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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According to the International Consensus on the Diabetic Foot (2003) a TcP[O.sub.2] in the range of 30-60 in combination with intermittent claudication is considered as grade 2 peripheral arterial disease.

Although these people did not complain of intermittent claudication, there might be silent ischaemia present.

Another cause of prolonged healing is persistence of infection. Surgical resection of infected areas by an experienced surgeon, with resection down to living bone, is of critical importance (Norden CW 1999). In our study, the re-operated patients all had persistence of infection and a prolonged healing time.

Although the results of conservative (medical) treatment of chronic osteomyelitis in the diabetic foot are satisfactory, the results are difficult to compare with the outcome of this study (Nix et al, 1987; Lipsky et al, 1991; Gentry et al, 1995; Senneville et al, 2001)

Selection criteria for the treatment of osteomyelitis varies between studies, and antibiotic regimen and duration of treatment differ. Some studies mention debridement but fail to specify the procedure.

In our opinion, the high percentage of healed patients in our series was achieved due to the multidisciplinary approach in each patient. The multidisciplinary foot team is supported by a group of dedicated nurses, who work strictly according to a protocol, taking young medical officers to a higher level. After discharge, all patients are checked on a regular basis in the outpatient clinic. If necessary offloading measures are taken, for instance the MaBal shoe (Hissink et al, 2000). Due to this, no re-ulcerations in the scar were reported during follow up.

Conclusion

The high healing rate of 94% as demonstrated in this series is comparable or might well be superior to alternative methods of treatment, according to the data obtained from literature.

The prolonged healing time in 34% of the patients seems to be due to persistence of infection and or silent ischaemia.

Prospective randomised trials are necessary to offer more defined guidelines of treatment for this medically, socially and economically difficult problem.

Table 2. Patient outcomes (n=47)

Outcome                          N (%)

Primary healed                   37 (79%)
Secondary healed                  7 (15%)
  Amputation at a higher level    3 (6.4%)
  Deep foot abscesses drainage    3 (6.4%)
  Forefoot amputation             1 (2.1%)
Failure of treatment              3 (6%)
  Below knee amputation           2 (4.2%)
  Mortality                       1 (2.1%)
Total healed                     44 (94%)

Apelqvist J, Larsson J (2000) What is the most effective way to reduce incidence of amputation in the diabetic foot. Diabetes & Metabolism 1: 75-83

Ballard JL, Eke CC, Bunt TJ et al (1995) A prospective evaluation of transcutaneous oxygen measurements in the management of diabetic foot problems. Journal of Vascular Surgery 22: 485-90

Bunt TJ, Holloway GA (1996) TcPO2 as an accurate predictor of therapy in limb salvage. Annals of Vascular Surgery 10: 224-27