Diabetic foot osteomyelitis
Medical treatment and conservative surgical approach in a Diabetic Foot Unit
Keywords:
OSTEOMYELITIS, DIABETIC FOOT, CONSERVATIVE SURGERY, CONSERVATIVE TREATMENT
Abstract
Infection is the most frequent complication in diabetic foot ulcers, and it is the main cause of minor and major lower extremities amputations.
Osteomyelitis accounts for 60% of cases and it constitutes a challenge when it comes to treatment, since controversies arise depending on its clinical presentation.
Resection of the infected bone has been the golden standard, despite it may cause functional sequelae and recurring ulcers. In the last two decades antibiotic therapy has emerged, combined with a conservative surgical approach or no surgery in forefoot lesions, the results being satisfactory.
Objective: to present the results of medical treatment of foot osteomyelitis in diabetic patients, prioritizing minimal resections that avoid amputations which alter the biomechanics of the foot.
The study evaluated 6 diabetic patients assisted at the Diabetic Foot Unit, with phalanx, metatarsal and calcaneal osteomyelitis. They received antibiotic therapy for 7 ± 2 weeks and resections were limited to the forefoot, showing good evolution. During a one-year follow-up, there were no signs of infection in the initial site or adjacent to the lesion, support of the foot being preserved.
Conclusion: minimum resection surgery with no local or major amputation is a successful therapy in selected cases of diabetic foot osteomyelitis. Prospective trials are necessary to determine benefits of this management when compared to other approaches.
References
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2) Henke PK, Blackburn SA, Wainess RW, Cowan J, Terando A, Proctor M, et al. Osteomyelitis of the foot and toe in adults is a surgical disease: conservative management worsens lower extremity salvage. Ann Surg 2005; 241(6):885-94. doi: 10.1097/01.sla.0000164172.28918.3f.
3) Aragón-Sánchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. Int J Low Extrem Wounds 2010; 9(1):37-59. doi: 10.1177/1534734610361949.
4) Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, et al. Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. Diabet Med 1998; 15(5):412-7. doi: 10.1002/(SICI)1096-9136(199805)15:5<412::AID-DIA584>3.0.CO;2-1.
5) Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care 2014; 37:789-95.
6) Tone A, Nguyen S, Devemy F, Topolinski H, Valette M, Cazaubiel M, et al. Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: a multicenter open-label controlled randomized study. Diabetes Care 2015; 38(2):302-7. doi: 10.2337/dc14-1514.
7) Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, et al. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36(Suppl 1):e3280. doi: 10.1002/dmrr.3280.
8) Schinca N, Jorge AM, Pedreira W. Amputaciones en infecciones profundas del pie diabético. (Resúmenes XIII Congreso de la Asociación Latinoamericana de Diabetes). Rev ALAD 2007; XV(4):187.
9) Tan JS, Friedman NM, Hazelton-Miller C, Flanagan JP, File TM Jr. Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation? Clin Infect Dis 1996; 23(2):286-91.
10) Shaikh N, Vaughan P, Varty K, Coll AP, Robinson AH. Outcome of limited forefoot amputation with primary closure in patients with diabetes. Bone Joint J 2013; 95-B(8):1083-7. doi: 10.1302/0301-620X.95B8.31280.
11) Widatalla AH, Mahadi SE, Shawer MA, Mahmoud SM, Abdelmageed AE, Ahmed ME. Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment. Diabet Foot Ankle 2012; 3:1. doi: 10.3402/dfa.v3i0.18809.
12) Lázaro-Martínez JL, García-Madrid M, García-Álvarez Y, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Morales E. Conservative surgery for chronic diabetic foot osteomyelitis: procedures and recommendations. J Clin Orthop Trauma 2020; 16:86-98. doi: 10.1016/j.jcot.2020.12.014.
13) Aragón-Sánchez J, Lázaro-Martínez JL, Álvaro-Afonso FJ, Molines-Barroso R. Conservative surgery of diabetic forefoot osteomyelitis: how can i operate on this patient without amputation?. Int J Low Extrem Wounds 2015; 14(2):108-31. doi: 10.1177/1534734614550686.
14) Fortuna C, Giaudrone I, Saucedo Á, Scópice R, Silva L, Silveira J, et al. Calidad de vida en pacientes diabéticos amputados menores de 60 años en Hospital Pasteur, Uruguay. En el período de agosto - setiembre de 2018. An Fac Med (Univ Repúb Urug) 2021; 8(S1). Disponible en: https://revistas.udelar.edu.uy/OJS/index.php/anfamed/article/view/458 [Consulta: 24 set 2021].
