Treating Diabetic Foot Osteomyelitis Primarily With Surgery or Antibiotics: Have We Answered the Question?

Foot infections are among the most frequent diabetes-related causes for hospitalization and the usual immediate predecessor to lower-extremity amputation in these patients (1). Infection usually starts in ulcerated soft tissues, but can spread contiguously to underlying bone (2). Overall, about 20% of patients with a diabetic foot infection (and over 60% of those with severe infections [3]) have underlying osteomyelitis, which dramatically increases the risk of lower-extremity amputation (4). Indeed, optimally managing diabetic foot osteomyelitis is widely considered the most difficult and controversial aspect of dealing with diabetic foot infections (5–7).

In the preantibiotic era, the only option for treating osteomyelitis was surgical resection of all necrotic and infected bone. Because surgeons feared further spread of infection up the limb in what was then called “diabetic gangrene,” most procedures were major (often above the knee) amputations (8). The advent of antibiotic therapy led to a marked reduction in both mortality (9–11) and need for major amputations (10,11) in patients with diabetic foot infections. Antibiotic therapy was largely considered adjunctive to surgery, but in the past two decades reports appeared of patients with diabetic foot osteomyelitis apparently cured by antibiotic therapy with little or no surgical resection (12), leading some to reexamine the belief that surgery was almost always needed for this form of chronic osteomyelitis (13).

There are potential advantages, as well as disadvantages, to both medical and surgical treatment of diabetic foot osteomyelitis (Table 1). In some clinical situations, it is clear that one or the other approach is most appropriate (Table 2), but in most cases the …