Osteomyelitis

Abstract

Diabetic foot osteomyelitis (DFO) is associated with longer treatment duration, greater need for surgery, higher recurrence and amputation rates, and lower treatment success. However, not all cases of DFO behave similarly, require the same diagnostic and therapeutic approach, or share the same prognosis. This presentation describes four major clinical presentations of DFO whose recognition may help individualize patient management.

The first presentation is osteomyelitis associated with an infected diabetic foot attack, characterized by an acute and rapidly progressive infection with tissue necrosis, abscesses, and involvement of different foot compartments. This represents an emergency requiring hospitalization, intravenous antibiotic therapy, and early surgical debridement based on the principle that “time is tissue.” Clinical findings, the probe-to-bone test, and plain radiographs are usually sufficient for diagnosis, and treatment should not be delayed while awaiting magnetic resonance imaging or bone biopsy.

The second presentation is the “sausage toe,” characterized by swelling, erythema, edema, and loss of the normal contour of the affected toe, frequently associated with an ulcer. It mainly involves the phalanges and, in the absence of extensive soft-tissue involvement, can often be successfully managed with 6–8 weeks of antibiotic therapy without the need for amputation.

The third presentation is osteomyelitis superimposed on Charcot neuroarthropathy, predominantly involving the midfoot or hindfoot. It usually develops from a plantar ulcer over a deformed foot and represents a diagnostic challenge because radiographic abnormalities may overlap with those caused by Charcot neuroarthropathy itself. Magnetic resonance imaging is often required, and treatment may involve complex surgical procedures aimed at preserving foot stability and function and preventing recurrent ulceration.

Finally, DFO may present as a chronic infection without extensive soft-tissue involvement, associated with a persistent or recurrent ulcer, foot deformity, or previous unsuccessful surgery. Treatment includes antibiotic therapy guided by bone cultures and frequently requires surgical removal of infected bone.

These four clinical presentations differ in diagnostic requirements, culture sampling, antibiotic and surgical management, and prognosis. Therefore, DFO should not be considered a single homogeneous entity, and current classification systems should be complemented by clinical presentation and individualized clinical judgment.