Early Clinical Recognition of Chronic Osteomyelitis in the Diabetic Foot Wound

Introduction: In a PT-driven wound clinic without physician oversight, it is important to clinically recognize chronic osteomyelitis in a diabetic foot wound to expedite early and appropriate treatment. As PTs, we cannot order imaging, labs or write referrals to other disciplines requiring us to reach out to providers with our recommendations.Methods:Regardless of your profession, early clinical recognition of chronic osteomyelitis can expedite appropriate imaging and treatment; including, imaging to confirm osteomyelitis and rule out arterial disease, early antibiotic treatment along with appropriate debridement, topical management and proper offloading with the gold standard being a total contact cast.Results:Optimizing outcomes for limb preservation includes appropriate antibiotic management, controlling diabetes, smoking cessation and appropriate offloading. The more chronic a wound is, the more likely it is to require surgical resection.Discussion: Early diagnosis is essential in preventing surgical measures.  The assessment of arterial perfusion is recommended by evidence-based guidelines for treatment of patients with lower extremity wounds. In patients with diabetes, TcPO2s can determine healing potential. Further research needs to be completed on removable offloading devices and their effectiveness on healing plantar diabetic foot wounds when the total contact cast is not appropriate.References: Arnold JF, Marmolejo V. Outcomes achieved with use of a prefabricated roll-on total contact cast. Foot Ankle Int. 2017;38(10):1126-1131.  Chemboli MJ, Rao R B, Pathri S, Pathri C, Paka VK. Total contact casting: A forgotten art in the management of neuropathic foot ulcers. J Orthop Dis Traumatol 2022; 5:151-6.  Cunha B. Diabetic Foot Infections. Emedicine. 2009. Retrieved online 4/23/23 at https://emedicine.medscape.com/article/237378-overview.  Dr. Sudhir S, Dr. Dilip DK, Dr. Kirthiga Thiagarajan, Dr. Deepak Naik P, Dr. Thulasi Vasudevaiah. Efficacy of total contact cast application versus conventional dressings in the management of plantar diabetic ulcers. Int J Surg Sci 2020;4(4):70-72.  Gardner SE, Hillis SL, Frantz RA. Clinical signs of infection in diabetic foot ulcers with high microbial load. Biol Res Nurs. 2009 Oct; 11(2):119-28  Hicks CW, Canner JK, Karagozlu H, Mathioudakis N, Sherman RL, Black JH 3rd, Abularrage CJ. Contribution of 30-day readmissions to the increasing costs of care for the diabetic foot. J Vasc Surg. 2019 Oct;70(4):1263-1270. doi: 10.1016/j.jvs.2018.12.028. Epub 2019 Mar 6. PMID: 30850287.  (IDSA) Infectious Diseases Society of America. Authors: Lipsky BA, Berendt AR, Deery HG, Embi JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DIP, Mader JT, Norden C, Tan JS; “Diagnosis and Treatment of Diabetic Foot Infections” Clinical Infectious Diseases 2004; 39:885-910.  International Working Group on the Diabetic Foot (IWGDF). IWGDF Guidelines for Diagnosis, Prognosis and Management of Peripheral Artery Disease in Patients with a Foot Ulcer and Diabetes. IWGOF; 2019.  Sahu B, Prusty A, Tudu B. Total contact casting versus traditional dressing in diabetic foot ulcers. J Orthop Surg (Hong Kong). 2018 May-Aug;26(3):2309499018802486. doi: 10.1177/2309499018802486. PMID: 30295168.  Snyder RJ, Frykberg RG, Rogers LC, Applewhite AJ, Bell D, Bohn G, Fife CE, Jensen J, Wilcox J. The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014 Nov;104(6):555-67. doi: 10.7547/8750-7315-104.6.555. PMID: 25514266.  Snyder RJ. Kirsner RS, Warriner RA 3rd. Lavery LA, Hanft JR, Sheehan P. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manage. 2010 Apr; 56(4 Suppl):S1-24.  Tickner A, Klinghard C, Arnold JF, Marmolejo V. Total contact cast use in patients with peripheral arterial disease: a case series and systematic review. Wounds. 2018;30(2):49-56.  Wound Care Education Institute. Diabetic Skin and Wound Management Course: Online Seminar Workbook. Relias LLC; 2012.