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Diabetic Foot Osteomyelitis
• Andrew J. Meyr, DPM
-Clinical Associate Professor,
Temple University School of Podiatric Medicine
-Program Director,
Temple University Hospital Podiatric Surgical
Residency Program
-Podiatric Director,
Temple University Hospital Limb Salvage Center
• July 12, 2018
• 2018 APMA National
• Feynman said: The first principle is that
you must not fool yourself – and you
are the easiest person to fool.
From the Flat Earth Society
Illusion of the Bird-Rabbit
Foot & Ankle
Surgery
Infectious
Disease
Radiology
General
Surgery
Endocrinology
Internal
Medicine
Wound
Care
Pathology
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
• Osteomyelitis
– Vs.
• Osteonecrosis
– Vs.
• Osteitis
– Vs.
• Periostitis
– Vs.
• Deep soft tissue infection near
and around bone
Foot & Ankle
Surgery
Infectious
Disease
Radiology
General
Surgery
Endocrinology
Internal
Medicine
Wound
Care
Pathology
“Gold Standard” Diagnostic Test
“Standard Reference” for other Diagnostic Tests
Bone Biopsy
What do I do with a “bone biopsy”?
Bone Biopsy
Histopathology Microbiology
What do I do with a “bone biopsy”?
Bone Biopsy
Histopathology Microbiology
PubMed ID#: 7853630
What do I do with a “bone biopsy”?
Bone Biopsy
Histopathology Microbiology
PubMed ID#: 17259493
What do I do with a “bone biopsy”?
Bone Biopsy
Histopathology Microbiology
PubMed ID#: 17259493
55%: Both positive
11%: Both negative
34% Didn’t Agree
PubMed ID#: 21251855
Microbiologic Assessment of Bone (Bone Culture)
Microbiologic Assessment of Bone (Bone Culture)
• Potential Pitfalls:
– Contiguous
extension leading to
contamination
– Culture swabs generally
misrepresenting the
number and type of
pathogens
– Antibiotics
Microbiologic Assessment of Bone (Bone Culture)
• Potential Pitfalls:
– Contiguous
extension leading to
contamination
– Culture swabs generally
misrepresenting the
number and type of
pathogens
– Antibiotics
PubMed ID#: 16323092
PubMed ID#: 18685049
PubMed ID#: 15209762 90% vs. 65%
49%
22.5%
Microbiologic Assessment of Bone (Bone Culture)
• Potential Pitfalls:
– Contiguous
extension leading to
contamination
– Culture swabs generally
misrepresenting the
number and type of
pathogens
– Antibiotics
• Clinical Solutions:
– Percutaneous approach
through unaffected skin
Microbiologic Assessment of Bone (Bone Culture)
• Potential Pitfalls:
– Contiguous
extension leading to
contamination
– Culture swabs generally
misrepresenting the
number and type of
pathogens
– Antibiotics
• Clinical Solutions:
– Only obtain culture specimens
through wounds following
complete irrigation & debridement
Microbiologic Assessment of Bone (Bone Culture)
• Potential Pitfalls:
– Contiguous extension
leading to contamination
– Culture swabs
potentially
misrepresenting the
number and type of
pathogens
– Antibiotics
-168 wounds evaluated with culture
and molecular diagnostics.
-Culture: -Molecular:
-17 diff’t bacteria -338 diff’t bacteria
-Max 3/wound -Max 33/wound
-% wound microbiota
PubMed ID#: 22489109
Microbiologic Assessment of Bone (Bone Culture)
• Potential Pitfalls:
– Contiguous extension
leading to contamination
– Culture swabs generally
misrepresenting the
number and type of
pathogens
– Antibiotics
• Clinical Solutions:
–Antibiotics?
Histopathologic Assessment of Bone(Bone Path)
Histopathologic Assessment of Bone(Bone Path)
• Potential Pitfalls:
– Lack of standardization
with respect to:
• Histopathologic
definition or
classification of
osteomyelitis
• Pathologist training
and personal
experience
• “Test the Testers”– Retrospective analysis of 39
specimens of bone taken from
consecutive diabetic patients in
which the diagnosis of
osteomyelitis was in question.
