Informativeness of bone intraoperative culture for diagnose osteomyelitis in diabetic foot patients.

BACKGROUND: Diagnosis of osteomyelitis in diabetic foot patients is frequently not obvious due to similar clinical and X-ray signs of bone infection and Sharcot osteopathy, but it is very important because of opposite approach to treatment of these conditions. Today we do not have reliable parameters to determine the devastation of bone infection and, therefore, the rational volume of bone resection and debridement.

AIMS: To determine the diagnostic value of bone culture for osteomyelitis in diabetic foot patients.

MATERIALS AND METHODS: 177 patients underwent surgery due to different forms of diabetic foot. In 131 of them clinical signs of osteomyelitis were revealed and this diagnosis was confirmed by histology. 46 patients with diabetes who underwent high-level amputation without bone infection formed the control group. Intraoperative bone cultures and histological samples were taken in all cases.

RESULTS: We found similar microbial landscape in various forms of diabetic foot and in control group. The frequency of positive intraoperative cultures in patients without osteomyelitis was detected as 63%. The sensitivity of bone culture was counted as 86,3%, the specificity – as 37%, the accuracy – 73.5%.

CONCLUSIONS: Our findings suggest that bone culture is not reliable sign of bone infection in diabetic foot patients due to its low specificity. In our judgment, the only way to determine rational level of bone resection is visual intraoperative assessment and clinical signs such as development of granulation tissue and wound healing.

diabetic foot, osteomyelitis, bacteriology

1. Soysal N, Аyhan M, Guney E, Akyol A. Differential diagnosis of Charcot arthropathy and osteomyelitis. Neuro Endocrinol Lett. 2007;28(5):556−559.

2. Berendt AR, Peters EJ, Bakker K, et al. Diabetic foot osteomyelitis: a progress report on diagnosis and systematic review of treatment. Diabetes Metab Res Rev. 2008;24(Suppl 1):S145−161. doi: https://doi.org/10.1002/dmrr.836

3. Ertugrul BM, Lipsky BA, Savk O. Osteomyelitis or Charcot neuro-osteoarthropathy? Differentiating these disorders in diabetic patients with a foot problem. Diabet Foot Ankle. 2013;4. doi: https://doi.org/10.3402/dfa.v4i0.21855

4. Удовиченко О.В., Грекова Н.М. Диабетическая стопа (Руководство для врачей). — М.: Практическая медицина, 2010. — 271 с. [Udovichenko OV, Grekova NM. Diabeticheskaya stopa (Rukovodstvo dlya vrachey). Moscow: Practical medicine; 2010. 271 р. (In Russ.)]

5. Токмакова АЮ. Современная концепция диагностики и лечения хронических ран у больных с синдромом диабетической стопы // Сахарный диабет. — 2009. — №1. — С. 14−17. [Tokmakova AYu. Up-to-date principles of diagnostics and treatment of chronic wound in diabetic foot patients. Diabetes mellitus. 2009;(1):14−17. (In Russ.)]

6. Бреговский В.Б., Храмилин В.Н., Демидова И.Ю., и др. Диабетическая дистальная полинейропатия: обзор современных рекомендаций // Анналы клинической и экспериментальной неврологии. — 2015. — Т. 9. — №1. — С. 60−68. [Beregovsky VB, Khramilin VN, Demidova IYu, et al. Distal diabetic neuropathy: review of evidence-based recommendations. Annals of clinical and experimental neurology. 2015;9(1):60−68. (In Russ.)]

7. Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis. 2004;39 Suppl 2:S115−122. doi: https://doi.org/10.1086/383272

8. Aragon-Sanchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. Int J Low Extrem Wounds. 2010;9(1):37−59. doi: https://doi.org/10.1177/1534734610361949

9. Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. J Diabetes Complications. 1999;13(5−6):254−263. doi: https://doi.org/10.1016/s1056-8727(99)00065-3

10. Armstrong D, Wrobel J, Robbins J. Guest editorial; are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286−287. doi: https://doi.org/10.1111/j.1742-481X.2007.00392.x

11. Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med. 2016;33(11):1493−1498. doi: https://doi.org/10.1111/dme.13054

12. Привольнев В.В. Диагностика остеомиелита при синдроме диабетической стопы // Клиническая микробиология и антимикробная химиотерапия. — 2011. — Т. 13. — №1. — С. 40−45. [Privolnev VV. Diagnosis of osteomyelitis in diabetic foot syndrome. Clinical microbiology and antimicrobial chemotherapy. 2011;13(1):40−45. (In Russ.)]

