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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Osteomyelitis in the Diabetic Patient



- See: diabetic foot menu

- Discussion:
    - see osteomyelitis
    - dx of osteomyelitis can be a difficult problem in diabetic pts w/ foot infections;
    - some physicians will make the dianosis of osteomyelitis if they can palpate bone thru the skin lesion;
            - this method is quick, inexpensive, and generally accurate;
            - if there is not a lesion over the area of question, then it is more likely that the lesion has resulted from Charcot changes;
    - neuropathic osteoarthropathy often appears indistinguishable from OM, w/ multiple and widespread abnormalities that can appear hot on all three phases of a bone scan;
            - peripheral vascular disease will also affect the uptake;
            - In-WBC may be most accurate for detection of OM in the diabetic foot;
    - cellulitis is frequently present and can be confused with OM, esp if osteoarthritis or neuropathic disease is also present;
    - references:
            The septic foot in patients with diabetes.
            Salvage of the diabetic foot with exposed os calcis.
            Partial and total calcanectomy: a review of thirty-one consecutive cases over a ten-year period.
            Osteomyelitis in the foot and ankle associated with diabetes mellitus.
            Diabetic foot infections. Bacteriologic analysis.
            Chemotaxis of polymorphonuclear leukocytes from patients with diabetes mellitus.


- Offending Organisms:
    - Aerobic Gram Positive Cocci
          - Gr A strep (may cause acute sepsis)
          - Enterococci (may be most common);
          - Staph aureus
    - Enterobacteriaceae;
    - references:
          - Microbiology of deep tissue in diabetic gangrene.
          - Aerobic and anaerobic bacteria in diabetic foot ulcers.
          - Quantitative aerobic and anaerobic bacteriology of infected diabetic feet.
          - Diabetic foot infections. Bacteriologic analysis.
          - Microbiology of superficial and deep tissues in infected diabetic gangrene.
          - Eikenella corrodens as a cause of osteomyelitis in the feet of diabetic patients. Report of three cases.

- Management of Cellulitis or Infected Superficial Ulcerations:
    - see Wagner grading system for diabetic foot infections:
    - non operative treatment is indicated for patients who are not septic;
          - i.e., no high fever, normal WBC, no altered mentation;
    - cultures from ulcers are unreliable (need to treat based on deep cultures obtained from researach studies);
          - enterococci may be most common and therefore a logical starting medication would be Augmentin or Unasyn;
    - references:
          Treatment of resistant ulcers on the plantar surface of the great toe in diabetics.
          Management of diabetic midfoot ulcers.


- Operative Treatment:
    - surgical debridement is indicated for all patients who appear acutely toxic;
    - compartmental anatomy of the foot
    - amputations in the diabetic patient
    - partial calcanectomy:
          - may be indicated in certain situations in which there is exposed bone over the calcaneus and limited osteomyelitis, and the only other alterantive is BKA;
          - references:
                 - Salvage of the diabetic foot with exposed os calcis.
                 - Partial calcanectomy for the treatment of osteomyelitis of the calcaneus.
                 - Partial and total calcanectomy: a review of thirty-one consecutive cases over a ten-year period.
                 - Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot.
                       


The diabetic foot: evolving technologies.

Management of the diabetic foot.

Eikenella corrodens as a cause of osteomyelitis in the feet of diabetic patients. Report of three cases

One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study.

Diabetic foot infections. Bacteriologic analysis.

Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, December 11, 2012 10:55 am