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Diabetic Foot Osteomyelitis (DFO)
CarloBiz , ElisaPagliarini ,
andPietroRuggieri
16
16.1 Introduction
16.1.1 Diabetic Foot Infection (DFI)
andDiabetic Foot
Osteomyelitis (DFO)
Osteomyelitis is a challenging condition characterized by the invasion of external microorganisms into the bone, often linked with diabetes
mellitus (DM), making it difcult to treat. It is
costly for healthcare, imposing a signicant
social burden with a substantial nancial impact
on healthcare resources to avoid amputation [1].
The complexity of treating osteomyelitis necessitates close collaboration among various medical specialists: surgeons, infectious disease
experts, endocrinologists, and podiatrists, as
patients with osteomyelitis commonly have other
complicating health issues.
According to the diabetes map of the
International Diabetes Federation (tenth version),
there are 578 million diabetic patients (DPs) in
the world [2]. With the increasing global prevalence of DM, many healthcare providers will
likely encounter patients with bone infections
[1]. In the long term, DM involves many compli-
C. Biz · E. Pagliarini · P. Ruggieri (*)
Department of Orthopedics and Orthopedic
Oncology, University of Padova, Padova, Italy
e-mail: carlo.biz@unipd.it;
elisa.pagliarini@aopd.veneto.it;
pietro.ruggieri@unipd.it
cations such as retinopathy, nephropathy, neuropathy, and vasculopathy. These last two
complications increase the risk of developing
plantar foot ulcers that allow infections to reach
the bone [2].
Diabetic foot osteomyelitis (DFO) is generally categorized as acute or chronic based on the
histopathological ndings or the duration of the
symptoms and the infection [3]. In recent years,
an increase in cases of osteomyelitis has been
recorded, also linked to the increase in the prevalence of DM because bone infection is caused by
the hematogenous dissemination or from the
direct contamination of the bone from open
wounds or adjacent soft tissue infections
(Fig.16.1) [3].
Today, there is still a lack of comprehensive
assessment regarding its outcomes, such as
chronic osteomyelitis, amputation, or disability
[4].
According to the International Working Group
on Diabetic Foot (IWGDF) report, one patient
will lose a leg because of Diabetic Foot (DF)
every 20s [3]. Hence, Diabetic Foot is associated
with serious nancial and health-related burdens
affecting patients, their families, and society.
DFO designates all infections that involve
bone and joint structures below the malleoli in
patients diagnosed with diabetes. The extension
of a foot ulcer infection to the foot osteoarticular
structures can occur between 20% and 60% of
patients with a diabetic foot ulcer depending on
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_16
221
222
C. Biz et al.
a1
a2
b
Fig. 16.1 A 48-year-old type II diabetic man having
undergone a below-knee amputation for sepsis due to
severe infection of soft tissues, gangrene, and osteomyeli-
c
tis of his left foot: clinical images (a1, a2), and CT sagittal
plane (b) of his leg and foot at the time of presentation and
X-ray after aggressive surgery (c)
the contiguous spread of any infection which
may complicate an ulcer. It is exclusively the
consequence of a soft-tissue infection (usually an
infected DFU) that spreads to the underlying
osteoarticular structures [5]. Bacteria enter from
the wound and reach the cortex where they can
affect the bone. For this reason, the most commonly affected sites are the phalanges, metatarsal
heads, and calcaneus [6].
Currently, there is no universally accepted
denition for diagnosing DFO.However, specic
ulcer characteristics such as size, depth, lack of
healing despite appropriate wound care, and
absence of ischemia can suggest an increased
likelihood of underlying DFO [7].
The treatment approach for DFO is distinct
from that of skin and soft tissue infections, necessitating prolonged anti-infective therapy and carrying a signicantly higher risk of amputation.
Traditionally, it was believed that complete
removal of infected bone was necessary.
