Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon

Abstract

Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.

Keywords: Diabetes; Diabetic foot osteomyelitis; Diabetic foot ulcer; Foot and ankle surgery; Podiatry.

Fig. 1

Clinical photograph of a diabetic foot ulcer affecting the calcaneum with underlying osteomyelitis.

Fig. 2

Criteria for diagnosis of diabetic foot osteomyelitis (based on Guidelines on the diagnosis and treatment of foot infection in persons with diabetes IWGDF/IDSA 2023 Update²⁸).

Fig. 3

Flowchart for investigation and management of suspected diabetic foot osteomyelitis.

Fig. 4

STIR sequence sagittal MRI image (left) demonstrating high signal throughout the calcaneum indicative of osteomyelitis alongside a plain radiograph (right) showing radiographic features of osteomyelitis.

Fig. 5

Graph demonstrating frequency of bacteria identified in diabetic foot osteomyelitis. Reproduced under Creative Commons Attribution 4.0 International License from Macdonald, K.E., Boeckh, S., Stacey, H.J. et al. The microbiology of diabetic foot infections: a meta-analysis. BMC Infect Dis 21, 770 (2021). https://doi.org/10.1186/s12879-021-06516-7.

Fig. 6

Intraoperative fluoroscopy images of calcaneal osteomyelitis with a fracture, demonstrating debridement of infected bone, and drill tunnels filled with antibiotic loaded injectable bone void filler for local antibiotic therapy.

Fig. 7

Pre and post-operative radiographs for a patient with calcaneal osteomyelitis following silo technique treatment.