Conservative surgical treatment for metatarsal osteomyelitis in diabetic foot: experience of two French centres

AIMS

Conservative surgery (CS) for diabetic foot osteomyelitis (DFO) consists in removing all or part of the infected bone tissues without amputation, in complement with antibiotic therapy. Data on CS for DFO therapy are scarce.

MATERIAL AND METHODS

We performed a retrospective analysis of all DFO episodes treated with CS between 06/2007 and 12/2017. Remission was defined by the absence of soft-tissue infection, complete sustained (i.e. > 1 month) healing of the foot ulcer, favourable (i.e., stabilisation or improvement) radiological outcome, and no need for additional surgery during a 1-year follow-up.

RESULTS

During the study period, 47 episodes (in 41 patients) were analysed. Excluding deaths (all unrelated to the DFO; n = 3) or loss to follow-up before 1 year (n = 5), the remission rate was 64.2%. Most failures occurred during the first 6 months (79%, 11/14). Patients who experienced failure had a higher rate of peripheral arterial disease with arterial stenosis than patients in remission (57% vs. 24%, P = 0.03), a higher C-reactive protein rate at admission (116 ± 112 mg/L vs. 48 ± 46 mg/L, P = 0.02), and a trend for a higher rate of abscesses (29% vs. 4%, P = 0.06). At 1-year follow-up, foot ulcers related to transfer lesion were identified in 25.5% of the cases. At the last follow-up (mean 3 ± 2 years), the remission rate was 23/25 (92%).

CONCLUSIONS

Our results suggest that CS is a therapeutic option in patients with localised but severe DFO. Clinicians should, however, consider the necessity of revascularisation, and higher risk of failure if surgery is performed in patients presenting with acute foot infections.

Six-week versus twelve-week antibiotic therapy for nonsurgically treated diabetic foot osteomyelitis: a multicenter open-label controlled randomized study

OBJECTIVE

Little is known about the optimal duration of antibiotic therapy for diabetic foot osteomyelitis (DFO). This study sought to compare the effectiveness of 6 versus 12 weeks of antibiotic therapy in patients with DFO treated nonsurgically (i.e., antibiotics alone).

RESEARCH DESIGN AND METHODS

This was a prospective randomized trial comparing 6- versus 12-week duration of antibiotic treatment. Remission of osteomyelitis during the monitoring period was defined as complete and persistent (>4 weeks) healing of the wound (if present initially), absence of recurrent infection at the initial site or that of adjacent rays, and no need for surgical bone resection or amputation at the end of a follow-up period of at least 12 months after completion of antibiotic treatment.

RESULTS

Forty patients followed at five French general hospitals were randomized between January 2007 and January 2009, with 20 treated for 6 weeks and 20 treated for 12 weeks with antibiotics. The two groups were comparable for all variables recorded at inclusion in the study. Remission was obtained in 26 (65%) patients, with no significant differences between patients treated for 6 versus 12 weeks (12/20 vs. 14/20, respectively; P = 0.50). We did not identify any significant parameters associated with patient outcome. Fewer patients treated for 6 weeks experienced gastrointestinal adverse events related to antimicrobial therapy compared with patients treated for 12 weeks (respectively, 15 vs. 45%; P = 0.04).

CONCLUSIONS

The present multicenter prospective randomized study provides data suggesting that 6-week duration of antibiotic therapy may be sufficient in patients with DFO for whom nonsurgical treatment is considered.

