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.     

Hybrid imaging with 99mTc‐WBC SPECT/CT to monitor the effect of therapy in diabetic foot osteomyelitis

This study sought to assess the utility of monitoring response to treatment of diabetic foot osteomyelitis (DFO) with Tc‐99m WBC‐labelled single photon emission computed tomography (SPECT/CT) imaging. This is a retrospective cohort study of 20 patients with DFO with sequential Tc‐99m WBC‐labelled SPECT/CT imaging. Radiologic findings of osteomyelitis were evaluated and imaging results were correlated with clinical outcomes subtracted from chart review. Successful treatment of osteomyelitis was defined by wound healing and/or lack of re‐admission for bone infection of the same site within 1 year. The sensitivity, specificity, positive predictive value and negative predictive value of SPECT/CT to determine osteomyelitis treatment remission were 90%, 56%, 69% and 83%, respectively. Tc‐99m WBC‐labelled SPECT/CT imaging may be useful to help determine treatment outcomes for DFO.     

Impact of Bacterial Infections on Osteogenesis: Evidence From In Vivo Studies

The clinical impact of bacterial infections on bone regeneration has been incompletely quantified and documented. As a result, controversy exists about the optimal treatment strategy to maximize healing of a contaminated defect. Animal models are extremely useful in this respect, as they can elucidate how a bacterial burden influences quantitative healing of various types of defects relative to non‐infected controls. Moreover, they may demonstrate how antibacterial treatment and/or bone grafting techniques facilitate the osteogenic response in the harsh environment of a bacterial infection. Finally, it a well‐known contradiction that osteomyelitis is characterized by uncontrolled bone remodeling and bone loss, but at the same time, it can be associated with excessive new bone apposition. Animal studies can provide a better understanding of how osteolytic and osteogenic responses are related to each other during infection. This review discusses the in vivo impact of bacterial infection on osteogenesis by addressing the following questions (i) How does osteomyelitis affect the radiographic bone appearance? (ii) What is the influence of bacterial infection on histological bone healing? (iii) How do bacterial infections affect quantitative bone healing? (iv) What is the effect of antibacterial treatment on the healing outcome during infection? (v) What is the efficacy of osteoinductive proteins in infected bones? (vi) What is the balance between the osteoclastic and osteoblastic response during bacterial infections? (vii) What is the mechanism of the observed pro‐osteogenic response as observed in osteomyelitis? © 2019 The Authors. Journal of Orthopaedic Research^© published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 37:2067–2076, 2019     

A critical review of the literature: part I: diagnosing osteomyelitis in patients with diabetes and foot ulcers.

Despite our best efforts, chronic wounds continue to confound us. Cases of patients with diabetes who have wounds are particularly perplexing and challenging to manage. The diagnosis and treatment of osteomyelitis in this population are of great interest to clinicians. Much of wound care is based on tradition and expert opinion. The current focus is on evidence-based practice. The purpose of this critical literature review is to determine the best evidence for diagnosing osteomyelitis as a basis for providing appropriate therapy to patients with diabetes and foot ulcers. Treatments vary greatly in terms of time, cost, and invasiveness depending on the accuracy of the diagnosis. The choice of oral versus parenteral antibiotics, the length of the treatment, and decisions about surgical intervention or aggressive debridement are based on correctly differentiating osteomyelitis from soft tissue infection, osteoarthropathy, and other conditions. It is difficult to differentiate soft tissue infection from bone infection in the patient with diabetes and neuropathic bone disease. The precision of available tools for diagnosing osteomyelitis in patients with diabetes and foot ulcers is widely debated. A gold standard as a reference test for clinical trials and treatment decisions has not been consistently used in published research studies. Without a reference test that is reliable and valid, the conclusions regarding effectiveness of diagnostic modalities and antibiotic treatment regimens are questionable.     

Comblement des cavités septiques par un ciment contenant des antibiotiques

The aim of this paper is to assess the use of antibiotic loaded acrylic cement as a treatment of septic cavities of bones. Seventeen patients have been divided in three groups: infected knee prosthesis, chronic haematogenous osteomyelitis, post-trau-matic osteomyelitis. Results were analysed in the three groups as far as “healing” or recurrence of infection was concerned.     