However, recent research indicates that DFO in
the toe can be resolved with antibiotic therapy
alone, without the need for amputation. Further
studies advocate for conservative surgery, where
the necrotic bone is entirely removed. Still, adjacent bone can be preserved if it appears “normal”
post-operation, characterized by being hard, with
healthy red bone marrow, and free of apparent
purulent necrosis.
16.2 Epidemiology, Etiology,
andPathophysiology ofDFO
Patients with diabetes have a 25% risk during
their lifetimes to develop a foot complication
such as soft tissue wounds and ulcers, which in
more than half of cases may eventually become
infected [8]. The most common DF problems are
plantar infected ulcers from overloading skin or
lesions. These alterations can be caused by the
typical peripheral neuropathy of diabetic patients
which makes ischemia asymptomatic and delays
the diagnosis of a Charcot joint (Fig.16.2).
The incidence of DFI is 35–40 per 1000 persons per year, and osteomyelitis is present in
20%–70% of diabetic foot ulcers DFUs. For dia-
1c
16 Diabetic Foot Osteomyelitis (DFO)
223
a
bc
3
c2
Fig. 16.2 A 62-year-old type I diabetic man presenting a mid-foot plantar ulcer of his right Charcot foot: clinical (a),
radiographic images (b) and CT axial (c1, c2) and sagittal (c3) views of the joint deformities
betic patients, 84% of amputations are performed
because of an infected or unhealed ulcer [9]. Any
foot bone can be affected by DFO, but it is more
frequent in the forefoot (90%), followed by the
midfoot (5%) and the hindfoot (5%). Forefoot
osteomyelitis has a better prognosis than the others, and the risk of ankle amputation is signicantly higher for hindfoot (50%) than midfoot
(18.5%) and forefoot (0.33%) osteomyelitis.
The microbiological etiology of DFOs is like
that of the contiguous soft-tissue infection,
although fewer isolates are usually found in bone
compared with soft-tissue infections. Bacteria
are responsible for most DFOs, and the colonization is usually polymicrobial [8].
In developed countries, the most common
pathogen cultured is Gram-positive bacteria,
such as Staphylococcus aureus (up to 50% of
cases), Staphylococcus epidermidis (approximately 25%), Streptococci (around 30%), and
Enterobacteriaceae (up to 40%). Gram-negative
bacilli (such as Pseudomonas aeruginosa and
Escherichia coli, Klebsiella pneumonia, and
Proteus) are more frequent in warm climate
countries. Obligate anaerobes (e.g., Finegoldia
magna, Clostridium spp., or Bacteroides spp.)
are generally less frequently cultured, but this
depends on how the bone fragments are sampled
and transported to the laboratory. Bacteria usually considered contaminants, such as coagulasenegative staphylococci and Corynebacterium sp.,
have been documented as pathogens in DFO.
At present, the resistance to antibiotics is
increasing in the diabetic population, and multiresistant organisms (MDRO) are common in
DFI. Hospitalization, surgical procedures, and
long antibiotic therapy induce the development
of MDRO or methicillin-resistant Staphylococcus
aureus (MRSA) and extended-spectrum betalactamase ESBL-producing Enterobacteriaceae
[5]. Rates of antibiotic-resistant pathogens vary
widely, making it necessary for prescribing clinicians to remain updated on their prevalence in
their work sites.
The process of bone infection in DFO involves
bacteria entering from the overlying soft tissue,
penetrating the cortex, and reaching the marrow.
This can lead to periostitis, osteitis, and ultimately osteomyelitis, impacting also the surrounding soft tissues. The spread of infection
from soft tissue to bone can take several weeks,
and pathogens adhere to the bone by expressing
adhesion factors for components of the bone
matrix, leading to complications in blood ow as
pus spreads into vascular channels. Bone involvement in DF results from the spread of infection
224
C. Biz et al.
from soft tissue in an ongoing process that can
take several weeks. Fissures in the dried skin can
harbor microorganisms, and microbes may
invade bone tissue, entering through the cortex
before spreading to the marrow if the infection
persists [10]. Pathogens adhere to bone by
expressing adhesion factors for components of
the bone matrix. Then, pus spreads into vascular
channels, raising the intraosseous pressure, and
impairing blood ow. The main risk factor for
skin ulceration and secondary spread to bone is
chronic wound infection. Consequently, all factors contributing to prolonging healing time will
increase the risk of osteomyelitis. In addition,
inefcient off-loading of a foot ulcer increases
the incidence of osteomyelitis [10].
