An Orthopaedist's Review of Diabetic Foot Wounds and Osteomyelitis

Matthew R. DeSanto, BS; Luke V. Weber, BS; Emmanuel Nageeb, BS; Kyle Petersen, MD; Jeffrey Junko, MD


Curr Orthop Pract. 2020;31(5):423-428. 

In This Article


Diabetic Foot Ulcers

The treatment of diabetic foot ulcers requires three primary principles: offloading, debridement, and patient education. Initially, diabetic foot ulcers and calluses should be sharply debrided to help minimize pressure, decrease bacterial load, and stimulate more rapid local wound healing.[54–58] Similar to CA, in the setting of a diabetic foot ulcer with no underlying infection, total contact casting can be attempted to offload the area of concern.[59–61] This helps expedite wound healing and prevent worsening of CA or diabetic foot ulceration.[62] Achilles tendon lengthening at the time of total contact casting also has been shown to improve outcomes with greater rates of healing.[63] In recent years, the advent of negative pressure wound therapy has become a treatment option for patients wishing to pursue limb salvage.[64–66] Negative pressure wound therapy mechanistically reduces edema, enhances profusion, stimulates granulation tissue, and decreases bacterial counts.[67–69] Nonetheless, there is no consensus on a specific dressing being superior or a definitive benefit to hyperbaric oxygen treatment.[70,71] One of the simplest, yet most advantageous, interventions to prevent and or treat diabetic foot ulcers is patient education. It is estimated that roughly 50% of patients do not understand neuropathy and the negative consequences that can result.[5,72] This quantification does not even envelope the number of patients who may not fully understand diabetes and its progression alone.

Surgical Intervention for Foot Wounds

Surgery should be considered the first line of treatment in cases of progressive disease including failed antibiotic therapy, necrotizing fasciitis, gangrene, inadequate soft-tissue coverage, abscess, or joint involvement.[42,73] There are several different accepted surgical interventions including debridement of soft tissue, excision of infected bone, and amputation of the infected limb (Table 4).[74] The ability to achieve appropriate margins with adequate soft-tissue coverage, healing potential, and surgeon preference all dictate the extent of debridement, excision, and amputation.

Nearly 50% of diabetic patients with diabetic foot ulcers have peripheral arterial disease, so it is regularly required to order peripheral vascular resistance studies. If ankle brachial index presents abnormally (<0.90), a consult for vascular surgery for limb salvage through potential revascularization is an option to consider in hopes of ameliorating healing potential.[75–78] This would be opposed to limb amputation. Ha Van et al.[79] demonstrated that a combination of antibiotics and surgical resection may improve time to achieve wound healing as opposed to antibiotics alone in patients with osteomyelitis.

Non-surgical Intervention for Osteomyelitis

When considering antibiotic therapy for osteomyelitis, it is critical to have accurate organism-specific antibiotic targeted therapy. This typically would be accomplished via bone biopsy or deep tissue cultures. Diabetic foot ulcers are commonly polymicrobial and encompass Grampositive cocci, Staphylococcus aureus presenting most commonly, followed by Enterobactericaceae, Streptococci, and Staphylococcus epidermidis. Less common are other Gram negatives and anaerobic bacteria.[42,80,81] Recent literature has suggested antibiotic treatment as a reasonable alternative to surgical means. Lazaro-Martinez et al.[82] conducted a randomized control trial of antibiotic therapy alone versus resection of osteomyelitis and found that wound healing time was similar between the two treatment methods. Only 16.6% of patients treated with antibiotics alone required surgical intervention when followed for 1 year. However, others have suggested that the use of antibiotics alone may increase antibiotic resistance. This is primarily witnessed in lieu of increased prevalence of methicillin-resistant Staphylococcus aureus and other drug resistant organisms secondary to duration of treatment and hospitalization.[83,84] In addition, there is concern for high rate of recurrence with long-term use of antibiotics alone.[21,73,85]

If the patient does not wish to undergo surgery and elects for antibiotic therapy, the recommendation is for at least 6 wk of antibiotics.[86] According to the Infectious Disease Society of America and International Working Group on the Diabetic Foot, a 4 to 6 wk course of antibiotics is recommended for surgery with inadequate resection of bone, and no more than a 2 to 5 day course is recommended if adequate bony resection is achieved.[42,80] This further cements the significance of adequate resection. Nevertheless, there is still debate regarding the superior route of administration of antibiotics, intravenous versus oral, and recommendations may change as new therapies become available.[71]