Magnetic Resonance Imaging of Diabetic Foot Osteomyelitis: Imaging Accuracy in Biopsy-Proven Disease

Magnetic resonance imaging (MRI) is the recommended diagnostic imaging technique for diabetic foot osteomyelitis (DFO). The gold standard to diagnose osteomyelitis is bone biopsy with a positive culture and/or histopathology finding consistent with osteomyelitis. The purpose of this study is to assess the accuracy of MRI readings in biopsy-proven diabetic foot osteomyelitis with a second read done by a blinded, expert musculoskeletal radiologist. A retrospective chart review of 166 patients who received a bone biopsy to confirm the diagnosis of a suspected DFO at a large county hospital between 2010 and 2014. A second, blinded musculoskeletal radiologist reviewed the images for accuracy, once the official reading was recorded. Imaging results were correlated with the final diagnosis of osteomyelitis determined by bone biopsy. In 17 of 58 patients (29.3%), the diagnosis of DFO by MRI was not confirmed by bone biopsy. There were 12 false positives and 5 false negatives. After the second expert read, there were 5 false positives and 4 false negatives. The overall accuracy was 84% for the second read. Our study demonstrated results comparable to the previously reported meta-analysis findings. There is a clear variation on the read of MRI that could lead to an incorrect diagnosis of DFO. An integrated approach with evaluation of clinical findings, communication with radiologist about the MRI results when indicated, and bone biopsy is warranted for accurate diagnosis management of DFO.     

Erythrocyte sedimentation rate and C‐reactive protein to monitor treatment outcomes in diabetic foot osteomyelitis

This study sought to evaluate the effectiveness of the inflammatory markers, erythrocyte sedimentation rate (ESR) and C‐reactive protein (CRP), in monitoring treatment of osteomyelitis in the diabetic foot. We screened 150 charts of patients admitted to our hospital with diabetic foot osteomyelitis (DFO), confirmed by positive results of bone culture and/or histopathology. We included patients who had an initial ESR/CRP within 72 hours of admission and two reported follow‐up values. We dichotomised patients based on the outcomes wound healing, re‐infection, recurrent ulceration, re‐hospitalisation, additional surgery, re‐amputation and death, all within 12 months, and analysed the trajectories of the markers over time. Our primary outcome, DFO remission, was defined as wound healing within 12 months of follow‐up without re‐infection. We included 122 subjects; 65 patients (53·3%) had a combination of positive culture and histopathology. Factors associated with DFO remission (n = 46) were a lower white blood count (WBC) at admission (P = 0·006) and a higher glomerular filtration rate (GFR, P = 0·049). Factors associated with healing were a lower WBC (P = 0·004), a higher GFR (P = 0·01), longer wound duration before admission (P = 0·01), location of the ulcer on the great toe (P = 0·01) and higher glycated haemoglobin (P = 0·03). Logistic regression analysis demonstrated no associations between DFO remission and other variables collected. Trajectories of the inflammatory markers showed an association between stagnating values of ESR and CRP and poor clinical outcomes. In this study population, the trajectories of both ESR and CRP during 12 months follow‐up suggest a predictive role of both inflammatory markers when monitoring treatment of DFO.     

Osteomyelitis im Erwachsenenalter

This review focuses on the presentation of the diagnostic and therapeutic principles for treatment of chronic osteomyelitis of long bones in adults. Early detection of the offending bacteria is a crucial step which has to be performed with tissue and fluids from the depth of the wound. Superficial samples and swaps from fistulas should be avoided and are not considered to be representative. Chronic osteomyelitis is characterized by necrotic and nonvascularized bony tissue which represents one of the most relevant sources for recurrence infection. Appropriate therapy includes radical excision of the diseased bone and infected scar tissue, closure of the wound with well-vascularized (muscle) flaps, stabilization, and administration of adequate antibiotics.     

Multidrug resistant organism predicts ulcer recurrence following surgical management of diabetic foot osteomyelitis

Diabetic foot ulcers commonly precede diabetic foot osteomyelitis (DFO) and once the latter occurs, surgical management is often performed. The presence of osteomyelitis is an independent risk factor for the development of re‐ulceration. We investigated the relationship between causative organisms in osteomyelitis and 1‐year diabetic foot outcomes (re‐ulceration, amputation, and death) following surgical management in an observational cohort of 223 patients. Univariate and multivariate analyses were performed for available demographic, clinical, and laboratory data. In addition, random forest plots were used to identify microbiologic predictors of 1‐year outcomes. Patients with osteomyelitis managed surgically were younger and exhibited more painful peripheral neuropathy than outpatients with diabetes alone (both P < .0001). Osteomyelitis proximal margin cultures were diverse, at times polymicrobial, and included multidrug‐resistant organisms in 13.9% of the cohort. In patients who underwent surgery, 44.5% experienced a re‐ulceration on the same foot within 12 months of surgery. The presence of multidrug‐resistant organisms on proximal bone culture was found to be a significant predictor of diabetic foot ulcer recurrence in univariate modelling (P < .001) and importance rankings. This is the first study to use prediction modelling to identify a relationship between multidrug‐resistant organisms and diabetic foot ulcer recurrence following DFO.     