16.3 Diagnosis ofDFO
Dealing with DFO is perhaps the most difcult
and controversial aspect of the management of
diabetic foot infections. Its diagnosis is based
currently on clinical signs of infection supported
by laboratory, microbiological, and radiological
evaluation and completed by the results of the
bone sample examination: positive culture and
histological abnormalities consistent with the
diagnosis of bone infection.
The guidelines suggest that the diagnosis of
DFO includes combining different diagnostic
tests, such as pulmonary tuberculosis (PTB),
serum inammatory markers, X ray, MRI, or
radionuclide scanning. X-ray should always be
the rst imaging evaluation; when more specic
imaging is required, MRI is the rst choice.
Severe osteomyelitis involving midfoot, hindfoot, and ankle detected by magnetic resonance
imaging cell-labelled radionuclide scan, SPECT/
CT, and 18F-FDG PET/CT are used only if MRI
is contraindicated [11].
DFO must be considered a potential complication of any deep or extensive ulcer, especially
one that is chronic or overlies a bony prominence
(Fig.16.3). Osteomyelitis should be considered
when an ulcer does not heal after at least 6weeks
of appropriate care and off-loading. Any ulcer in
which bone is either visible or can be easily pal-
pated with a sterile blunt metal probe is likely to
be complicated by osteomyelitis. In patients with
a limb-threatening infection, positive results of a
probe-to-bone test (PTB) may be taken as nearly
sufcient for diagnosis, but the performance
characteristics of this test have not yet been fully
dened. A swollen foot in a patient with a history
of foot ulceration, the classic “sausage toe” (i.e.,
a red, swollen digit), or an unexplained high
WBC count or inammatory markers should also
arouse suspicion of osteomyelitis. Finally, radiologically evident bone destruction beneath an
ulcer should be considered to represent osteomyelitis unless proven otherwise [12].
16.3.1 Clinical Signs
andPresentation
Infected wounds usually show purulent secretions
or some signs of inammation: swelling, erythema,
blood serum secretion, or simply blood with or
without bone fragments. However, DFO can occur
without any local sign of inammation. Systemic
symptoms such as fever and malaise are uncommon, especially in cases of chronic DFOs [13].
Physical examination is essential for the diagnosis. Osteomyelitis is unlikely when there is no
clinical foot ulcer even when bone lesions are
present on imaging. The most suitable clinical
approach involves examining the wound with a
sterile metal probe to search for positive bone contact, as described above. This indicates osteomyelitis in infected ulcers but does not rule it out if
positive contact is lacking. A negative result, however, is likely to rule out bone infection in ulcers
without clinical signs of infection. Combining
bone contact with data from standard foot radiographs enhances the accuracy of DFO diagnosis,
which should be suspected in cases of exposed
bone or when bone fragments are present. The
absence of local signs of inammation does not
eliminate the possibility of DFO diagnosis [5].
Most DPs present with erythema and drainage, but pain may be absent because of the associated neuropathy. Often, they are afebrile, and
some present with an ulcer without evidence of
surrounding inammation. The ulcer size
16 Diabetic Foot Osteomyelitis (DFO)
225
a1 a2 b1 c1
b2
Fig. 16.3 A 74-year-old type I diabetic woman with
chronic plantar DFU of her right Charcot foot: clinical
images before (a1) and after (a2) debridement; AP (b1)
(>2cm2) and depth (>3mm) predict the likeli-
and LL (b2) X-ray images; and CT sagittal plane images
(c1, c2) with 3D reconstruction (c3)
16.3.2 Serum Inammatory Markers
hood of bone involvement (Fig.16.3).
