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Surgical treatment of chronic osteomyelitis of the neuropathic toe - Surgery

Diabetic Foot, The, Spring, 2004 by M.E. Bodegom, A.K. Jahrome, J.T.F.J. Raymakers, J.G. van Baal

Introduction

The results of surgical treatment of chronic osteomyelitis of the diabetic foot, as reported in literature, are disappointing. In this retrospective study, 47 patients with chronic osteomyelitis of the toe were treated surgically; all patients had diabetes and neuropathy. A total of 37 of 47 (79%) patients had complete wound healing after primary surgery. Chronic osteomyelitis of the toe in the neuropathic diabetic foot is best treated with early surgical treatment combined with antibiotic therapy; a cure rate of 94% is possible. A multidisciplinary approach may lead to low recurrence rates.

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Infection of the foot, usually as a consequence of skin ulceration, remains one of the major final pathways to lower extremity amputations in patients with diabetes (Apelqvist et al, 2000).

Although a multidisciplinary and aggressive approach lowers the amputation rate, limb loss due to infection remains a major problem (Larsson et al, 1995). Usually the extent of the infection is underestimated and a concomitant osteitis can be demonstrated in many cases (Lipsky, 1999).

Chronic osteomyelitis in people with diabetes is considered to have a better outcome than deep infections of the diabetic foot (Eneroth et al, 1997). The treatment of chronic osteomyelitis of the toe is considered to be surgical, i.e. removal of all the infected bone (Norden, 1999). Most reports mention an amputation of the toe or ray amputation in combination with culture-guided antibiotic treatment. In many retrospective studies, however, the results are disappointing with primary and secondary failure rates of up to 70% (Nehler et al, 1999; Murdoch et al, 1997; Wong et al, 1996).

In this retrospective study, we analysed the results of the surgical treatment of chronic osteomyelitis of the toe in 47 patients with diabetes.

Methods and materials

The Twenteborg hospital is a training hospital; there are 200 000 inhabitants in this rural area. The estimated incidence of diabetes mellitus is 2% of the population. The diabetic foot unit in the Twenteborg Hospital is a subdivision of the department of surgery.

Patients with diabetic foot problems are referred by general practitioners or diabetologists. Diabetes care is supported by specially trained nurses who register and visit patients at home. Therefore, a large number of the patients with diabetes in the area are screened for foot problems on a yearly basis. About 10% of our patients are referred to us from other areas of the country.

Between 1999 and 2001, 47 patients with chronic osteomyelitis of the toe were treated; 22 were female and 25 male. The mean age was 67.8 (range 42-91) years.

Thirty-one patients were treated with oral antidiabetics and 16 were on insulin. All patients had neuropathy, which was diagnosed using a tuning-fork (128 Hz) and 10g Semmes Weinstein monofilament. All patients had absent sensation of pressure with the monofilament on four points of the foot, and had negative discrimination of vibration.

Osteomyelitis was considered present in case of signs of infection in combination with bone contact when probing, and/or the x-ray showed signs of cortical destruction (Grayson et al, 1995). If a positive culture of the probed bone was obtained, this led to the diagnosis of osteomyelitis.

None of the patients had ischaemia. Ischaemia was considered absent if pedal pulses were palpable, ankle brachial indices were above 0.8 or if the transcutaneous oxygen pressure (TcP[O.sub.2]) was above 30 mmHg. All patients had one infected toe.

Patients were treated with antibiotics for 6 weeks. If the results of the culture were not known, a combination of clindamycin 1200 mg and ciprofloxacin 1000 mg daily was administered intravenously. Usually this was changed into oral administration after 2 weeks. The antibiotic regimen was adjusted according to the results of the bacterial culture.

Technique

The incision was always made on the dorsum of the foot, leaving the plantar surface free of scars and avoiding weight bearing on the scar. In all cases, we avoided damage to the surrounding soft tissue, leaving as much skin as possible to achieve a tension-free closure of the wound. In all cases, the metatarsophalangeal joint was sacrificed. All patients had non-healing defects prior to surgery for more than 6 weeks. During surgery, a deep culture was obtained. In 35 of 47 (74%) patients, the wound was primarily closed without tension. In case of gross oedema or extensive redness, the wound was left open (26%). Strict bed rest was given until the wound showed a healing tendency, which we defined as a reduction in oedema and redness, and the development of healthy granulation tissue.

Open wounds were treated with an offloading cast. After wound closure, all patients received custom-made shoes. The wound was considered completely healed when there was 100% epithelialisation i.e. intact skin. Outclinic patients with incomplete wound healing were followed up on a weekly basis. Patients with complete healing were seen at 4-6 week intervals during the first year.

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Surgical treatment of chronic osteomyelitis of the neuropathic toe - Surgery

Diabetic Foot, The, Spring, 2004 by M.E. Bodegom, A.K. Jahrome, J.T.F.J. Raymakers, J.G. van Baal

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