Annals of Clinical Case Reports Clinical Image · 2017. 2. 1. · Mohd Yazid Bajuri* Department of...
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Remedy Publications LLC., | http://anncaserep.com/ Annals of Clinical Case Reports 2017 | Volume 2 | Article 1249 1 Clinical Image Osteomyelitis is a common complication and present in approximately 20% of diabetic foot ulcer cases, and was reported as high as 79% in some other case series [1-3]. It is responsible for most of the non-traumatic amputation of the lower limb [4]. Amputation of a digit in the foot causes a change in the biomechanics of the amputated limb. is potentially creates higher pressure areas and new bony deformities that leads to another ulcer and subsequently leads to amputation, especially with first ray amputation [5,6]. A study by Izumi and associates found that there is an increased risk of reamputation of the same limb within 6 months aſter the initial amputation [7]. Diabetic foot infections have a spectrum of clinical presentation, varying in severity and this present a great challenge in the management. ere is difficulty in identifying the optimal treatment for specific patient with different clinical presentation. e debates focus around the roles of antibiotic therapy only, combined antibiotic therapy with limited debridement or a more radical surgery such as amputation. Aragón-Sánchez classified osteomyelitis in diabetic foot ulcer in order to guide the optimal method of treatment [8]. His system comprised 4 classes of osteomyelitis that assess the presence of ischemia and soſt tissue involvement (Figure 1). He observed 82.2% of total 94 patients who presented with infected diabetic foot ulcer, had osteomyelitis. ere was no amputation performed in class 1. However, 37.5% of class 2 (n=16), 82% of class 3 (n=17), and all 23 patient in class 4 had amputation (Table 1). is confirmed the positive correlation between presence of soſt tissue involvement and ischemia with higher rate of amputation. e findings also support the notion that presence of osteomyelitis does not necessitate amputation. However, the weakness of this classification is that the presence of soſt tissue involvement can only be confirmed intraoperatively. Virtual amputation falls under the category of conservative surgery. It is defined as any procedure in which bone and non-viable soſt tissue are removed without amputation of any part of the foot is undertaken [2,8]. e procedure is aimed at preserving the physical appearance of foot while Virtual Amputation in Diabetic Foot Infection with Osteomyelitis OPEN ACCESS *Correspondence: Mohd Yazid Bajuri, Department of Orthopedics, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, E-mail: [email protected] Received Date: 23 Dec 2016 Accepted Date: 26 Jan 2017 Published Date: 30 Jan 2017 Citation: Bajuri MY. Virtual Amputation in Diabetic Foot Infection with Osteomyelitis. Ann Clin Case Rep. 2017; 2: 1249. Copyright © 2017 Bajuri MY. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Clinical Image Published: 30 Jan, 2017 Mohd Yazid Bajuri* Department of Orthopedics, Universiti Kebangsaan Malaysia, Malaysia (A) (B) Figure 1: Radiograph of the left foot – evidence of osteomyelitis of proximal phalanx second toe and distal end of the second metatarsal bone.
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Remedy Publications LLC., | http://anncaserep.com/
Annals of Clinical Case Reports
2017 | Volume 2 | Article 12491
Clinical ImageOsteomyelitis is a common complication and present in approximately 20% of diabetic foot
ulcer cases, and was reported as high as 79% in some other case series [1-3]. It is responsible for most of the non-traumatic amputation of the lower limb [4].
Amputation of a digit in the foot causes a change in the biomechanics of the amputated limb. This potentially creates higher pressure areas and new bony deformities that leads to another ulcer and subsequently leads to amputation, especially with first ray amputation [5,6]. A study by Izumi and associates found that there is an increased risk of reamputation of the same limb within 6 months after the initial amputation [7].
Diabetic foot infections have a spectrum of clinical presentation, varying in severity and this present a great challenge in the management. There is difficulty in identifying the optimal treatment for specific patient with different clinical presentation. The debates focus around the roles of antibiotic therapy only, combined antibiotic therapy with limited debridement or a more radical surgery such as amputation.
Aragón-Sánchez classified osteomyelitis in diabetic foot ulcer in order to guide the optimal method of treatment [8]. His system comprised 4 classes of osteomyelitis that assess the presence of ischemia and soft tissue involvement (Figure 1).
