be an effective and safe option in the treatment of osteomyelitis of the diabetic foot.     

Complete fifth ray amputation with peroneal tendon transfer-a staged surgical protocol

Nonhealing neuropathic ulcers overlying the fifth metatarsal are frequently associated with cavus foot structure and are often complicated by osteomyelitis. Partial fifth ray amputation for metatarsal phalangeal joint ulceration and osteomyelitis is a time-proven procedure. Recurrent wounds and persistent osteomyelitis at the amputation stump or fifth metatarsal base create significant challenges in a cavus foot with neuropathy. Long-term success with removal of the entire fifth ray is largely dependent on preventing infection of the cuboid and maintaining peroneal tendon function. The described technique demonstrates our surgical principles and technical pearls in performing a staged complete fifth ray amputation with initial antibiotic bead placement and delayed peroneal tendon transfer. The peroneus longus tendon transfer has the advantage of preserving the eversion force to counterbalance the posterior tibial tendon and allowing the first ray to elevate, thereby alleviating some of the sagittal plane deformity associated with a cavus foot structure. The surgical tips and pearls are accompanied by procedure indications and incision planning options. To our knowledge, this is the first report of a staged protocol involving complete fifth ray resection, initial antibiotic bead placement, and delayed peroneus longus tendon transfer.     

Osteomyelitis following puncture wounds of the foot in children.

Review of the laboratory and clinical findings and treatment of eight patients with osteomyelitis of the foot after puncture wounds revealed that: 1) osteomyelitis after puncture wounds is a infrequent but potentially serious complication, with significant morbidity; 2) osteomyelitis is frequently preceded by inadequate primary care for simple puncture wounds, and when treatment is appropriate, osteomyelitis usually can be avoided; 3) P. aeruginosa is the most commonly recovered organism; 4) the clinical presentation is characterized by a lack of systemic toxicity, paucity of laboratory abnormalities, and evidence of a localized infection process and the patient may be asymptomatic for a few days to several months after the injury before presentation of the osteomyelitis; and 5) once the infection has become established, treatment must be aggressive, including surgical debridement.     

The efficacy of prophylactic intravenous antibiotics in elective foot and ankle surgery

A retrospective chart review of 555 patients who received elective foot and ankle surgeries between 1995 and 2001 at 1 outpatient podiatric hospital clinic was performed to evaluate the efficacy of preoperative intravenous antibiotic use. Only those patients who were having elective foot or ankle surgery for the first time, were being followed up at the hospital's outpatient clinic, and had a nontraumatic cause for their surgery were included in this study. A wound was considered infected when purulent material from the wound sites was noted and an organism(s) was cultured. A wound complication was defined as a superficial dehiscence, edema, erythema, or stitch abscess. Three hundred six (55.1%) patients received a preoperative antibiotic and 249 (44.9%) patients did not. Of the 306 patients who received a preoperative antibiotic, 9 (1.6%) acquired a postoperative wound infection, whereas 8 (1.4%) of the 249 patients who did not receive preoperative antibiotics acquired a postoperative infection. A logistic regression model and chi square tests of association were used to determine if preoperative antibiotic use, age, gender, type of surgical procedure, operative time, tourniquet use, past medical history, and internal fixation were predictive of or associated with postoperative wound infection or complication. None of the study factors was predictive of postoperative wound infection or complication (P >.01). Preoperative antibiotic use was associated with surgical category and internal fixation use (P <.001) but not postoperative wound infection or complication (P >.01). The results suggest that prophylactic intravenous antibiotic use in routine elective foot and ankle surgery is not warranted.     

Extensive eggshell-like debridement technique plus antibiotic-loaded calcium sulphate for one-stage treatment of chronic calcaneal osteomyelitis