15) López Chapuis D, Esperón A, Vallverdú M, Gómez Fossati C. Amputaciones de causa vascular. Selección del nivel. Cir Urug 1996;66(3):139-47. Disponible en: https://revista.scu.org.uy/index.php/cir_urug/article/view/4254 [Consulta: 24 set 2021].
16) Toursarkissian B, Shireman PK, Harrison A, D’Ayala M, Schoolfield J, Sykes MT. Major lower extremity amputations: contemporary experience in a single Veterans Affairs institution. Am Surg 2002; 68(7):606-10.
17) Schofield CJ, Libby G, Brennan GM, MacAlpine RR, Morris AD, Leese GP, et al. Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes. Diabetes Care 2006; 29(10):2252-6. doi: 10.2337/dc06-0926.
18) Martins-Mendes D, Monteiro-Soares M, Boyko EJ, Ribeiro M, Barata P, Lima J, et al. The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk. J Diabetes Complications 2014; 28(5):632-8.
19) Rice LB. The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and clostridium difficile. Clin Infect Dis 2008; 46:491-6.
20) Hayashi Y, Paterson DL. Strategies for reduction in duration of antibiotic use in hospitalized patients. Clin Infect Dis 2011; 52:1232-40.
21) van Asten SAV, Mithani M, Peters EJG, La Fontaine J, Kim PJ, Lavery LA. Complications during the treatment of diabetic foot osteomyelitis. Diabetes Res Clin Pract 2018; 135:58-64. doi: 10.1016/j.diabres.2017.06.002.
22) Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54(12):e132-73. doi: 10.1093/cid/cis346.
23) Hartemann-Heurtier A, Senneville E. Diabetic foot osteomyelitis. Diabetes Metab 2008; 34:87-95.
24) Senneville E, Lombart A, Beltrand E, Valette M, Legout L, Cazaubiel M, et al. Outcome of diabetic foot osteomyelitis treated nonsurgically: a retrospective cohort study. Diabetes Care 2008; 31:637-42.
25) Game FL, Jeffcoate WJ. Primarily non-surgical management of osteomyelitis of the foot in diabetes. Diabetologia 2008; 51(6):962-7. doi: 10.1007/s00125-008-0976-1.
26) Jordano-Montañez Q, Muñiz-Tatay M, Viadé-Julia J, Jaen-Manzanera A, Royo-Serrando J, Cuchí-Burgos E, et al. [Diabetic foot osteomyelitis: is conservative treatment possible?]. Enferm Infecc Microbiol Clin 2014; 32(9):555-9. doi: 10.1016/j.eimc.2014.03.012.
27) Lipsky BA. Bone of contention: diagnosing diabetic foot osteomyelitis. Clin Infect Dis 2008; 47(4):528-30.
28) Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, et al. Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment. Diabetes Metab Res Rev 2008; 24(Suppl 1):S145-61. doi: 10.1002/dmrr.836.
29) Lipsky BA. Treating diabetic foot osteomyelitis primarily with surgery or antibiotics: have we answered the question?. Diabetes Care 2014; 37(3):593-5. doi: 10.2337/dc13-251.
30) Senneville E, Robineau O. Treatment options for diabetic foot osteomyelitis. Expert Opin Pharmacother 2017; 18(8):759-65. doi: 10.1080/14656566.2017.13163.
31) Zeun P, Gooday C, Nunney I, Dhatariya K. Predictors of outcomes in diabetic foot osteomyelitis treated initially with conservative (nonsurgical) medical management: a retrospective study. Int J Low Extrem Wounds 2016; 15(1):19-25. doi: 10.1177/1534734615596892.
32) Conterno LO, da Silva Filho CR. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev 2009; 3:CD004439.
33) Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis 2012; 54(3):393-407. doi: 10.1093/cid/cir842.
34) Molines-Barroso RJ, Lázaro-Martínez JL, Aragón-Sánchez J, García Morales E, Beneit-Montesinos JV, Álvaro-Afonso FJ. Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads. Diabet Med 2013; 30(8):973-6. doi: 10.1111/dme.12202.
35) Atway S, Nerone VS, Springer KD, Woodruff DM. Rate of residual osteomyelitis after partial foot amputation in diabetic patients: a standardized method for evaluating bone margins with intraoperative culture. J Foot Ankle Surg 2012; 51(6):749-52. doi: 10.1053/j.jfas.2012.06.017.
36) Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, et al. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32(Suppl 1):45-74. doi:1 0.1002/dmrr.2699.
37) Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle 2016; 7:30079. doi: 10.3402/dfa.v7.30079.
38) Aragón-Sánchez J, Lázaro-Martínez JL, Hernández-Herrero C, Campillo-Vilorio N, Quintana-Marrero Y, García-Morales E, et al. Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series. Diabet Med 2012; 29(6):813-8. doi: 10.1111/j.1464-5491.2011.03528.
39) Lázaro-Martínez JL, Aragón-Sánchez J, Álvaro-Afonso FJ, García-Morales E, García-Álvarez Y, Molines-Barroso RJ. The best way to reduce reulcerations: if you understand biomechanics of the diabetic foot, you can do it. Int J Low Extrem Wounds 2014; 13(4):294-319. doi: 10.1177/1534734614549417.
40) Piaggesi A, Iacopi E, Pieruzzi L, Coppelli A, Goretti C. Diabetic foot surgery “Made in Italy”. Results of 15 years of activity of a third-level centre managed by diabetologists. Diabetes Res Clin Pract 2020; 167:108355.
41) Boffeli TJ, Goss MS. Distal Syme hallux amputation for tip of toe wounds and gangrene complicated by osteomyelitis of the distal phalanx: surgical technique and outcome in consecutive cases. J Foot Ankle Surg 2018; 57:456-61.
42) Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg 2007; 24:469-82.
43) Griffiths GD, Wieman TJ. Metatarsal head resection for diabetic foot ulcers. Arch Surg 1990; 125:832-5.
44) Tardáguila-García A, Sanz-Corbalán I, Molines-Barroso RJ, Álvaro-Afonso FJ, García-Álvarez Y, Lázaro-Martínez JL. Complications associated with the approach to metatarsal head resection in diabetic foot osteomyelitis. Int Wound J 2018; 16(2):467-72.
45) Molines-Barroso RJ, Lázaro-Martínez JL, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Klepzig JL, Aragón-Sánchez J. Validation of an algorithm to predict reulceration in amputation patients with diabetes. Int Wound J 2017; 14(3):523–8. doi: 10.1111/iwj.12639.
46) Bakker K, Schaper NC. The development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012; 28(Suppl 1):116–8. doi: 10.1002/ dmrr.2254.
47) Game FL. Osteomyelitis in the diabetic foot: diagnosis and management. Med Clin North Am 2013; 97(5):947–56. doi: 10.1016/j.mcna.2013.03.010.
2) Henke PK, Blackburn SA, Wainess RW, Cowan J, Terando A, Proctor M, et al. Osteomyelitis of the foot and toe in adults is a surgical disease: conservative management worsens lower extremity salvage. Ann Surg 2005; 241(6):885-94. doi: 10.1097/01.sla.0000164172.28918.3f.
3) Aragón-Sánchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. Int J Low Extrem Wounds 2010; 9(1):37-59. doi: 10.1177/1534734610361949.
4) Piaggesi A, Schipani E, Campi F, Romanelli M, Baccetti F, Arvia C, et al. Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial. Diabet Med 1998; 15(5):412-7. doi: 10.1002/(SICI)1096-9136(199805)15:5<412::AID-DIA584>3.0.CO;2-1.
5) Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care 2014; 37:789-95.
6) Tone A, Nguyen S, Devemy F, Topolinski H, Valette M, Cazaubiel M, et al. Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: a multicenter open-label controlled randomized study. Diabetes Care 2015; 38(2):302-7. doi: 10.2337/dc14-1514.
7) Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, et al. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36(Suppl 1):e3280. doi: 10.1002/dmrr.3280.
8) Schinca N, Jorge AM, Pedreira W. Amputaciones en infecciones profundas del pie diabético. (Resúmenes XIII Congreso de la Asociación Latinoamericana de Diabetes). Rev ALAD 2007; XV(4):187.
9) Tan JS, Friedman NM, Hazelton-Miller C, Flanagan JP, File TM Jr. Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation? Clin Infect Dis 1996; 23(2):286-91.
10) Shaikh N, Vaughan P, Varty K, Coll AP, Robinson AH. Outcome of limited forefoot amputation with primary closure in patients with diabetes. Bone Joint J 2013; 95-B(8):1083-7. doi: 10.1302/0301-620X.95B8.31280.
