Who should a patient with osteomyelitis of the diabetic toe be referred to?

Management of Osteomyelitis in Diabetic Toe: Referral Pathway

Patients with diabetic toe osteomyelitis should be referred to a multidisciplinary foot care team that includes an infectious disease specialist, orthopedic surgeon or podiatrist, and vascular surgeon. 1, 2

Initial Assessment and Referral

• Diabetic foot osteomyelitis requires urgent evaluation by specialists as it can rapidly progress to limb-threatening infection within days or even hours 1
• Immediate referral to a multidisciplinary foot care team is essential to prevent clinical deterioration and reduce the risk of amputation 1, 2

Primary Specialist Referrals:

• Infectious Disease Specialist: For antibiotic management and coordination of care 1, 2
• Orthopedic Surgeon or Podiatrist: For surgical assessment, bone biopsy, and potential debridement 1
• Vascular Surgeon: For assessment of peripheral arterial disease, which is common in diabetic patients and affects treatment decisions 1, 2

Diagnostic Approach Before or During Referral

• Obtain plain radiographs of the affected foot to look for bony abnormalities (cortical erosion, periosteal reaction, mixed lucency, and sclerosis) 1, 3
• Consider MRI as the preferred imaging study when the diagnosis remains uncertain or when soft tissue abscess is suspected 1, 2
• Perform probe-to-bone test, which can help diagnose or exclude diabetic foot osteomyelitis when properly conducted 1, 3
• Collect appropriate specimens for culture, preferably bone samples rather than soft tissue swabs 2, 3

Treatment Decision Algorithm

Surgical vs. Medical Management

• Consider surgical management when:

  • Patient has persistent sepsis syndrome 1
  • Severe infection with exposed bone 2
  • Progressive bone destruction despite appropriate therapy 1
  • Mid or hindfoot lesions (more difficult to treat) 1, 2
  • Peripheral arterial disease requiring revascularization 1, 2

• Consider medical management (antibiotics alone) when:

  • Infection is confined to the forefoot with minimal soft tissue loss 1, 4
  • Surgical intervention would cause unacceptable loss of function 1, 2
  • Patient has unreconstructable vascular disease but wishes to avoid amputation 1
  • Patient and healthcare professional agree that surgery carries excessive risk 1, 5

Special Considerations

• Bone biopsy (percutaneous or operative) should be performed by a properly trained physician (orthopedic surgeon, podiatrist, or interventional radiologist) 1
• Cultures of bone specimens provide more accurate microbiologic data than soft-tissue specimens for patients with osteomyelitis 1, 6
• Antibiotic therapy should be guided by culture results and typically continues for 4-6 weeks for osteomyelitis without surgical resection 2, 6
• Offloading devices (total contact casts or removable walking boots) are essential components of treatment and should be prescribed by podiatrists or orthopedic specialists 1

Common Pitfalls to Avoid

• Delayed referral to a multidisciplinary team can lead to significant clinical deterioration and increased risk of amputation 1, 4
• Relying solely on soft tissue cultures rather than bone cultures can lead to inappropriate antibiotic selection 1, 2
• Failing to assess vascular status can result in poor treatment outcomes, as adequate blood supply is essential for healing and antibiotic delivery 1, 7
• Treating without proper offloading of the affected area will likely result in treatment failure 1

By following this referral pathway and treatment algorithm, clinicians can optimize outcomes for patients with diabetic toe osteomyelitis, reducing the risk of amputation and improving quality of life.