How to diagnose a lipodystrophy syndrome

The spectrum of adipose tissue diseases ranges from obesity to lipodystrophy, and is accompanied by insulin resistance syndrome, which promotes the occurrence of type 2 diabetes, dyslipidemia and cardiovascular complications. Lipodystrophy refers to a group of rare diseases characterized by the generalized or partial absence of adipose tissue, and occurs with or without hypertrophy of adipose tissue in other sites. They are classified as being familial or acquired, and generalized or partial. The genetically determined partial forms usually occur as Dunnigan syndrome, which is a type of laminopathy that can also manifest as muscle, cardiac, neuropathic or progeroid involvement. Gene mutations encoding for PPAR-gamma, Akt2, CIDEC, perilipin and the ZMPSTE 24 enzyme are much more rare. The genetically determined generalized forms are also very rare and are linked to mutations of seipin AGPAT2, FBN1, which is accompanied by Marfan syndrome, or of BANF1, which is characterized by a progeroid syndrome without insulin resistance and with early bone complications. Glycosylation disorders are sometimes involved. Some genetically determined forms have recently been found to be due to autoinflammatory syndromes linked to a proteasome anomaly (PSMB8). They result in a lipodystrophy syndrome that occurs secondarily with fever, dermatosis and panniculitis. Then there are forms that are considered to be acquired. They may be iatrogenic (protease inhibitors in HIV patients, glucocorticosteroids, insulin, graft-versus-host disease, etc.), related to an immune system disease (sequelae of dermatopolymyositis, autoimmune polyendocrine syndromes, particularly associated with type 1 diabetes, Barraquer-Simons and Lawrence syndromes), which are promoted by anomalies of the complement system. Finally, lipomatosis is currently classified as a painful form (adiposis dolorosa or Dercum's disease) or benign symmetric multiple form, also known as Launois-Bensaude syndrome or Madelung's disease, which are sometimes related to mitochondrial DNA mutations, but are usually promoted by alcohol. In addition to the medical management of metabolic syndrome and the sometimes surgical treatment of lipodystrophy, recombinant leptin provides hope for genetically determined lipodystrophy syndromes, whereas modifications in antiretroviral treatment and tesamorelin, a GHRH analog, is effective in the metabolic syndrome of HIV patients. Other therapeutic options will undoubtedly be developed, dependent on pathophysiological advances, which today tend to classify genetically determined lipodystrophy as being related to laminopathy or to lipid droplet disorders.

Outcome of patients with diabetes with negative percutaneous bone biopsy performed for suspicion of osteomyelitis of the foot

AIMS

To assess the outcome of patients with diabetes with suspicion of osteomyelitis of the foot who had undergone a percutaneous bone biopsy that yielded negative microbiological results, with focus on the occurrence of osteomyelitis at the biopsied site.

METHODS

Medical charts of adult patients with diabetes with a negative percutaneous bone biopsy were reviewed. Patients' outcome was evaluated at least 2 years after the initial bone biopsy according to wound healing, the results of a new bone biopsy and bone imaging evaluation when applicable.

RESULTS

From January 2001 to January 2008, 41 patients with diabetes (30 men/11 women; mean age 58.1 ± 9.6 years; mean diabetes duration 15.8 ± 6.7 years) met study criteria. Osteomyelitis was suspected based on combined clinical and imaging diagnostic criteria. On follow-up at a mean duration of 41.2 ± 22.5 months post-bone biopsy, 16 patients had complete wound healing (39.0%). Of the 25 other patients, 15 had a new bone biopsy performed, six of which yielded positive microbiological results, and among the 10 patients who neither healed nor underwent bone biopsy, comparative radiography of the foot showed a stable aspect of the biopsied site in six of them, for whom the data were available. Finally, osteomyelitis of the foot at the site where the initial bone biopsy had been performed was confirmed during follow-up in six patients (14.6%) and was suspected in four additional patients (9.7%).

CONCLUSIONS

The results of the present study suggest that, of patients with diabetes with the suspicion of osteomylelitis and a negative percutaneous bone biopsy, only one out of four will develop osteomyelitis within 2 years of the biopsy.

Operant thermoregulation of rats with anterior hypothalamic lesions

The relative importance of different effector mechanisms of thermoregulation may change depending on their availability. Intact rats make only limited use of a learned response on a cold ambient temperature stimulus, and rely almost entirely on autonomic regulatory functions. After destruction of the anterior hypothalamus, rats exhibit a reduced thermoregulatory capacity; i.e. body temperature drops in the cold and rises in the heat. Under this situation a conditioned operant behavior (lever pressing for increasing or decreasing ambient temperature) becomes an important factor to keep body temperature almost constant. Receptor blockers of some putative transmitters in central thermoregulatory pathways influence thermoregulation. Phentolamine induces hypothermia in intact rats in the cold. Hypothalamic lesions are additive in effect with with the drug. Pimozide has no effect neither in the cold nor in the heat intact and lesioned rats. Biperiden in the heat reinforces hyperthermia in intact and lesioned rats as well; in the cold the drug is ineffective. Performance of lesioned rats in an operant pain titration procedure does not differ from intact rats.