BackgroundManagement of chronic calcaneal osteomyelitis is challenging. At present, there is still no widely accepted, simple, and effective surgical method to eradicate the infection and prevent osteomyelitis recurrence. The objective of this study was to assess the outcomes of one-stage treatment of chronic calcaneal osteomyelitis with a shape-preserving debridement technique combined with antibiotic-loaded calcium sulphate.MethodsBetween 2012 and 2018, 33 patients (33 limbs) with chronic calcaneal osteomyelitis were treated with a novel debridement technique, named “eggshell-like debridement”, plus antibiotic-impregnated calcium sulphate. The infection remission rate, recurrence rate, and amputation rate were analyzed. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess postoperative hindfoot function.Results26 patients (81.8%) achieved infection remission without recurrence. In the patients with osteomyelitis remission, pain, limitation of movement, sinus tracts, and typical redness and swelling were generally eliminated. Most of the patients could tolerate full weight-bearing without pain. The average AOFAS ankle and hindfoot score was 88 points (range, 67–100 points), implying the foot function was mostly restored. 6 patients (18.2%) had osteomyelitis recurrence but no amputation was required to elimilate the infection.ConclusionsEggshell-like debridement combined with antibiotic-loaded calcium sulphate is an effective method for one-stage management of chronic calcaneal osteomyelitis. With the application of this technique, secondary autogenous bone or muscle flap grafts are unnecessary. The surgical procedure can be simplified whlie the hindfoot function is well preserved.     

Association of Aspirin Use With Postoperative Hematoma and Bleeding Complications in Foot and Ankle Surgery: A Retrospective Study

Discontinuation of nonsteroidal antiinflammatory drugs 3 to 5 days before elective or nonelective foot and ankle surgery has been recommended, as its continued use during the perioperative period may result in complications; however, data supporting this are limited. In this study, we evaluated the incidence of postoperative bleeding, hematoma formation, and wound dehiscence after perioperative aspirin ingestion before foot and ankle surgery. The medical records of 379 patients treated over a 3-year period were reviewed. Patient demographics, surgical procedures, affected limbs (right foot versus left foot), anatomical surgical sites (forefoot, midfoot, and rearfoot), and week 2 surgical site inspection data were recorded. Mean patient age was 60.12 (range 21 to 81) years, and the overall wound complication rate was 0.80%. The patients were classified into 2 groups: those who took 81 mg of aspirin preoperatively (n = 238, 62.80%) and those who did not (n = 141, 37.20%). Of the 3 patients who developed postoperative bleeding complications, 2 were taking aspirin and 1 was not. Patients taking aspirin had similar wound complication and healing rates as those not taking aspirin. Postoperative hematomas were evacuated in the clinic under sterile conditions and healed by secondary intention. Perioperative aspirin use appears to be safe and effective in foot and ankle surgery, and patients taking aspirin had good surgical outcomes with minimal postoperative complications.     

Surgical management of diabetic foot infections and osteomyelitis

Foot ulceration and subsequent infection are a major complication of diabetes mellitus. Without proper diagnosis and treatment, these infections often lead to amputation. A multidisciplinary team approach is essential to maximize outcomes in the attempt to limit amputation and decrease patient morbidity. Mild to moderate diabetic foot infections often respond favorably to local wound care, offloading, and antibiotic therapy. When conservative measures fail or when faced with limb- or life-threatening infection, surgical intervention, whether it be incision and drainage or possible amputation, is warranted. The authors review underlying pathophysiology of diabetic foot infections and an evidenced-based approach to surgical management, with additional emphasis on treatment of osteomyelitis.     

Current concepts of Charcot foot in diabetic patients

The Charcot foot is an uncommon complication of neuropathy in diabetes. It is a disabling and devastating condition. The etiology of the Charcot foot is unknown, but it is characterized by acute inflammation with collapse of the foot and/or the ankle. Although the cause of this potentially debilitating condition is not known, it is generally accepted that the components of neuropathy that lead to foot complications must exist. When it is not detected early, a severe deformity will result in a secondary ulceration, infection, and amputation. Immobilization in the early stages is the key for success, but severe deformity may still develop. When severe deformity is present, bracing may be attempted but often patients will need surgical intervention. Good success has been shown with internal and external fixation. In patients with concomitant osteomyelitis, severe deformity, and/or soft tissue infection, a high amputation may be the best treatment of choice.     

Puncture wounds of the foot.

Serious complications occurred in 29 of 887 children with puncture wounds of the feet treated over a four-year period at the Dr. Charles A. Janeway Child Health Centre. Osteomyelitis in one of the small bones of the foot was the commonest complication and occurred when a cartilaginous surface (physeal plate or articular cartilage) had been violated. Although systemic signs of osteomyelitis frequently are absent, this infectious process is refractory to medical management. The combined surgical and medical management of this complication is outlined. Management of puncture wounds in the emergency room should include a thorough history concisely recorded, tetanus prophylaxis, and cleansing, debridement, and probing of the wound. Antimicrobial agents are not routinely required but should be reserved for patients presenting late with cellulitis or an established infection. A semisynthetic penicillinase-penicillin appears to be the agent of choice until the results of microbiologic studies are available.     

