Table 8. Diagnostic Bone Biopsy is Most Recommended When:
• Patient or provider prefers definitive diagnosis to justify choice of early surgery in favor of prolonged treatment
• Cultures of soft tissue or blood suggest high risk of osteomyelitis with antibiotic resistant organism(s)
• There is progressive bony deterioration or persistently elevated inflammatory markers during empiric or culture-directed therapy (should consider surgical resection)
• Suspect bone is a planned target for insertion of orthopaedic metalware
Table 9. Approach to Treating a Patient with Diabetic Foot Osteomyelitis
When to consider a trial of nonsurgical treatment • No persisting sepsis (after 48-72 hours if on treatment) • Patient can receive and tolerate appropriate antibiotic therapy
• Degree of bony destruction has not caused irretrievable compromise to mechanics of foot (bearing in mind potential for bony reconstitution)
• Patient prefers to avoid surgery • Patient comorbidities confer high risk to surgery
• No contraindications to prolonged antibiotic therapy (eg, high risk for C. difficile infection)
• Surgery not otherwise required to deal with adjacent soft tissue infection or necrosis
When to consider bone resectiona • Persistent sepsis syndrome with no other explanation • Inability to deliver, or patient to tolerate, appropriate antibiotic therapy • Progressive bony deterioration despite appropriate therapy • Degree of bony destruction irretrievably compromises mechanics of foot • Patient prefers to avoid prolonged antibiotics or to hasten wound healing • To achieve a manageable soft tissue wound or primary closure
• Prolonged antibiotic therapy is relatively contraindicated or is not likely to be effective (eg, presence of renal failure)
a
Definitive surgical solutions to osteomyelitis, such as ray and transmetatarsal amputations, may risk architectural reorganization of the foot, resulting in altered biomechanics and additional cycles of "transfer ulceration," that is, skin breakdown at a new high-pressure site.
11