一期手术治疗跟骨创伤性慢性骨髓炎

目的探讨腓动脉穿支(肌)皮瓣联合载抗生素人工骨一期治疗跟骨创伤性慢性骨髓炎的临床疗效。方法对32例跟骨创伤性慢性骨髓炎患者在一期扩创彻底清除骨髓炎病灶的基础上采用载抗生素人工骨植骨抗感染、切取腓动动脉穿支(肌)皮瓣覆盖创面的方式修复治疗。结果患者均获得随访,时间6~32个月。皮瓣均成活,外观形态良好。骨髓炎无复发情况,骨折愈合情况良好,无畸形愈合,骨性愈合时间为6~9.8个月。结论腓动脉穿支(肌)皮瓣联合载抗生素人工骨一期治疗跟骨创伤性慢性骨髓炎是治疗创伤性慢性骨髓炎较理想的方法。     

The reverse sural artery fasciomusculocutaneous flap for small lower-limb defects: the use of the gastrocnemius muscle cuff as a plug for small bony defects following debridement of infected/necrotic bone

The reverse sural artery fasciomusculocutaneous flap is a modification of the original fasciocutaneous flap in which a midline gastrocnemius muscle cuff around the buried sural pedicle is included in the flap. This modification was done to improve the blood supply of the distal part of the flap, which is harvested from the upper leg. The aim of this paper is to demonstrate that there is another important advantage of the modified flap: the use of the muscle cuff as a "plug" for small lower limb defects following debridement of infected/necrotic bone. A total of 10 male adult patients with small complex lower-limb defects with underlying bone pathology were treated with the modified flap using the muscle component to fill up the small bony defects. The bony pathology included necrotic exposed bone without evidence of osteomyelitis or wound infection (n = 1), an underlying neglected tibial fracture with wound infection (n = 4), and a sinus at the heel with underlying calcaneal osteomyelitis (n = 5). Primary wound healing of the flap into the defect was noted in all patients. No recurrence of calcaneal osteomyelitis was seen and all tibial fractures united following appropriate orthopedic fixation. It was concluded that the reverse sural artery fasciomusculocutaneous flap is well suited for small complex lower-limb defects with underlying bone pathology.     

Microbiology and management of joint and bone infections due to anaerobic bacteria

Purpose To describes the microbiology, diagnosis, and management of septic arthritis and osteomyelitis due to anaerobic bacteria. Results The predominant anaerobes in arthritis are anaerobic Gram-negative bacilli (AGNB) including the Bacteroides fragilis group, Fusobacterium spp., Peptostreptococcus spp., and Propionibacterium acnes. Infection with P. acnes is associated with a prosthetic joint, previous surgery, and trauma. B. fragilis group is associated with distant infection, Clostridium spp. with trauma, and Fusobacterium spp. with oropharyngeal infection. Most cases of anaerobic arthritis, in contrast to anaerobic osteomyelitis, involved a single isolate, and most cases are secondary to hematogenous spread. The predominant anaerobes in osteomyelitis are Bacteroides, Peptostreptococcus, Fusobacterium, and Clostridium spp. as well as P. acnes. Conditions predisposing to bone infections are vascular disease, bites, contiguous infection, peripheral neuropathy, hematogenous spread, and trauma. Pigmented Prevotella and Porphyromonas spp. are mostly isolated in skull and bite infections, members of the B. fragilis group in hand and feet infections, and Fusobacterium spp. in skull, bite, and hematogenous long bone infections. Many patients with osteomyelitis due to anaerobic bacteria have evidence of an anaerobic infection elsewhere in the body that is the source of the organisms involved in the osteomyelitis. Treatment of arthritis and osteomyelitis involving anaerobic bacteria includes symptomatic therapy, immobilization in some cases, adequate drainage of purulent material, and antibiotic therapy effective against these organisms. Conclusions Anaerobic bacteria can cause septic arthritis and osteomyelitis. Correct diagnosis and appropriate therapy are important contributor to successful outcome.     

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.     

Osteomyelitis associated with peripheral vascular disease secondary to diabetes mellitus.

Diabetes mellitus and arteriosclerotic vascular disease have been found to be the predisposing factors of osteomyelitis associated with peripheral vascular disease (10). A diabetic person is more susceptible to osteomyelitis because of the microangiopathy, peripheral neuropathy and decreased resistance to infection. In diabetes mellitus there can be microangiopathy which results from the proliferation of the endothelium of the intima and thickening of the basement membrane. This further contributes to a sluggish blood flow. In the patient with arteriosclerotic vascular disease, the lumens of the arterioles and arterioles are compromised by the atheromatous plaques. The anatomic structure of the blood supply to bone along with the pathologic membrane thickening, allows for slowing of blood. This slowing of blood flow causes micro-thrombi and enhances bacterial growth. In diabetes mellitus it has been shown that there is a decreased immunologic response which, along with the above, contributes to the sheltering and proliferation of bacteria in the small bones of the foot.     

