Acute on Chronic Diabetic Forefoot Osteomyelitis Treated With Internal Pedal Amputation and Cement: A Preliminary Report.

Background: Very few studies reported outcomes of common conservative surgeries with antibiotic-impregnated cement when treating diabetic foot osteomyelitis (DFO). The aim of this descriptive study is to report the results of the association of cement with a specific type of toe-sparing resection, combining total metatarsectomy/phalangectomy (internal pedal amputation) with partial bone excision, for acute on chronic forefoot DFO. Methods: Six patients with confirmed acute on chronic DFO were included. A probe-to-bone test was performed for open wounds. For all patients, radiographs, magnetic resonance imaging (MRI), and pathology were conducted in search of osteomyelitis signs. The level of resection was defined as 1 cm away from the contrast enhancement shown on MRI. The polymethylmethacrylate (PMMA) cement was prepared with 2 g of vancomycin before being placed in the defect. A minimum period of 6 months of clinical follow-up was set. Results: All patients demonstrated wound healing at last follow-up with normalized C-reactive protein. There were no clinical signs of osteomyelitis recurrence. One wound infection was recorded 4 weeks postoperatively and treated successfully with debridement and lavage. None of the cement had to be removed or exchanged. Subjectively, 5 patients were extremely satisfied scoring 5/5 on Likert scale, and 1 patient was moderately satisfied (3/5). All patients were able to walk with full weight using insoles. Conclusion: This preliminary report demonstrated that PMMA cement could be a viable option when used to locally control infection following an internal pedal amputation for acute on chronic DFO of the toes. In addition to the high rate of healing, the esthetical result was highly appreciated by the patients. Level of Evidence: Level IV, case series.