Medical vs Surgical Treatment for the Management of Diabetic Foot Osteomyelitis: A Systematic Review



A systematic review and quality assessment was performed to assess the management
of diabetic foot osteomyelitis by medical or surgical treatment. The Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used. All selected studies
were evaluated using the Cochrane Risk of Bias Tool to assess the risk of bias for randomized
controlled trials.

The literature was revised using PubMed (Medline) and Embase (Elsevier) up
to September 2020 to identify clinical trials assessing medical or surgical treatment to manage
diabetic foot osteomyelitis. A total of six clinical trials that met our inclusion criteria, with a total of
308 participants. Healing rate, complete closure of the wound, and type of complications were the
outcomes evaluated.

Risk of bias assessment showed that only two of the six clinical trials included in the systematic review had a low risk of bias. Based on our findings, we believe that the management of diabetic foot osteomyelitis remains challenging. There are few high-quality clinical trials that both stratify clinical presentations and compare these treatments. We conclude that the available evidence is insufficient to identify the best option to cure diabetic foot osteomyelitis.

1. Introduction

Diabetic foot osteomyelitis (DFO) is considered a frequent and severe complication of
diabetic foot infections (DFIs), affecting approximately 20% of moderate DFIs and between
50% and 60% of severe DFIs [1,2]. DFO can lead to both minor or major amputation
and death [3]. DFO represents a challenging diagnostic and management condition; its
devastating consequences are related to late diagnosis, late referral, and late and inadequate
treatment [2].

There is a growing trend for non-surgical management of DFO [4], which has resulted in good results in remission from infection, with rates being higher than 60% in
patients managed exclusively with antibiotic therapy [5]. The published literature is,
however, limited to retrospective studies [6–12], and in certain selected cases, surgery
is essential, for instance, where there is bone exposure and/or severe bone destruction,
and/or patients with antibiotic resistance or medical treatment failure [2,13].

The surgical approach is based on timely containment of infection with effective debridement [14],
utilizing conservative surgical techniques, which aim to avoid unnecessary minor and
major amputations [15,16]. The remission rates after surgical treatment are varied, but it has been estimated as ~50% [17,18]. Several studies have concluded that a combination of
conservative surgery and antibiotic therapy could be the most appropriate treatment for
DFO [15,19–21].
Nevertheless, debate continues about the best approach to DFO [13,22,23]. A multidisciplinary approach is mandatory in this type of infection [24]. In 2014, Lázaro-Martínez et al. [25] published the first randomized controlled trial (RCT) to directly compare medical versus surgical treatment, highlighting the importance of combined conservative surgery and antibiotic therapy.

Further studies have been reported comparing these treatment options, but are few and are limited by selection criteria. The purpose of this systematic review is to assess the cure rates after receiving medical or surgical treatment in patients with DFO by systematically reviewing the published literature.

2. Materials and Methods

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)
checklist [26] was used to perform this systematic review. All selected studies were
evaluated with the Cochrane Risk of Bias Tool in order to assess the risk of bias for
randomized controlled trials (RCTs) [27].

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