Diagnosing diabetic foot osteomyelitis

Abstract

Bone involvement during an infection of the diabetic foot represents a serious complication associated with a high risk of amputation, prolonged antibiotic treatment and hospitalization. Diabetic foot osteomyelitis (DFOs) require a multidisciplinary approach given the usual complexity of these situations. DFO should be suspected in most cases especially in the most severe forms of soft tissue diabetic foot infections (DFIs) where the prevalence of bone infection may be up to 60%. Suspicion is based on clinical signs in particular a positive probe‐to‐bone (PTB) test, elevated inflammatory biomarkers especially erythrocyte sedimentation rate and abnormal imaging assessment using plain X‐ray as a first‐line choice. The combination of PTB test with plain X‐ray has proven effective in the diagnosis of DFO. The confirmation (definite) diagnosis of DFO is based on the results of a bone sample examination obtained by either surgical or percutaneous biopsy. Sophisticated imaging examinations such as Magnetic Resonance Imaging (MRI) and nuclear imaging techniques are useful where doubt persists after first‐line imaging assessment. These techniques may also help localize the bone infection site and increase the diagnostic performance of percutaneous bone biopsy. The quality of the microbiological documentation of DFO is likely to improve the adequacy of the antimicrobial therapy especially when medical (ie, no surgical resection of the infected bone tissues) is considered. The use of new (molecular) techniques for the identification of the bone pathogens have not yet proven superiority on classic cultural techniques for the management of such patients.

Escherichia coli Isolated from Diabetic Foot Osteomyelitis: Clonal Diversity, Resistance Profile, Virulence Potential, and Genome Adaptation

“…After wound debridement, samples for bacterial culture were obtained by transcutaneous bone or tissue biopsy performed by a trained orthopaedist using the procedure previously described [ 3 ]. All the samples were immediately sent to the Department of Microbiology.…”

“…Infection of these ulcers is frequent (40–80%), representing a major cause of mortality and morbidity [ 2 ]. Diabetic Foot Osteomyelitis (DFOM) is a common complication of DFU and/or diabetic foot infections (DFI) [ 3 ]. In Western developed countries, DFI are mainly caused by aerobic Gram-positive cocci (especially Staphylococcus aureus ).…”

Ultrasound in the Modern Management of the Diabetic Foot Syndrome: A Multipurpose Versatile Toolkit

“…114 Radiologically, 80% of bone osteomyelitis in DF can be detected with plain radiography, which can account for 69% of sensitivity and 80% of specificity. 115 When the images are questionable and further examination are required, the second-level technique more useful is represented by MR (sensitivity 100% and specificity 75%), which is usually decisive in solving doubts. 116 Occasionally it can be necessary the use bone scintigraphy (sensitivity 83%, specificity 75%), which can be used for rare, very difficult, and complicated patients.…”

Instruments of Choice for Assessment and Monitoring Diabetic Foot: A Systematic Review

“…The variable measured by the highest number of OCOMs (five) was the 'diagnosis of osteomyelitis', for which the probe-to-bone test was the most sensitive (98.1%), however, it is important to mention that this instrument has a high interrater variability [61]. In this sense, the gold standard for the diagnosis of osteomyelitis continues to be bone biopsy [61]. Plain radiography, positron emission tomography (PET), MRI and leukocyte counting were other OCOMs used for the diagnosis of osteomyelitis.…”

“…Given that diabetic neuropathy has several components (peripheral, autonomic and proximal), it seems a good strategy to examine each one independently to make more accurate recommendations [61].…”