– 4 pathologists from individually
analyzed the specimens and
only told that it was a
“specimen of bone taken from a
diabetic patient to evaluate for
osteomyelitis”.
Arrive at 1 of 3 potential
diagnoses:
• No evidence of
osteomyelitis,
• No definitive findings
of osteomyelitis, but
cannot rule it out, OR
• Findings consistent
with osteomyelitis
Pubmed ID#: 21907594
• Results:
–33% (13/39): • Complete agreement between pathologists
with respect to primary diagnosis
– 41% (16/39):• Clinically significant disagreement between
pathologists with respect to primary diagnosis
Pubmed ID#: 21907594
• Results:
–Kappa Coefficient: 0.31
• 0 = Poor agreement
• 0.01-0.20 = Slight agreement
• 0.21-0.40 = Fair agreement
• 0.41-0.60 = Moderate agreement
• 0.61-0.80 = Substantial agreement
• 0.81-1.0 = Almost perfect agreement
Pubmed ID#: 21907594
Histopathologic Assessment of Bone(Bone Path)
Histopathologic Assessment of Bone(Bone Path)
Pubmed ID#: 23328849
Lymphocytes, plasma cells
and PMNs
What do I do with a “bone biopsy”?
Bone Biopsy
Histopathology Microbiology
Pubmed ID#: 18442163
Definite (beyond reasonable doubt): >90%
Probable (more likely than not): 51-90%
Possible (less rather than more likely): 10-50%
Unlikely: <10%
“Definite” Diagnostic Criteria for
Diabetic Foot Osteomyelitis (>90%)
(1) Bone sample with positive culture AND
positive histology
(2) Purulence in bone found at surgery
(3) Atraumatically detached bone fragment
removed from ulcer by pod/surgeon
(4) Intraosseous abscess found on MRI
Pubmed ID#: 18442163
“Probable” Diagnostic Criteria for
Diabetic Foot Osteomyelitis (51-90%)
(1)Visible cancellous bone in an ulcer
(2)MRI showing bone edema with other signs of
osteomyelitis
(3)Bone sample with positive culture, but
negative histology
(4)Bone sample with positive histology, but
negative culture
-Any two of these bump you up into “definite”
Pubmed ID#: 18442163
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
What does osteomyelitis actually look like?
“Possible” Diagnostic Criteria for
Diabetic Foot Osteomyelitis (10-50%)(1) Plain film radiographs showing cortical erosion
(2) MRI showing bone edema or cloaca
(3) Positive probe to bone test/Visible cortical bone
(4) ESR > 70 mm/hr with no other plausible explanation
(5) Non-healing wound despite adequate offloading and
perfusion > 6 weeks
(6) Ulcer of > 2 weeks duration with clinical evidence
of infection
-Any two of these bump you up into “probable”
Pubmed ID#: 18442163
“Unlikely” Diagnostic Criteria for
Diabetic Foot Osteomyelitis (<10%)
(1)No s/s of inflammation AND normal plain
film radiographs AND ulcer present for < 2
weeks AND superficial ulceration
(2)Normal MRI
(3)Normal bone scan
Pubmed ID#: 18442163
Pubmed ID#: 18442163
Definite (beyond reasonable doubt): >90%
Probable (more likely than not): 51-90%
Possible (less rather than more likely): 10-50%
Unlikely: <10%
Level of Agreement with a Multitest Approach to the
Diagnosis of Diabetic Foot Ostetomyelitis
There are multiple ways to assess the
same exact set of information.
Bone biopsy likely remains our best
diagnostic tool, but both the
histopathologic and microbiologic
evaluations are far from perfect.
Infection is first and foremost a
clinical diagnosis and your eyes,
nose, hands and brain will likely
provide you with the most
information if you trust them.
Take Home Points
• Please do not hesitate to contact
Andy if there is anything at all
that he can do for you:
Hockney’s Mount Fuji and Flowers
Questions?
T E A Ex AV
