Multisystem Management Of Diabetic Foot Osteomyelitis: A Systematic Review Of Surgical Debridement, Glycemic Control, And Cardiovascular Optimization And Neurological Assessment

Abstract

Background: Diabetics foot osteomyelitis is a huge morbidity for diabetic population and possesses a higher 5-year mortality than most cancers. Multi systemic approach for treatment, consisting of surgical removal, appropriate antibiotics therapy, good glycemic control and cardiac risk optimization and full neurological assessment are the cornerstone of the treatment of DFO. However in spite of the immense complexity of the treatment approach, management guidelines in DFO are focused on infective issues and not enough attention has been given to the integrated approach involving neurological and cardiovascular systems. Aim: This is a systematic review on a multi systemic management approach for DFO, focusing on surgical intervention, glycemic control, cardiac management, and neurological assessment/imaging published between  2020-2024 and to combine the current evidence to create awareness about their treatment strategies. Method: PRISMA 2020 compliant systematic review of literature search in PubMed/MEDLINE, CINAHL, Scopus, Web of Science, Cochrane library and EMBASE. We included 10 studies from the 3079 articles screened at title/abstract. The quality of included articles was evaluated using CASP, JBI, Cochrane RoB 2, AMSTAR-2 criteria. Result: We found six main themes of management of DFO. Surgical debridement (58% vs 38% on conservative treatment for remission, P<0.01); Antibiotic stewardship (Oral treatment is non-inferior to IV administration post adequate surgical debridement); Glycaemic control (HbA1c>8% leads to doubling of treatment duration for healing,HbA1c<7.5% decreases amputation risk by 44%); Cardiac optimization (Preoperative cardiac evaluation decreases MACE by 52% at 30 days and there is undiagnosed CAD in 38% in patients with surgical DFO); Neurological assessment (MNSI>5 can be predictor for deep DFO with OR 3.1); Advanced imaging (MRI can be gold standard, PET-CT decreases re-operation by 31%).Conclusion: A multispecialty team, including endocrinology, vascular surgery, cardiology, neurology, infectious disease, orthopedics, podiatry and nursing, must be involved in the care of DFO; management by single specialties will likely lead to worse outcomes regarding higher amputation rates, longer duration of illness and increased cardiovascular mortality.