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Background: A universally accepted histopathologic classification of diabetic foot osteomyelitis does not currently exist. We sought to evaluate the histopathologic characteristics of bone infection found in the feet of diabetic patients and to analyze the clinical variables related to each type of bone infection., Methods: We conducted an observational prospective study of 165 diabetic patients with foot ulcers who underwent surgery for bone infection. Samples for microbiological and histopathologic analyses were collected in the operating room under sterile conditions., Results: We found four histopathologic types of osteomyelitis: acute osteomyelitis (n = 46; 27.9%), chronic osteomyelitis (n = 73; 44.2%), chronic acute osteomyelitis (n = 14; 8.5%), and fibrosis (n =32; 19.4%). The mean ± SD time between the initial detection of ulcer and surgery was 15.4 ± 23 weeks for acute osteomyelitis, 28.6 ± 22.4 weeks for chronic osteomyelitis, 35 ± 31.3 weeks for chronic acute osteomyelitis, and 27.5 ± 27.3 weeks for the fibrosis stage (analysis of variance: P = .03). Bacteria were isolated and identified in 40 of 46 patients (87.0%) with acute osteomyelitis, 61 of 73 (83.5%) with chronic osteomyelitis, 11 of 14 (78.6%) with chronic acute osteomyelitis, and 25 of 32 (78.1%) with fibrosis., Conclusions: Histopathologic categorization of bone infections in the feet of diabetic patients should include four groups: acute, chronic, chronic acute, and fibrosis. We suggest that new studies should identify cases of fibrosis to allow comparison with the present results.

The forefoot has been reported as the most frequent location of osteomyelitis in the feet of patients with diabetes. The forefoot includes toes and metatarsal heads as common locations of bone infections, but the anatomy of these bones is quite different. As a result, such differences in anatomy may have an impact on the outcomes. The aim of the present study was to determine whether different locations of osteomyelitis in the forefoot have any influence on time to healing after undergoing surgery in a prospective series including 195 patients without peripheral arterial disease and osteomyelitis confirmed by histopathology. Location of the lesion was classified into 4 groups: hallux, first metatarsal head, lesser metatarsal heads, and lesser toes. The time required to achieve healing and the cumulative rate of wounds healed and likelihood of healing were analyzed at 4, 8, and 12 weeks after surgery. Time of healing (mean ± SD) in the whole series was 10.7 ± 8.4 weeks. Osteomyelitis located in the lesser toes has a higher probability of healing by the fourth week (odds ratio [OR] = 5.7, 95% confidence interval [CI] = 2.8-11.6, P < .001), eighth week (OR = 3.2, 95% CI = 1.6-6.4, P < .001), or twelfth week (OR = 3.1, 95% CI = 1.3-7.0, P = .008) than other osteomyelitis locations. Osteomyelitis located in the first metatarsal joint was less likely to heal by the eighth week (OR = 0.4, 95% CI = 0.2-0.9, P = .037) and 12th week (OR = 0.4, 95% CI = 0.2-1.0, P = .040). In conclusion, time to healing is significantly different according to the location of the bone infection in the forefoot. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to analyze the interobserver and intraobserver variability in plain radiography in the diagnosis of diabetic foot osteomyelitis. A prospective observational study was performed from October 1, 2009, to July 31, 2011, on patients with diabetic foot ulcers, with clinically suspected osteomyelitis who were admitted to the Diabetic Foot Unit of the Complutense University of Madrid. Two professional groups examined 123 plain X-rays, each group comprising 3 different levels of clinical experience. To analyze intraobserver variability, 2 months later plain X-rays were reanalyzed by one of the clinical groups. When using only plain radiography for the diagnosis of osteomyelitis in the diabetic foot, low concordance rates were observed for clinicians with a similar level of experience: experienced clinicians (K11AB = .35, P < .001), moderately experienced clinicians (K22AB = .39, P < .001), and inexperienced clinicians (K33AB = .40, P < .001). Intraobserver agreement was highest in experienced clinicians (K11A = .75, P < .001), followed by moderately experienced clinicians (K22A = .61, P < .001) and inexperienced clinicians (K33A = .57, P < .001). Plain radiography for the diagnosis of diabetic foot osteomyelitis is operator dependent and shows low association strength, even among experienced clinicians, when interpreted in isolation without knowing the clinical characteristics of the lesion. [ABSTRACT FROM AUTHOR]

Abstract: Osteomyelitis is a challenging problem when it appears in the feet of patients with diabetes. Although the most frequent port of entry for bacteria is an ulcer, surgical wounds also permit entry of bacteria into the foot. This surgical complication may become limb-threatening, and treatment is a challenge. Here we present two cases of patients with neuropathic feet and palpable distal pulses, who were previously treated with surgery, and who presented with spreading bone infection in the midfoot. Pictures and radiological studies are shown. In both cases, bone infection caused severe destruction of the architecture of the midfoot, and the limbs of both patients were threatened. Midfoot osteomyelitis is associated with a higher rate of major amputations than osteomyelitis of the forefoot. Furthermore, meticillin-resistant Staphylococcus aureus was isolated in one of the cases. Our successful limb salvage approach was based on three steps: 1) removing the infected bone; 2) culture-guided antibiotic treatment; and 3) stabilizing the infected foot by means of total contact casting with openings resulting in a stable foot. To the best of our knowledge, there are no reports of the use of a total contact cast to stabilize an unstable and infected foot. Eight years (Case 1) and four years (Case 2) after complete healing, there were no recurrences of infection. [Copyright &y& Elsevier]