Three specic clinical signs are predictive of
osteomyelitis:
Serum inammatory markers such as white
blood cells (WBC), C-reactive protein, erythrocyte sedimentation rate (ESR), and procalcito-
• the width and depth of the foot ulcer. An ulcer
larger than 2cm2 has a sensitivity of 56% and a
specicity of 92%. Deep ulcers (>3 mm) are
more easily associated with underlying osteomyelitis than supercial ulcers (82% vs 33%) [14].
• the probe-to-bone test, performed by probing
the ulcer area with a sterile blunt probe. If the
probe reaches the bone surface, the test is considered positive. This test was found to have a
sensitivity of 87%, a specicity of 91%, a
positive predictive value of only 57%, and a
negative predictive value of 98%. The combination of the PTB test with X-ray improves
the sensitivity and specicity in the diagnosis
of DFO [15].
• no ulcer healing despite appropriate nursing
and off-loading, an inammatory toe (“sausage toe”), drainage of synovial liquid, and its
location over a bony prominence [9]
(Fig.16.4).
nin (PCT) are usually higher in DFO than in
soft-tissue infections. However, WBC and procalcitonin may be negative, while
ESR>60mm/h and/or CRP>3.2mg/dL in the
presence of an ulcer deeper than >3 mm may
signicantly predict DFO.Furthermore, WBC,
CRP, and PCT values return to their normal
range in approximately three weeks after treatment in both soft-tissue and bone infection,
while ESR usually remains high only in the case
of osteomyelitis. ESR appears to be the most
useful inammatory biomarker available in
daily practice for diagnosis. A high erythrocyte
sedimentation rate, especially if it is over
70mm/hour, helps make the diagnosis of osteomyelitis more likely, but a negative test is less
helpful in excluding the presence of bone infection. Leukocytosis is a poor indicator of foot
osteomyelitis: the white blood cell (WBC) count
is normal in 50% of cases [16].
c2
c3
226
ab
Fig. 16.4 A 73-year-old
type II diabetic woman
with a history of swollen
left foot, second
“sausage toe, and signs
of ulceration: dorsal (a)
and plantar (b) clinical
aspects
C. Biz et al.
16.3.3 Radiographic Examinations
2. Empirical treatment: antibiotic therapy
should be provided for another 24weeks, and
Radiographic examinations are usually required
to detect bone involvement in cases of suspected
osteomyelitis. Because bone destruction is
usually not seen with plain radiography performed during the early stages of disease and
neuro- osteoarthropathy can mimic infection,
diagnosing osteomyelitis when the patient is rst
examined can be difcult. Characteristic progressive changes on serial plain radiographs may help
in more chronic cases [17].
If the ndings of radiography are only consistent with, but not characteristic of DFO, one of
the following choices should be considered
(Fig.16.5):
then radiographs should be taken again to
determine whether bony changes have progressed (which would suggest infection).
3. Bone biopsy: an appropriate procedure should
be used, as described here. Collection of a
sample of a bony lesion (either operatively or
percutaneously) is recommended if the diagnosis remains in doubt after imaging or if
osteomyelitis is likely but the etiologic agent
or antibiotic susceptibilities are not predictable [19]. Some physicians would also obtain
biopsy specimens of most mid- or hind-foot
lesions because these are more difcult to
treat and more often lead to a high-level
amputation. Percutaneous biopsy should pref-
1. Additional imaging studies: Magnetic reso-
nance imaging is the preferred imaging study,
with nuclear medicine scans (preferably using
newer generation leukocyte or immunoglobulin techniques) being a second choice. If the
results of the imaging tests are negative,
osteomyelitis is unlikely; if results suggest
osteomyelitis, bone biopsy should be considered [18].
erably be done under uoroscopic or CT guidance, traversing uninvolved skin if possible.
