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Does All Osteomyelitis Necessarily Need Surgery?

I was trained and I still very much believe that we have the ability to surgically remove osteomyelitis in the foot and ankle and that is often the best treatment. This is so often the case because the “thing” that caused the osteomyelitis, namely a contiguous diabetic foot ulcer, was caused by excessive stress over that area, ostensibly from a foot deformity. Therefore, the thought is that if we are to eradicate the thing that caused the foot deformity, we are also secondarily eradicating the resultant bone infection.

However, data over the last generation, particularly over the last decade, has challenged the assumption that we always need to be treating osteomyelitis surgically. Most recently in Lancet Diabetes and Endocrinology, Mutluoglu and Lipsky have a really interesting case presentation of a patient who was treated with antibiotics all the way to osteomyelitis suppression with quite impressive radiographic evidence of diabetic foot osteomyelitis.1

The case report concerned a 68-year-old man with well-controlled type 2 diabetes who presented with a swollen red toe, a longstanding plantar ulcer on his first metatarsal and a complete loss of sensation.1 The authors noted that plain radiographs showed a disrupted cortex and lytic lesions of the first proximal phalanx and metatarsal head while tissue cultures sampled from the wound grew Proteus mirabilis. For his osteomyelitis of the great toe, the patient received intravenous piperacillin–tazobactam (4.5 g every eight hours for three weeks) followed by oral ciprofloxacin (500 mg every 12 hours for nine weeks).

The study notes that the patient’s serial radiographs showed the progression of osteomyelitis with “substantial destruction” of the bone while later radiographs showed signs of healing with new periosteal bone, the formation of hypertrophic callus and nearly complete bone regeneration.1

This case report coupled with other studies in the past five to 10 years should challenge the conventional thinking and help us realize that maybe osteomyelitis is not a primarily surgical eventuality in every single patient.

Reference

1. Mutluoglu M, Lipsky BA. Non-surgical treatment of diabetic foot osteomyelitis. Lancet Diabetes Endocrinol. 2017; epub Jan 17.

Comments

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The sequelae to that however is an insensitive foot with a deformity that is most likely resistant to effective non-operative offloading. So, is the next step staged operative offloading?
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