SLR - August 2020 - Christopher A. Bergen

Low Intensity Pulse Ultrasound: A New Tool in the Conservative Management of Diabetic Foot Complicated by Osteomyelitis?

Reference: Di Campli C, Collina MC, Gossetti B, Ricci E. Low Intensity Pulse Ultrasound: A New Tool in the Conservative Management of Diabetic Foot Complicated by Osteomyelitis? Clin Surgery. 2019 Feb 10; 5, 2732

Scientific Literature Review

Reviewed By: Christopher A. Bergen, DPM
Residency Program: St. Mary’s General Hospital – Passaic, NJ 

Podiatric Relevance: Diabetic foot ulcers (DFUs)  are a common etiology seen by the podiatric community. These DFUs are frequently complicated by infection that represents the main cause for major lower limb amputation in the non-traumatic patient. When osteomyelitis is present, conservative options are limited to long term antibiotic therapy, however is associated with increased risk of antibiotic resistance and systemic complications including renal and hepatic toxicity. This article presents a new tool in utilizing Low Intensity Pulse Ultrasound (LIPUS) as a safe and effective adjunct procedure for the conservative management of DFU complicated by osteomyelitis in order to demonstrate a beneficial effect on clinical and radiographical healing. 

Methods: This observational study followed 15 patients affected by Diabetic Foot Osteomyelitis (DFO) between June 2016 – December 2016.  Inclusion criteria included age ≥ 18 years, type 2 diabetes neuropathic complicated by osteomyelitis, non-healing for at least six months, and compliance to attend the visits during the follow up period. At enrollment of study all patients had a complete medical evaluation and focused examination, wound cultures were obtain, radiographic images were performed, inflammatory markers (WBC, ESR, CRP) were recorded, along with offloading of wound, and initiation of empirical antibiotic therapy. Treatment with the LIPUS device was applied at home for 20 minutes daily at the site of affected bone for 90 days. At the end of LIPUS therapy, the effectiveness of treatment was assessed by decrease inflammatory markers, radiographic findings, ulcer healing and recurrence rate. 

Results: After 12 weeks of treatment with LIPUS, no side effects were recorded in all 15 patients treated. Normalization of all inflammatory markers were observed. Thirteen out of 15 patients healed after LIPUS treatment. Of the two exceptions, one had full healing of ulcer site two months after completion of LIPUS treatment, while the other improvement was observed but without complete re-epithelization of ulcer. No recurrence, defined as an absence of any signs of infection at the initial or a contiguous site, during the one-year follow up period.  

Conclusions: This study demonstrated LIPUS as a feasible adjunct treatment option with addition of antibiotic therapy and proper local wound care in the conservative management of DFO. It showed LIPUS to be a safe, low risk, and an effective therapy. The authors hypothesized that this treatment by helping bone consolidation and microcirculation in the wound area, may lead to acceleration of wound healing and promote the bone reaction avoiding also recurrence of ulceration. These results show LIPUS as a promising new tool in the armamentarium of the podiatric physicians in the treatment of limb salvage for these complex and challenging  problems in the treatment of the diabetic patient. 

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