For DPs with sensory neuropathy, anesthesia
may be unnecessary. Various types of bonecutting needles, such as Jamshidi (Perfectum
Corporation; distributed by Propper and Sons)
and Ostycut (Bard Products; distributed by
Angiomed), have been used. Obtain specimens if possible, sending at least one for
16 Diabetic Foot Osteomyelitis (DFO)
227
a
b1 b2
c1 c2
Fig. 16.5 A 67-year-old type II diabetic man with a history of spina bida presenting a left hind-foot plantar
ulcer with radiographic signs of osteomyelitis: clinical
image (a); X-rays (b1, b2) and MRI (c1, c2) images at the
time of presentation
culture and another for histological analysis.
With small toe bones, it may only be possible
to aspirate a few bony spicules. Foot bone
biopsy is a safe procedure, and cultures of
bone specimens provide more accurate microbiologic data than those of soft-tissue specimens for DPs with osteomyelitis [19].
16.3.3.1 X-ray
Plain X-rays have indisputable advantages for a
rst diagnostic study: they are not expensive, can
be repeated and therefore can be compared, are
easily performed, and are not limited by contraindications. Signs of DFO are bone erosion of cortical bone, osteopenia, cortical osteolysis,
sequestration, and periosteal thickening, but they
become evident after 2–3 weeks from onset
(Figs. 16.2, 16.3, 16.5, and 16.6). Moreover,
X-rays are useful for understanding the severity
of bone involvement and the possible presence of
gas (for example in gangrene), foreign bodies,
and enlargement of soft tissue in cases of associated cellulitis [20].
Planar beam radiography can visualize anomalies indicative of osteitis, such as periosteal
reaction, sequestrum, medulla damage, and cortical rupture. In the case of clinically suspected
osteitis, it is advisable to repeat the radiographic
process at least two weeks later due to delayed
appearances of these anomalies.
16.3.3.2 MRI
MRI is the most useful of the available imaging
modalities for dening bone infections, providing the most reliable image of deep soft-tissue
infections (Fig.16.5). Its sensitivity and specicity for diagnosing DFOs are 90% and 83%,
respectively [21]. The performance characteristics of all of these diagnostic tests are highly correlated with the pretest probability of
osteomyelitis, and they are most useful for probable cases. However, the gold standard for diagnosing osteomyelitis is the isolation of bacteria
from a reliably obtained sample of bone, concomitant with histological ndings of inammatory cells and osteonecrosis.
228
C. Biz et al.
a1
a2 bc d
e1 e2 f1 f2
Fig. 16.6 An 81-year-old type II diabetic man presenting
ischemia and gangrene of the rst ray of his left foot with
signs of osteomyelitis of the rst metatarsal head: clinical
(a1, a2), X-ray (b), MRI (c), and Scintigraphy (d) images
before surgery; clinical (e1, e2) and radiographic (f1, f2)
images during and after surgical procedure
MRI is usually not needed as a rst-line investigation in cases of DFO.When osteomyelitis is a
possibility, obtaining plain radiographs often sufces. If these radiographs show no evidence of
pathological ndings in bone, the patient should
be treated for 2weeks for the soft-tissue infection
[22]. If suspicion of osteomyelitis persists, plain
radiography should be performed again 24weeks
later. If the initial X-rays show clear changes suggestive of osteomyelitis (cortical erosion, periosteal reaction, and mixed lucency and sclerosis),
and if there is little likelihood of noninfectious
osteoarthropathy, treatment for presumptive
osteomyelitis should be carried out, preferably
after obtaining appropriate specimens for culture.
16.3.3.3 PET-CT
Positron Emission Tomography-Computed
Tomography (PET-CT) is useful to distinguish
soft tissues from bone infections as well as MRI
with gadolinium. An undoubted advantage of this
method is that the pathology becomes evident
only 3days after the onset, thus allowing an early
diagnosis [8]. PET-CT offers exceptional spatial
resolution and identies essential anatomical
details necessary for effective management. Its
sensitivity and specicity in the diagnosis of
DFO are 90% and 83%, respectively. Additionally,
the use of SPECT-CT and labeled polynuclear
scintigraphy aids inlocating hyperxation in soft
tissues and bone tissues, allowing for precise
determination of the extension of infectious
lesions (Fig. 16.6). Moreover, 18F-FDG PET/
Scan offers signicant sensitivity (89%) and
specicity (92%), but it does not consistently differentiate between soft tissue infection and osteitis from inammation in acute Charcot
osteoarthropathy [21].