He observed 82.2% of total 94 patients who presented with infected diabetic foot ulcer, had osteomyelitis. There was no amputation performed in class 1. However, 37.5% of class 2 (n=16), 82% of class 3 (n=17), and all 23 patient in class 4 had amputation (Table 1). This confirmed the positive correlation between presence of soft tissue involvement and ischemia with higher rate of amputation. The findings also support the notion that presence of osteomyelitis does not necessitate amputation. However, the weakness of this classification is that the presence of soft tissue involvement can only be confirmed intraoperatively.
Virtual amputation falls under the category of conservative surgery. It is defined as any procedure in which bone and non-viable soft tissue are removed without amputation of any part of the foot is undertaken [2,8]. The procedure is aimed at preserving the physical appearance of foot while
Virtual Amputation in Diabetic Foot Infection with Osteomyelitis
OPEN ACCESS
*Correspondence:Mohd Yazid Bajuri, Department of
Orthopedics, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia,E-mail: [email protected]
Received Date: 23 Dec 2016Accepted Date: 26 Jan 2017
Published Date: 30 Jan 2017
Citation: Bajuri MY. Virtual Amputation in Diabetic Foot Infection with
Osteomyelitis. Ann Clin Case Rep. 2017; 2: 1249.
Copyright © 2017 Bajuri MY. This is an open access article distributed under
the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work
is properly cited.
Clinical ImagePublished: 30 Jan, 2017
Mohd Yazid Bajuri*
Department of Orthopedics, Universiti Kebangsaan Malaysia, Malaysia
(A) (B)
Figure 1: Radiograph of the left foot – evidence of osteomyelitis of proximal phalanx second toe and distal end of the second metatarsal bone.
Mohd Yazid Bajuri Annals of Clinical Case Reports - Foot and Ankle
Remedy Publications LLC., | http://anncaserep.com/ 2017 | Volume 2 | Article 12492
removing the infection load (Figure 2). This is coupled with antibiotic therapy to achieve remission in infection. The antibiotic duration should be tailored according to wound condition and culture with infective markers as guidance to predict remission of acute infection (Figure 3).
ClassDescription
Osteomyelitis Soft tissue involvement Ischemia
1 Yes No No
2 Yes No Yes
3 Yes Yes -
4 Yes No No
Table 1: Osteomyelitis grading system in diabetic foot ulcer.
(A) (B)
Figure 2: (A) The wound bed after removal of proximal phalanx and head of second metatarsal bone. (B) proximal phalanx of the toe.
(A) (B) Figure 3: (A) Wound at two weeks. (B) Wound at one month.
The end result is minimal disruption in the biomechanics of the foot, therefore avoiding the creation of another high-pressure point within the same foot, which in turn creates another ulcer. Furthermore, the psychological effect on patient is greater in a positive way as patient is able to keep the normal appearance of the foot.
Proper wound care and bandaging while waiting for the wound to heal in a normal axis following the other toes. A proper “guided healing” of the virtually amputated toe should be in line of the management plan to maximize the benefit of this procedure.
References1. Lavery LA, Armstrong DG, Peters EJ, Lipsky BA. Probe-to bone test for
diagnosing diabetic foot osteomyelitis: reliable or relic?. Diabetes Care. 2007; 30: 270-274.
2. Aragón-Sánchez FJ, Cabrera-Galván JJ, Quintana-Marrero Y, Hernández-Herrero MJ, Lázaro-Martínez JL, García-Morales E, et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia. 2008; 51: 1962-1970.
3. 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: 254-263.
4. Green MF, Aliabadi Z, Green BT. Diabetic foot: evaluation and management. South Med J. 2002; 95: 95-101.
5. Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care. 1995; 18: 1460-1462.
6. Nehler MR, Whitehill TA, Bowers SP, Jones DN, Hiatt WR, Rutherford RB, et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg. 1999; 30: 509-517.
7. Izumi Y, Satterfield K, Lee S, Harkless LB. Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care. 2006; 29: 566-570.
8. Aragón-Sánchez FJ. Clinical-pathological characterization of diabetic foot infections: Grading the severity of osteomyelitis. Int J Low Extrem Wounds. 2012; 11: 107-112.