诱导膜技术修复前臂骨髓炎并大段骨缺损的疗效分析

背景:前臂骨髓炎合并骨缺损,特别是大段骨缺损,治疗难度大。诱导膜技术(Masquelet技术)修复下肢大段骨缺损取得满意疗效。目的:分析诱导膜技术修复前臂骨髓炎合并大段骨缺损的临床疗效。方法:回顾性分析2013年1月至2017年11月收治的12例前臂骨髓炎合并大段骨缺损患者。其中5例为桡骨骨缺损,7例为尺骨骨缺损。一期手术病灶区彻底清创后,采用抗生素骨水泥占位器填充缺损病灶诱导生物膜形成;二期手术取出骨水泥占位器后,植入自体松质骨或混合骨。随访记录患者术后骨缺损的愈合情况、并发症的发生情况,根据Anderson前臂功能评分标准,评估患肢的术后恢复情况。结果:所有患者均获得随访,随访时间为12~34个月,平均(17.5±3.3)个月。1例患者在一期术后出现感染复发,2例患者在二期植骨后期遗留肘关节僵硬,经治疗,感染控制、肘关节屈伸功能基本恢复。末次随访时,所有患者均实现骨与软组织愈合,根据Anderson前臂功能评分标准,本组病例优良率为83.3%(10/12)。结论:采用诱导膜技术修复前臂骨髓炎合并大段骨缺损疗优势明显,术后并发症少,骨缺损修复和患肢功能恢复效果满意。     

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36–74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84–100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.     

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.     

Reconstruction of post-osteomyelitis 1st ray phalangeal loss by reverse dermis cross toe flap and fibula bone grafting: A rare case report

Osteomyelitis is defined as infection of the bone and its marrow. It is more common in children due to growing bones and rich blood supply. Although long tubular bones are most common to get involved, no bone is exempted from acute hematogenous osteomyelitis and metatarsals account for 2% of all cases of acute hematogenous osteomyelitis. A rare case of Community Aquired-Methicillin Resistant Staphylococcus Aureus (CA-MRSA) osteomyelitis of great toe with complete sequestration of proximal phalanx in an adolescent managed with reverse dermis cross-toe flap and inter-positional fibular grafting is presented. On the basis of our experience with this case, it is also concluded that post infective phalangeal loss with significant soft tissue necrosis does not necessarily entails amputation. With a staged soft tissue coverage and bone loss management, a good clinical, cosmetic and functional outcome can be achieved.     

The current burden of diabetic foot disease

Neuropathy and ischaemia are two great pathologies of the diabetic foot which lead to the characteristic features of foot ulceration (neuropathic and ischaemic) and Charcot neuroarthropathy. These can be complicated by infection and eventually may result in amputation (minor or major) and increased mortality. All of these features contribute to considerable clinical and economic burden.Peripheral nerves in the lower limbs are susceptible to different types of damage in patients with diabetes leading to distinctive syndromes. These include symmetrical sensory neuropathy associated with autonomic neuropathy, which advances gradually, and acutely painful neuropathies and mononeuropathies which have a rather acute presentation but usually recover. Ischaemia in the form of peripheral arterial disease is an important contributor to the burden of the diabetic foot. The incidence of atherosclerotic disease is raised in patients with diabetes and its natural history is accelerated. Diabetes causes severe and diffuse disease below-the knee. The lifetime risk of developing a diabetic foot ulcer is between 19% and 34%. Recurrence is common after initial healing; approximately 40% of patients have a recurrence within 1 year after ulcer healing, almost 60% within 3 years, and 65% within 5 years. Charcot neuroarthropathy is characterised by bone and joint destruction on the background of a neuropathy. Its prevalence in diabetes varies from 0.1% to 8%.Infection develops in 50%–60% of ulcers and is the principal pathology that damages diabetic feet. Approximately 20% of moderate or severe diabetic foot infections result in lower extremity amputations. The incidence of osteomyelitis is about 20% of diabetic foot ulcers.Every 20 s a lower limb is amputated due to complications of diabetes. Of all the lower extremity amputations in persons with diabetes, 85% are preceded by a foot ulcer. The mortality at 5 years for an individual with a diabetic foot ulcer is 2.5 times as high as the risk for an individual with diabetes who does not have a foot ulcer. The economic burden exacted on health care systems is considerable and includes direct and indirect costs, with loss of personal earnings and burden to carers. The diabetic foot is a significant contributor to the global burden of disability and reduces the quality of life. It remains a considerable public health problem.     

Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations

Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU.Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications.A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot.Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection.When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures.Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.