Bone scan: indium-WBC correlation in the diagnosis of osteomyelitis of the foot

A retrospective study was performed of 20 podiatric cases using technetium-99m methylene diphosphonate three-phase bone scans along with indium-111 oxine leukocyte scans, as needed, to determine the presence and extent of osteomyelitis of the foot. Using criteria developed at our institution, the authors attempt to provide a mechanism to make a reliable diagnosis for osteomyelitis that has been supported by surgical/pathologic confirmation of long-term clinical follow-up. The sensitivity, using bone scans alone, was 100%, and specificity was 47%. Correlating bone and indium-111 leukocyte scans yielded a sensitivity of 100% with a specificity raised to 81%. Indium-111 leukocyte scans were used in 40% of cases when a definitive diagnosis for osteomyelitis could not be made on the basis of the three-phase bone scan or clinical presentation alone. Indium-111 leukocyte scans were also helpful in delineating the extent of the disease process. The authors present a standard technique for a 5-hour delayed imaging in the three-phase bone scan, as well as marking the foot in the indium-111 leukocyte scan with three routine views obtained for each imaging procedure, to ensure clinical accuracy.     

Surgical treatment strategy for diabetic forefoot osteomyelitis

The aim of this study was to propose an appropriate surgical treatment for diabetic forefoot osteomyelitis (DFO) involving ischemia or moderate to severe soft tissue infection. The records of 28 patients with osteomyelitis from 2009 to 2015 were retrospectively studied. All patients had undergone surgery based on preoperative magnetic resonance imaging examinations and histopathological or culture analyses confirming the surgical bone margin. The appropriate surgical margin, crucial factors for early healing, and prognosis after complete resection of osteomyelitis were examined. After healing, patients were followed up to assess prognosis (range 32–1,910 days, median 546 days). The healing rate of nonischemic cases of DFO with negative surgical margins was 100% and that of ischemic cases was 84.6%; the ambulatory rates for both types of cases were 100%. No wound (and/or osteomyelitis) recurrence was observed. Nine new cases of DFO developed in six patients (21.4%; eight were due to vascular stenosis, and one was due to biomechanical changes in the foot. After complete resection of osteomyelitis, preoperative and postoperative C‐reactive protein levels and the size of the ulcer were significant predictors of early healing (p < 0.05, 0.01, and 0.05, respectively). The appropriate surgical margin should be set in the area of bone marrow edema, based on magnetic resonance imaging examinations after revascularization. In cases with high preoperative or postoperative C‐reactive protein levels, long‐term antibiotic therapy is recommended, and surgery should be planned after the C‐reactive protein levels decrease, except in emergencies.     

Hydrosurgery: alternative treatment technique for management of chronic osteomyelitis and septic arthritis of hallucial joint of a juvenile foot

The surgical principles of management of chronic osteomyelitis of metatarsal bone of the foot have remained unchanged, but the debridement tools and level of precision have improved. This study reports the use of the Versajet system to achieve accurate, effective wound debridement during an elective orthopedic surgery in the difficult and confined geometric and anatomical area of the metatarsophalangeal joint of the foot. The patient experienced minimum blood loss and tissue resection during the procedure and healed well without complications.     

The impact of Syme amputation in surgical treatment of patients with diabetic foot syndrome and Charcot-neuro-osteoarthropathy

