Isabel Gloor

Background/Objectives: When presented with chronic osteomyelitis of the adult diabetic foot (DFO), clinicians, patients and their families have two options: rational use of antibiotics or direct surgery. Methods: We conducted a scientific literature review of 118 different articles and administered questionnaires to eighty DFO international and Swiss experts who have already published on the specific choice between a first-line conservative, antibiotic-based therapy versus direct surgery for DFO. Results: According to this specific literature and the ranking of clinical importance, the presence of ischemia came first (91% consensus favoring surgery), followed by the presence of gangrene (94% consensus), the perceived frailty of the patient (80%), sepsis (83%), and major soft tissue loss (81% consensus). Generally, for more than 90% of all experts, gangrene, bone exposed to air, destroyed bone, and hindfoot DFO motivated for direct surgery. We obtained twenty-four questionnaires from colleagues who we addressed as experts. Their opinions aligned with the literature. Compared to the international experts, Swiss clinicians were less hesitant to amputate in case of long-lasting foot ulcers, soft tissue loss, sepsis or patients with a history of low compliance. Combining literature reviews and questionnaires, large necrotic areas and destructed bone may predict direct surgery. Alternatively, clinicians can choose a first-line antibiotic therapy with minimal soft tissue debridement, off-loading and professional wound care. Conclusions: There is no universal consensus. The decision between antibiotics and surgery remains individualized, while severe ischemia, destroyed bone and large tissue loss are predictors of direct surgery; their absence favors antibiotic treatment.

Background/Objectives: When presented with chronic osteomyelitis of the diabetic foot (DFO), clinicians, patients and their families have two options: rational use of antibiotics or direct surgery. Methods: We conducted a narrative, scientific literature review and administered questionnaires to DFO experts to investigate the factors indicating conservative, antibiotic-based therapy vs. direct surgery to treat DFO. Results: If large necrotic areas and destructed bone are present, providers may opt for a direct surgical amputation or internal resection of the infected bone (conservative surgery). Alternatively, they can choose conservative (targeted) antibiotic therapy lasting several weeks, with minimal soft tissue debridement, off-loading and iterative professional wound care. Conclusions: It is difficult to decide between the two treatments. The rationale for choosing either approach is complex, involving many clinical aspects to consider, which we discuss in this article.