Charcot neuroarthropathy triggered and complicated by osteomyelitis. How limb salvage can be achieved.

BACKGROUND: Charcot neuroarthropathy is a severe complication in the feet of patients with diabetes, which can lead to a major amputation. Osteomyelitis and surgery for osteomyelitis have been reported as trigger mechanisms of developing Charcot neuroarthropathy. However, the development of acute Charcot neuroarthropathy triggered by osteomyelitis during conservative antibiotic treatment is not well outlined in the medical literature. CASE REPORTS: Two patients apparently developed mid and rear foot Charcot neuroarthropathy, which was clinically suspected while being treated with antibiotics for osteomyelitis. One of them presented osteomyelitis of the navicular bone and subsequently developed acute Charcot neuroarthropathy of the tarsometatarsal joints. The other presented calcaneal osteomyelitis with pathological fracture and developed Charcot neuroarthropathy of the transverse tarsal joint. No offloading had been implemented in either case. A major amputation had been indicated in both cases in their teaching hospitals. Limb salvage was achieved in both cases by means of surgery, culture-guided post-operative antibiotics, intraosseus instillation of super-oxidized solution, bed rest before placing a total contact cast and stabilization of the unstable foot with a total contact cast with an opening for checking the healing course and to detect any complications. The mechanisms of the development of acute Charcot neuroarthropathy in a patient with osteomyelitis are discussed. CONCLUSIONS: Osteomyelitis in the feet of patients with diabetes and neuropathy may trigger the development of acute Charcot neuroarthropathy. Fractures and dislocated joints may subsequently become infected from the index focus, producing a severe infected and unstable foot that may require a major amputation. Limb salvage can be achieved in specialized departments.

Does osteomyelitis in the feet of patients with diabetes really recur after surgical treatment? Natural history of a surgical series.

AIMS/HYPOTHESIS: The aim of this study was to determine the rate of recurrence, reulceration and new episodes of osteomyelitis and the duration of postoperative antibiotic treatment in a prospective cohort of patients with diabetes who underwent conservative surgery for osteomyelitis. METHODS: The prospective cohort included patients with diabetes and a definitive diagnosis of osteomyelitis who were admitted to the Diabetic Foot Unit (Surgery Department, La Paloma Hospital, Las Palmas de Gran Canaria, Spain) and underwent surgical treatment from 1 November 2007 to 30 May 2010. RESULTS: Eighty-one patients were operated on for osteomyelitis during the study period. Seven patients were lost to follow-up at different stages of the study. The median duration of follow-up was 101.8 weeks (quartile 1 = 56.6, quartile 3 = 126.7). Forty-eight patients (59.3%) underwent conservative surgery, 32 (39.5%) had minor amputations and there was one (1.2%) major amputation. Twenty patients (24.7%) required reoperation because of persistent infection. Postoperative antibiotic treatment over a median period of 36 days was provided. Wound healing was achieved by secondary intention for a median of 8 weeks. Sixty-five patients were available for follow-up after healing. The percentage of recurrence, reulceration, and new episodes of osteomyelitis was 4.6% (3/65), 43% (28/65) and 16.9% (11/65), respectively. Mortality during follow-up (excluding in-hospital deaths and patients lost to follow-up) was 13% (9/69). CONCLUSION: A low rate of recurrence of osteomyelitis after surgical treatment for osteomyelitis was achieved. Despite new episodes, our approach to managing this cohort of patients with diabetes and foot osteomyelitis achieved 98.8% limb salvage.

Triggering mechanisms of neuroarthropathy following conservative surgery for osteomyelitis.

BACKGROUND: The purpose of this study was to raise awareness and stimulate discussion of the possible triggering factors of Charcot neuroarthropathy by presenting the case of one patient who had both undergone surgery and was suffering from osteomyelitis. CASE REPORT: We have extracted one case from our data set for a patient who underwent conservative surgery for osteomyelitis and subsequently developed acute Charcot in the midfoot. We present the clinical findings, photographs and X-ray studies. Preoperative X-ray showed irregular severe bone destruction in the fourth metatarsal head and a fracture of the fourth metatarsal bone. No signs of midfoot Charcot neuroarthropathy were found in this preoperative X-ray. The third and fourth metatarsal bones were both removed and the surgical wound was left open to heal by second intention. Histopathological study confirmed osteomyelitis in the bone sample. Twenty-five days after surgery, the surgical wound showed no signs of infection and healing progressed in a satisfactory way. However, the foot was swollen, erythematous and warm. Skin temperature was two degrees higher than the contralateral foot. X-ray was taken and acute neuroarthropathy of the tarso-metatarsal joints was diagnosed. CONCLUSIONS: Charcot neuroarthropathy appears to have been triggered by bone infection and/or surgery. We believe that the pivotal factor in the development of acute Charcot neuroarthropathy in this case was the weight bearing in the deformed foot so soon after the operation. Immobilization of the foot is critical as it serves to decrease the inflammation which has a key role in the development of Charcot neuroarthropathy.

Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series.

AIMS: The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). METHODS: We abstracted data of a series of 185 consecutive patients with diabetes and foot osteomyelitis undergoing surgery within the first 12 h after admission at a single hospital. Bone infection was confirmed by histopathological studies. Only cases where Staphylococcus aureus was isolated from bone specimens were included in this analysis. We analysed several variables between the two groups: MRSA vs. MSSA. RESULTS: MRSA bone infection was associated with higher body temperature (P = 0.02) and white blood cell count (P = 0.02) than MSSA. Patients with MRSA infections underwent a greater number of surgical procedures (P = 0.03). Limb salvage was achieved in 93.6% of the patients, with no statistically significant difference in limb salvage rates between MRSA and MSSA-related osteomyelitis. CONCLUSIONS: From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis.

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement.

AIMS/HYPOTHESIS: We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation. METHODS: A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death. RESULTS: Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection. CONCLUSIONS/INTERPRETATION: Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.