Introduction Charcot-neuro-osteoarthropathy with its severe destruction of bones remains a challenge for physicians and surgeons. The aim of the study was to characterise a patient population treated in a specialised foot care centre who underwent surgical treatment for their diabetic foot syndrome. Special attention was paid to patients who suffered from Charcot-neuro-osteoarthropathy and the impact of Syme amputation if amputation of the foot was inevitable.Materials and methods A total of 121 patients with diabetic foot syndrome and ulcerations underwent an interdisciplinary strategy for diagnostic and therapeutic procedures including MRI and surgical interventions. If peripheral arterial vessel disease was present, revascularisation by distal bypass grafting was done before the orthopaedic intervention. Some 24% showed the typical neuro-osteoarthropathy with severe bone destruction. In 8 cases amputation of the foot was performed using the Syme technique.Results In our population the short-term results (follow-up 12 months, 20% lost to follow-up) are good, only 4% of the patients required further surgery on the same foot. In all patients with Charcot feet, plain radiographs showed the typical radiographic signs of the disease, and MRI was most helpful to detect abscess formations. The typical clinical problems of patients with Charcot disease are pointed out, and conservative and surgical treatment options are discussed. All patients with Syme amputation did well, wound healing and weight-bearing of the limb were accomplished.Conclusion The crucial diagnostic tool for decision-making in diabetic foot syndrome was MRI, which normally shows osteomyelitis with high sensitivity and specificity. In patients with Charcot-neuro-osteoarthropathy, the bone marrow oedema of the involved parts of the skeleton might misleadingly suggest the diagnosis of osteomyelitis. If amputation is inevitable in severe abscess formation combined with instability and perforation of the dislocated and destroyed bones in Charcot-neuro-osteoarthropathy, these patients might benefit from a foot amputation according to the technique Syme described. For this procedure the blood supply of the posterior tibial artery is essential. All these patients were able to walk without support. The material presented helps to generate hypotheses for further prospective studies.     

Complex Foot Infection Treated With Surgical Debridement and Antibiotic Loaded Calcium Sulfate—A Retrospective Cohort Study of 137 Cases

Complex foot infections involving bone and soft tissue in patients with co-morbidities such as diabetes and peripheral arterial disease (PAD) are a cause of significant hospital admission. They are associated with substantial economic costs to health services worldwide. Historically, severe foot infection has been treated with surgical debridement and prolonged courses of systemic antibiotics. Prolonged systemic antibiotic use increases the risk of drug side effects, antimicrobial resistance and Clostridium difficile infection. The purpose of this study was to investigate whether surgical debridement and implantation of antibiotic loaded calcium sulfate is effective in the resolution of foot infection and wound healing. A retrospective cohort study of 137 consecutive cases of osteomyelitis (127) or significant soft tissue infection (10) over 62 months from 02/2013 to 04/2018 was conducted following local ethical approval. All cases of infection were treated with surgical debridement and local antibiotic-loaded calcium sulfate. The primary outcomes of infection resolution, time to healing and duration of postoperative antibiotics were measured. In 137 cases, 88.3% of infections resolved. Infection was eradicated in 22 patients without postoperative systemic antibiotics. About 82.5% of wounds healed, with an average healing time of 11.3 weeks. Healing time was significantly increased for the co-morbidities of diabetes and PAD (p =< .05) and for those requiring prolonged systemic postoperative antibiotics. Conservative surgical debridement and implantation of local antibiotic impregnated calcium sulfate is safe and effective in managing complex foot infections. We advocate early surgical intervention before deeper tissue involvement to help preserve lower limb structure and function.     

Interdisciplinary treatment of diabetic foot syndrome

The amputation rate in patients with diabetic foot syndrome (DFS) in Germany is still as high as 28,000 per year. Ischemia and osteomyelitis often complicate the DFS. Impaired wound healing frequently requires further surgery with a higher amputation level. The results of treating patients with DFS in our specialized foot care center were evaluated in order to assess our interdisciplinary strategy. Advanced diabetic foot wounds in patients with ischemia and osteomyelitis first require diagnostics concerning polyneuropathy, osteomyelitis, and blood supply. If peripheral arterial vessel disease is present, surgical revascularization by distal bypass grafting is the first and crucially important element of the interdisciplinary approach. Minor amputation or elective resection of the infected bone improves wound healing. Post-interventional care for wounds with secondary healing and prevention of new ulcers are provided in a foot care clinic specialized in diabetes. The clinical and radiological results of 77 patients who underwent this treatment algorithm including bypass surgery and bone resection within 1 year were collected using a standardized questionnaire. Those results were subjected to a historical comparison. Only three patients needed further intervention because of persisting ulcers and osteomyelitis. The frequency of major amputations in all patients with DFS and ischemia combined with osteomyelitis was low (10.3%). This interdisciplinary concept of treatment guarantees a high healing rate in patients even with osteomyelitis and ischemia and allows the reduction of the rate of major amputations. The data obtained allow a fact-based design for future studies.     

Haematogenous osteomyelitis of the metatarsal sesamoid.

