Diabetic Foot Infections Guidelines

Updated: Mar 05, 2018
  • Author: Michael Stuart Bronze, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Guidelines

Guidelines Summary

A 2016 study by Allahabadi et al developed consensus statements on the surgical management of diabetic foot osteomyelitis. These included the following with regard to the operative management of diabetic forefoot osteomyelitis [17] :

  • Before bone is definitively resected and soft-tissue closure/reapproximation is performed over remaining bone, concomitant deep soft-tissue infection (ie, abscess, joint-space infection) or soft-tissue necrosis should be drained/debrided and controlled
  • When serial operations are performed for soft-tissue infection in patients with diabetic foot osteomyelitis, the use of negative-pressure wound therapy dressings with instillation may be considered during intervals between surgeries
  • Whenever possible, bone should be resected until grossly healthy bone is revealed (that is, bone with normal caliber, smooth cortical contour, firm density, and punctate bleeding)
  • All areas of significant cortical destruction demonstrated on plain radiography, as well as any grossly infected, necrotic, or fragmented bone, should be included in the bone resection.
  • Grossly abnormal or infected bone should be sent for microbiology
  • Analysis of operative bone specimens sent for microbiology should include microscopic examination of a Gram-stained smear, along with the assessment of aerobic and anaerobic cultures
  • Grossly abnormal or infected bone should be sent for histopathology
  • A sample of the proximal-most bone resected (ie, a bone-margin specimen) should be labeled separately and sent for histopathology
  • A sample of the proximal-most bone resected (ie, a bone-margin specimen) should be labeled separately and sent for microbiology
  • A power saw is the preferred instrument for bone transection
  • Final bone resection and attempted delayed primary skin and soft-tissue closure should be performed 3-7 days after soft-tissue infection or necrosis has been attended to and appropriate antibiotic therapy has commenced
  • Preferably, grossly normal-appearing bone margins should be obtained at the time of the final planned operative debridement
  • For selected patients with osteomyelitis, partial ostectomy of the distal metatarsal and/or proximal phalanx is an acceptable alternative to ray amputation if there is no radiographic involvement of the remaining bone, if the bone looks normal at surgery, and if abnormal biomechanics of the residual forefoot are not anticipated
  • In patients with significant ankle equinus deformity (inability to dorsiflex the ankle past neutral), adjunctive tendo-Achilles lengthening should always be considered
  • When significant forefoot biomechanical issues (eg, hallux valgus and hammertoe deformities) pose the risk of reulceration or new (transfer) ulcers, podiatric/orthopedic procedures should always be considered