13. Peters EJ, Lipsky BA, Aragón-Sánchez J, et al.; International Working Group on the Diabetic Foot. Interventions in the management of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32 Suppl 1:145−153. doi: https://doi.org/10.1002/dmrr.2706

14. Баккер К., Апельквист Д., Липски Б.А., и др. Руководство и документы Международной рабочей группы по диабетической стопе 2015 г. по профилактике и лечению заболеваний стопы при диабете: достижение доказательного консенсуса (сокращенная русскоязычная версия). Раны и раневые инфекции // Журнал имени проф. Б.М. Костючёнка. — 2016. — Т. 3. — №2. — С. 59−70. [Bakker K, Apelqvist J, Lipsky BA, et al. Manual and documents of International Working Group on the Diabetic Foot 2015 for prevention and treatment of diabetic foot diseases: the achievement of argumentative consensus (Russian cut version). Wounds and wound infections. The prof. B.M. Kostyuchenok journal. 2016;3(2):59−70. (In Russ.)] doi: https://doi.org/10.17650/2408-9613-2016-3-2-59-70

15. Meyr AJ, Singh S, Zhang X, et al. Statistical reliability of bone biopsy for the diagnosis of diabetic foot osteomyelitis. J Foot Ankle Surg. 2011;50(6):663−667. doi: https://doi.org/10.1053/j.jfas.2011.08.005

16. Kwon KT, Armstrong DG. Microbiology and antimicrobial therapy for diabetic foot infections. Infect Chemother. 2018;50(1):11–20. doi: https://doi.org/10.3947/ic.2018.50.1.11

17. Mijuskovic B, Kuehl R, Widmer AF, et al. Culture of bone biopsy specimens overestimates rate of residual osteomyelitis after toe or forefoot amputation. J Bone Joint Surg Am. 2018;100(17):1448–1454. doi: https://doi.org/10.2106/JBJS.17.01152

18. Peters EJ. Pitfalls in diagnosing diabetic foot infections. Diabetes Metab Res Rev. 2016;32 Suppl 1:254−260. doi: https://doi.org/10.1002/dmrr.2736

19. Ellison RT III. What’s the value of intraoperative bone cultures in managing foot infections? [Internet] NEJM Journal Watch. 2018. Available from: https://www.jwatch.org/na47662/2018/10/09/whats-value-intraoperative-bone-cultures-managing-foot

20. Ertugrul MB, Baktiroglu S, Salman S, et al. The diagnosis of osteomyelitis of the foot in diabetes: microbiological examination vs. magnetic resonance imaging and labelled leucocyte scanning. Diabet Med. 2006;23(6):649−653. doi: https://doi.org/10.1111/j.1464-5491.2006.01887.x

21. Elmarsafi T, Kumar A, Cooper PS, et al. Concordance between bone pathology and bone culture for the diagnosis of osteomyelitis in the presence of charcot neuro-osteoarthropathy. J Foot Ankle Surg. 2018;57(5):919−923. doi: https://doi.org/10.1053/j.jfas.2018.03.016

22. Отдельнова К.А. Определение необходимого числа наблюдений в социально-гигиенических исследованиях // Сб. трудов 2-го ММИ. — 1980. — Т. 150. — №6. — С. 18–22. [Otdel’nova KA. Opredeleniye neobkhodimogo chisla nablyudeniy v sotsial’no-gigiyenicheskikh issledovaniyakh. In: (Collection of articles) 2nd MMI. 1980;150(6):18–22. (In Russ.)]

23. Atway S, Nerone VS, Springer KD, Woodruff DM. Rate of residual osteomyelitis after partial foot amputation in diabetic patients: a standardized method for evaluating bone margins with intraoperative culture. J Foot Ankle Surg. 2012;51(6):749−752. doi: https://doi.org/10.1053/j.jfas.2012.06.017