Abstract
Diabetic patients are at increased risk of developing foot ulcers which may cause bone infections associated with a high probability of both amputation and mortality. Therefore, prompt diagnosis and adequate treatment are of key importance. In our Diabetic Foot Unit, effective multidisciplinary treatment of osteomyelitis secondary to diabetes involves the application of a gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute to fill residual bone voids after debridement. The data of all patients treated with the gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute for diabetic foot infections with ulcer formation and osteomyelitis at metatarsals, calcaneus and hindfoot at our institute from July 2013 to September 2016 were retrospectively collected and evaluated. A total of 35 patients were included in this retrospective single-arm case series and were either continuously followed up for at least one year or until healing was confirmed. Nineteen lesions affected the distal row of tarsus/talus, ten the calcaneus and a further six were located at the metatarsals. While all of the metatarsal lesions had healed at 1-year follow-up, the healing rate in the hindfoot region was lower with 62.5% at the calcaneus and 72.2% at the distal tarsus and talus at 12 months, respectively. The overall cure rate for ulcerous bone infection was 81.3%. In two calcaneal lesions (25%) and two lesions of distal tarsus/talus (11.1%) amputation was considered clinically necessary. Promising results were achieved in the treatment of diabetic foot infections with soft tissue ulcers by a multidisciplinary approach involving extensive debridement followed by adequate dead space management with a resorbable gentamicin-eluting bone graft substitute.
Highlights
Pathologies of the foot, for example chronic foot ulcers, Charcot neuropathic osteoarthropathy or osteomyelitis of the foot are common complications secondary to diabetes mellitus and are considered to be an increasing medical problem [1]
In this paper we present a multidisciplinary team approach for the treatment of diabetic foot osteomyelitis including surgical debridement of the bone, microbiological sampling, and application of an absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite (CERAMENT® G, BONESUPPORT AB, Lund, Sweden)
Apart from insulin-treated diabetes mellitus type 2 (5/6; 83%), further risk factors associated with non-healing lesions involved arterial hypertension (5/6, 83%), Charcot foot or foot deformity (3/6; 50%), renal impairment or chronic kidney disease (3/6; 50%), coronary heart disease or ischemic cardiomyopathy (50%), atrial fibrillation (50%), dyslipidaemia (50%) and critical limb ischemia or peripheral artery disease (2/6; 33%)
Summary
Pathologies of the foot, for example chronic foot ulcers, Charcot neuropathic osteoarthropathy or osteomyelitis of the foot are common complications secondary to diabetes mellitus and are considered to be an increasing medical problem [1]. The lifetime risk of developing a foot ulcer is as high as 15% in diabetic patients [4,5] and 14% to 24% of the patients with chronic ulcers are treated by amputation [6]. Foot ulcers are the most common foot problem in diabetic patients [3] and are often associated with Charcot neuropathy or osteomyelitis [11,12]. Bone infection is considered rather as a consequence than a cause of the ulceration [13,14], and is present in more than half of diabetic ulcer cases [3]. Diabetic foot ulcers progressing to bone infection and, to amputation, account for 60% of nontraumatic lower limb amputations [15]
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