11) Widatalla AH, Mahadi SE, Shawer MA, Mahmoud SM, Abdelmageed AE, Ahmed ME. Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment. Diabet Foot Ankle 2012; 3:1. doi: 10.3402/dfa.v3i0.18809.
12) Lázaro-Martínez JL, García-Madrid M, García-Álvarez Y, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Morales E. Conservative surgery for chronic diabetic foot osteomyelitis: procedures and recommendations. J Clin Orthop Trauma 2020; 16:86-98. doi: 10.1016/j.jcot.2020.12.014.
13) Aragón-Sánchez J, Lázaro-Martínez JL, Álvaro-Afonso FJ, Molines-Barroso R. Conservative surgery of diabetic forefoot osteomyelitis: how can i operate on this patient without amputation?. Int J Low Extrem Wounds 2015; 14(2):108-31. doi: 10.1177/1534734614550686.
14) Fortuna C, Giaudrone I, Saucedo Á, Scópice R, Silva L, Silveira J, et al. Calidad de vida en pacientes diabéticos amputados menores de 60 años en Hospital Pasteur, Uruguay. En el período de agosto - setiembre de 2018. An Fac Med (Univ Repúb Urug) 2021; 8(S1). Disponible en: https://revistas.udelar.edu.uy/OJS/index.php/anfamed/article/view/458 [Consulta: 24 set 2021].
15) López Chapuis D, Esperón A, Vallverdú M, Gómez Fossati C. Amputaciones de causa vascular. Selección del nivel. Cir Urug 1996;66(3):139-47. Disponible en: https://revista.scu.org.uy/index.php/cir_urug/article/view/4254 [Consulta: 24 set 2021].
16) Toursarkissian B, Shireman PK, Harrison A, D’Ayala M, Schoolfield J, Sykes MT. Major lower extremity amputations: contemporary experience in a single Veterans Affairs institution. Am Surg 2002; 68(7):606-10.
17) Schofield CJ, Libby G, Brennan GM, MacAlpine RR, Morris AD, Leese GP, et al. Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes. Diabetes Care 2006; 29(10):2252-6. doi: 10.2337/dc06-0926.
18) Martins-Mendes D, Monteiro-Soares M, Boyko EJ, Ribeiro M, Barata P, Lima J, et al. The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk. J Diabetes Complications 2014; 28(5):632-8.
19) Rice LB. The Maxwell Finland Lecture: for the duration-rational antibiotic administration in an era of antimicrobial resistance and clostridium difficile. Clin Infect Dis 2008; 46:491-6.
20) Hayashi Y, Paterson DL. Strategies for reduction in duration of antibiotic use in hospitalized patients. Clin Infect Dis 2011; 52:1232-40.
21) van Asten SAV, Mithani M, Peters EJG, La Fontaine J, Kim PJ, Lavery LA. Complications during the treatment of diabetic foot osteomyelitis. Diabetes Res Clin Pract 2018; 135:58-64. doi: 10.1016/j.diabres.2017.06.002.
22) Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54(12):e132-73. doi: 10.1093/cid/cis346.
23) Hartemann-Heurtier A, Senneville E. Diabetic foot osteomyelitis. Diabetes Metab 2008; 34:87-95.
24) Senneville E, Lombart A, Beltrand E, Valette M, Legout L, Cazaubiel M, et al. Outcome of diabetic foot osteomyelitis treated nonsurgically: a retrospective cohort study. Diabetes Care 2008; 31:637-42.
25) Game FL, Jeffcoate WJ. Primarily non-surgical management of osteomyelitis of the foot in diabetes. Diabetologia 2008; 51(6):962-7. doi: 10.1007/s00125-008-0976-1.
26) Jordano-Montañez Q, Muñiz-Tatay M, Viadé-Julia J, Jaen-Manzanera A, Royo-Serrando J, Cuchí-Burgos E, et al. [Diabetic foot osteomyelitis: is conservative treatment possible?]. Enferm Infecc Microbiol Clin 2014; 32(9):555-9. doi: 10.1016/j.eimc.2014.03.012.
27) Lipsky BA. Bone of contention: diagnosing diabetic foot osteomyelitis. Clin Infect Dis 2008; 47(4):528-30.
28) Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, et al. Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment. Diabetes Metab Res Rev 2008; 24(Suppl 1):S145-61. doi: 10.1002/dmrr.836.