A case of haematogenous osteomyelitis of the medical first metatarsal sesamoid is presented and the differential diagnosis discussed. Review of the literature suggests that the condition is rarely seen and tends to present in childhood and adolescence. This contrasts with metatarsal sesamoid osteomyelitis due to direct spread of infection, which occurs in the elderly as an important complication of the diabetic foot.     

Imaging of the diabetic foot diagnostic dilemmas

Multiple diagnostic imaging modalities are available and beneficial for the evaluation of the diabetic foot. There is not yet "one best test" for sorting out the diagnostic dilemmas commonly encountered. The differentiation of cellulitis alone from underlying osteomyelitis and the early detection of abscesses remain important diagnostic goals. Equally important, differentiation of osteomyelitis and neuroarthropathy remains a difficult job. This is often compounded by postoperative diabetic foot states status after reconstruction. Diagnostic evaluation often involves multiple studies that are complementary and that include conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, ultrasonography, and positron emission tomography.     

Bioactive glass in the treatment of chronic osteomyelitis in children: Description of four consecutive cases and literature review

IntroductionChronic osteomyelitis in children is a rare condition. Debridement surgery, along with appropriate antibiotic therapy, is widely agreed to represent the best procedure in the treatment of chronic osteomyelitis but can result in an extensive dead space formation. In this study, we evaluated the use of bioactive glass to address dead space management.MethodsFour consecutive cases of chronic osteomyelitis treated with antibiotic therapy, one stage- surgical debridement and bioglass implantation between September 2016 and February 2017 were prospectively followed for a minimum of three years. Two cases followed acute hematogenous osteomyelitis, two cases followed fracture fixation. Clinical, histology, laboratory and radiographic findings were recorded. Primary endpoint was eradication of infection. Possible complication related to bioglass application were investigated.ResultsAll patients achieved healing at the latest follow-up of minimum three years. No successive surgical treatments were required at any time. No complications related to the bioglass were detected. Radiographic reconstruction of normal anatomy progressed through the years.ConclusionsBioglass for the treatment of dead space after surgical debridement appears a viable option in the treatment of chronic osteomyelitis in children.     

Surgical Reconstruction of the Diabetic Charcot Foot: Internal,External or Combined Fixation?

Charcot neuroarthropathy of the foot and ankle is a devastating neuropathic complication that can eventually lead to a lower extremity amputation in the presence of an ulceration or infection. Current surgical approaches for the management of the diabetic Charcot foot and ankle deformities are largely based on expert opinions in various fixation methods attempting to avoid major postoperative complications. The goal of this article is to discuss the advantages and disadvantages of various internal, external, or combined fixation methods as they relate to the inherent challenges in the management of the diabetic Charcot foot.     

Use of gracilis muscle free flap for reconstruction of chronic osteomyelitis of foot and ankle

Despite low donor-site morbidity and a straightforward dissection, the gracilis muscle flap is still for many surgeons a second choice in microsurgical reconstruction of the lower extremity in cases of osteomyelitis. They underscore the difficulty of the procedure, and the problems of insufficient muscle volume and a small sized vascular pedicle. The aim of this study was to assess the reliability of the gracilis muscle free flap in the treatment of osteomyelitis of the foot and ankle. Between 1992 and 1999, 12 consecutive cases (age 9 to 71 years) of osteomyelitis of the foot and ankle were treated using a skin-grafted gracilis free muscle flap. Criteria for osteomyelitis were the presence of exposed bone, positive cultures and bone scans. The wound defect surface ranged from 9 to 90 cm2 (mean 50.5 cm2). Six flaps were applied on the weight bearing area of the foot. Flap harvesting time never exceeded 30 minutes. The mean follow-up is 15 months (range 2 to 60 months). All flaps survived completely. Secondary skin grafts were needed in two cases. One hematoma was noted at the flap donor site. Two patients (18%) had persistent osteomyelitis due to insufficient debridement in the presence of what appeared to be extensive bone involvement. Attempt to salvage the extremity was first performed but ultimately led to amputation. No patients complained of any donor site morbidity. Failure to cure the osteomyelitis was never caused by inadequate flap coverage. Gracilis muscle flap reliability in terms of vascular supply and ease of dissection made it our first choice in osteomyelitis of the foot and ankle. In the presence of extensive bone involvement, complex bone reconstruction is necessary to avoid amputation.