Osteomyelitis in the Diabetic Patient

by Robert Snyder, DPM, FACFAS, CWS
 Medical Director of the Wound Healing Center
University Hospital, Tamarac, Florida
Director of Wound Management Education,
Northwest Medical Center in Margate, Florida

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Dr. Snyder knows a thing or two about wound care. In 1999, he was selected to participate in the renowned wound-healing program held every summer at Oxford University, Oxford, England.  It seems each time you canvas through the podiatry literature, there is an informative article by Dr. Snyder.  PRESENT Courseware decided to pick his brain and see what his thoughts were on Osteomyelitis.

Dr. Snyder first presents a typical diabetic foot emergency admission. We are then challenged to determine whether or not this patient has Osteomyelitis. A comprehensive history and physical exam including vascular, neurologic and nutritional assessments is warranted. A good blood work up is especially important as well.

Typical radiographs are inaccurate, and often lag 14 days behind the clinical course. At that juncture, 30%-60% of the bone is already destroyed. Triple phase scans are blood flow dependent and therefore may not be a good stand-alone test in a patient with micro vascular dysfunction. Indium and Ceretec scans are more accurate and less blood flow dependent. The MRI may be the single best imaging test to diagnose Osteomyelitis, but the gold standard is the bone biopsy. The biopsy is the most credible way of distinguishing between Osteomyelitis and Charcot arthropathy. Dr. Snyder advises that a bone culture be performed with all biopsies; in this way a clinician can choose antibiotic protocols wisely.

The patient with ulcers greater than 2cm² and /or 3mm in depth should probably be treated as though they have Osteomyelitis. Eighty five percent of patients who have exposed bone or have wounds that probe to bone have Osteomyelitis as well.

Dr. Snyder reminds us that a subtle balance between medical and surgical therapies is necessary to achieve a potentially curative outcome. Because concentrations of antibiotics in bone is a fraction of the level in serum, the duration of treatment for Osteomyelitis is longer (4-6 weeks) than for soft tissue infections. Dr. Snyder discusses antibiotic impregnated polymethylmethacrylate beads and how they can augment the treatment of Osteomyelitis. If surgery had been used to eradicate all necrotic tissue, the course of treatment may be shorter. This is especially true after amputations.

Restoring a viable vascular environment is of paramount importance. Dr. Snyder discusses newer approaches to vascular reconstruction including endovascular techniques.

Treating a patient with confidence and assurance is what it is all about. Dr. Snyder gives us the boost we all need.

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