16 Diabetic Foot Osteomyelitis (DFO)
229
16.3.4 Biopsy
The undoubted gold standard for diagnosing
osteomyelitis is bone biopsy, which provides
histological ndings such as necrosis and the
presence of inammatory cells as well as microbiological characterization. To achieve a truthful antibiogram, it is mandatory to perform this
procedure after an antibiotic-free period of at
least two weeks because of the prolonged
release of some antibiotics from bones [5].
When antibiotic therapy is initiated before a
bone biopsy can be obtained, the bacteria may
be suppressed, which can interfere with the
accurate identication of the infecting organism
[3]. If possible, bone biopsy should be performed without passing through an open wound
to avoid contamination by colonizing organisms. In patients with profound peripheral neuropathy, bone biopsy can generally be done with
little or no anesthesia.
Bone biopsy provides histological and microbiological ndings characteristic of DFO [23],
such as bone erosion, marrow edema, brosis,
and necrotic inammatory cells.
The bone can be removed by a percutaneous
approach through non-infected skin or during
open surgical procedures. In the case of bone
infection, a supercial swab shows low sensitivity; a reliable correspondence between bacteria
isolated from bone biopsy and swab culture is
approximately 38%. Therefore, a supercial
swab should not be used in case of DFO.Bone
biopsy is the most accurate test even if in several
cases it is not technically feasible. However, a
recent study showed that the pathogens isolated
from a culture of deep tissues (removed from the
area closest to the bone) are very similar to those
obtained from bone biopsy (74.3% vs 82.8%)
[24].
While bone biopsy has traditionally been
viewed as the primary method for diagnosing
diabetic foot osteomyelitis, recent research has
questioned its reliability as a standalone test. The
International Working Group on the Diabetic
Foot (IWGDF) suggests using a combination of
clinical, radiographic, and laboratory ndings,
along with diagnostic categories like “denite,”
“probable,” “possible,” and “unlikely” to diagnose osteomyelitis. The term “bone biopsy” can
be ambiguous, as it may refer to the physical act
of removing a bone specimen rather than the specic examination conducted on the excised fragment [25].
16.4 Treatment ofDFO
In the past, the only successful method of eradicating DFO was complete surgical resection.
There are now many published case series, and at
least one randomized controlled trial [17], demonstrating that for properly selected patients with
DFO, antibiotic therapy without surgery can offer
similar results to those with surgery. The most
recent and comprehensive guidance for treating
DFO is found in the 2023 update of the guidelines on infection from the International Working
Group on the Diabetic Foot (IWGDF), which
provides rigorously reviewed recommendations
on managing all aspects of diabetic foot
infections.
These guidelines broadly recommend the
specic conditions for a medical approach combined with conservative surgery. Conservative
surgery is usually a procedure in which only the
infected bone and the nonviable soft tissues are
removed without any amputation. Although an
aggressive surgical approach could be mandatory under some circumstances, retrospective
studies have shown that conservative treatment
associated with prolonged antibiotic therapy is
effective in promoting wound healing and reducing the risk of major amputation and ulcer recurrence [26].
Denitive surgical solutions to osteomyelitis,
such as ray and transmetatarsal amputations, may
risk architectural reorganization of the foot,
resulting in altered biomechanics and additional
cycles of ulceration (Fig.16.7). Neuropathy and
reduced systemic manifestations of infection may
make osteomyelitis tolerable for the patient, who
may thus opt for attempts at medical management. In contrast, these diabetic complications
may also mask progressive bone destruction, with
delayed or inadequate surgery resulting in poorly