SLR - June 2018 - Samuel G. Kellner
Treatment Failure and Leg Amputation Among Patients with Foot Osteomyelitis
Reference: Barshes NR, Mindru C, Ashong C, Rodriguez-Barradas M, Trautner BW. Treatment Failure and Leg Amputation Among Patient with Foot Osteomyelitis. Intl Journal of Lower Extremity Wounds. 2016 Aug; 15(4):303–312.
Scientific Literature Review
Reviewed By: Samuel G. Kellner, DPM
Residency Program: MetroWest Medical Center, Framingham, MA
Podiatric Relevance: Osteomyelitis of the foot is a highly frequented topic in podiatric literature due to its incidence and associated healthcare costs. Management of this disease remains somewhat controversial and continues to develop and change through evidence-based medicine. Most of the reported literature available provides diagnostic information; however, this article focuses more on prognostic value with the association of amputation rates with treatment failure of foot osteomyelitis.
Methods: This is a retrospective review between 2011 and 2015 of 184 patients evaluated at a VA Medical Center. All patients met the inclusion criteria, which was meeting “definite or probable” osteomyelitis according to the International Working Group for the Diabetic Foot consensus definition. The primary outcome of the study measured the incidence at which treatment failure lead to unanticipated bone resection or proximal leg amputation.
Results: Of the 184 patients in the study, 91.8 percent of patients were treated with surgical management while 8.2 percent were treated with antibiotic therapy alone. Treatment failure occurred in 28.8 percent of patients with 11.4 percent of patients undergoing a proximal leg amputation. There was a higher correlation of treatment failure in patients with underlying PAD, increased severity of foot infection (especially with E. coli and P. aeruginosa organisms) and somewhat more common in patients who underwent revascularization.
Conclusions: The authors discuss the reasoning for the increased treatment failure rates to a multifactorial cause. Patients with severe PAD resulted in increased treatment failure rates; however, there did not seem to be much difference to those who underwent revascularization. There does not appear to be a significant relationship between unanticipated bone resection and proximal leg amputation, as this occurred in only 28.6 percent of cases. The majority of leg amputations were linked to severe PAD, lack of targeted antibiosis with bone cultures, malnutrition, homelessness, ESRD and patients treated under palliative care. The limitations of this study are that it is retrospective with inability to link direct causal relationships to outcomes of foot osteomyelitis. Very few patients underwent isolated antibiotic therapy, and there was inconsistency for duration of antibiotics. At this time, there needs to be more development of objective endpoints to study the long-term outcomes of osteomyelitis, as well as evaluation of alternative management approaches inclusive of all patient risk factors.