29) Lipsky BA. Treating diabetic foot osteomyelitis primarily with surgery or antibiotics: have we answered the question?. Diabetes Care 2014; 37(3):593-5. doi: 10.2337/dc13-251.
30) Senneville E, Robineau O. Treatment options for diabetic foot osteomyelitis. Expert Opin Pharmacother 2017; 18(8):759-65. doi: 10.1080/14656566.2017.13163.
31) Zeun P, Gooday C, Nunney I, Dhatariya K. Predictors of outcomes in diabetic foot osteomyelitis treated initially with conservative (nonsurgical) medical management: a retrospective study. Int J Low Extrem Wounds 2016; 15(1):19-25. doi: 10.1177/1534734615596892.
32) Conterno LO, da Silva Filho CR. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev 2009; 3:CD004439.
33) Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis 2012; 54(3):393-407. doi: 10.1093/cid/cir842.
34) Molines-Barroso RJ, Lázaro-Martínez JL, Aragón-Sánchez J, García Morales E, Beneit-Montesinos JV, Álvaro-Afonso FJ. Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads. Diabet Med 2013; 30(8):973-6. doi: 10.1111/dme.12202.
35) Atway S, Nerone VS, Springer KD, Woodruff DM. Rate of residual osteomyelitis after partial foot amputation in diabetic patients: a standardized method for evaluating bone margins with intraoperative culture. J Foot Ankle Surg 2012; 51(6):749-52. doi: 10.1053/j.jfas.2012.06.017.
36) Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, et al. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32(Suppl 1):45-74. doi:1 0.1002/dmrr.2699.
37) Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle 2016; 7:30079. doi: 10.3402/dfa.v7.30079.
38) Aragón-Sánchez J, Lázaro-Martínez JL, Hernández-Herrero C, Campillo-Vilorio N, Quintana-Marrero Y, García-Morales E, et al. Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series. Diabet Med 2012; 29(6):813-8. doi: 10.1111/j.1464-5491.2011.03528.
39) Lázaro-Martínez JL, Aragón-Sánchez J, Álvaro-Afonso FJ, García-Morales E, García-Álvarez Y, Molines-Barroso RJ. The best way to reduce reulcerations: if you understand biomechanics of the diabetic foot, you can do it. Int J Low Extrem Wounds 2014; 13(4):294-319. doi: 10.1177/1534734614549417.
40) Piaggesi A, Iacopi E, Pieruzzi L, Coppelli A, Goretti C. Diabetic foot surgery “Made in Italy”. Results of 15 years of activity of a third-level centre managed by diabetologists. Diabetes Res Clin Pract 2020; 167:108355.
41) Boffeli TJ, Goss MS. Distal Syme hallux amputation for tip of toe wounds and gangrene complicated by osteomyelitis of the distal phalanx: surgical technique and outcome in consecutive cases. J Foot Ankle Surg 2018; 57:456-61.
42) Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg 2007; 24:469-82.
43) Griffiths GD, Wieman TJ. Metatarsal head resection for diabetic foot ulcers. Arch Surg 1990; 125:832-5.
44) Tardáguila-García A, Sanz-Corbalán I, Molines-Barroso RJ, Álvaro-Afonso FJ, García-Álvarez Y, Lázaro-Martínez JL. Complications associated with the approach to metatarsal head resection in diabetic foot osteomyelitis. Int Wound J 2018; 16(2):467-72.
45) Molines-Barroso RJ, Lázaro-Martínez JL, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Klepzig JL, Aragón-Sánchez J. Validation of an algorithm to predict reulceration in amputation patients with diabetes. Int Wound J 2017; 14(3):523–8. doi: 10.1111/iwj.12639.
46) Bakker K, Schaper NC. The development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012; 28(Suppl 1):116–8. doi: 10.1002/ dmrr.2254.
47) Game FL. Osteomyelitis in the diabetic foot: diagnosis and management. Med Clin North Am 2013; 97(5):947–56. doi: 10.1016/j.mcna.2013.03.010.
Published
2022-03-29
How to Cite
1.
Orellano P, Maglione O, Irastoza L, Gastambide M, Torres Negreira M, Urdangarin M del H, Introini L, Cabrera M, Vucovich L. Diabetic foot osteomyelitis. Rev. Méd. Urug. [Internet]. 2022Mar.29 [cited 2024Dec.18];38(1):e38110. Available from: https://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/878
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