Newman L G, Waller J, Palestro C J, Schwartz M, Klein M J, Hermann G, Harrington E, Harrington M, Roman S H, Stagnaro-Green A
Department of Medicine, Mount Sinai Medical Center, New York, NY 10029.
JAMA. 1991 Sep 4;266(9):1246-51. doi: 10.1001/jama.266.9.1246.
The prevalence of osteomyelitis in diabetic foot ulcers is unknown. Early diagnosis of this infection is critical, as prompt antibiotic treatment decreases the rate of amputation. We therefore assessed the prevalence of osteomyelitis in 35 diabetic patients with 41 foot ulcers. We compared results of roentgenograms, leukocyte scans with indium In 111 oxyquinoline, and bone scans with the diagnostic criterion standards of bone histologic and culture findings. Leukocyte scans were repeated at 2- to 3-week intervals during antibiotic treatment.
Cohort study.
Institutional and private, ambulatory and hospitalized patients.
Consecutive sample of 54 diabetic patients. Thirty-five patients with 41 foot ulcers were included.
As determined by bone biopsy and culture, osteomyelitis was found to underlie 28 (68%) of 41 diabetic foot ulcers. Only nine (32%) of the 28 cases were diagnosed clinically by the referring physician. Underscoring the clinically silent nature of osteomyelitis in these ulcers, 19 (68%) of 28 occurred in outpatients, 19 (68%) of 28 occurred in ulcers not exposing bone, and 18 (64%) of 28 had no evidence of inflammation on physical examination. All patients with ulcers that exposed bone had osteomyelitis. Of the imaging tests, the leukocyte scan had the highest sensitivity, 89%. In patients with osteomyelitis, the leukocyte scan image intensity decreased by 16 to 34 days of antibiotic treatment and normalized by 36 to 54 days.
The majority of diabetic foot ulcers have an underlying osteomyelitis that is clinically unsuspected. Leukocyte scans are highly sensitive for diagnosing osteomyelitis in diabetic foot ulcers and may be useful for monitoring the efficacy of antibiotic treatment. We recommend that diabetic patients with foot ulcers that expose bone should be treated for osteomyelitis. Diabetic patients with foot ulcers that do not expose bone should undergo leukocyte scanning, which eliminates the risk of bone biopsy in diagnosing osteomyelitis and allows for the diagnosis and treatment of this well-known but often silent precursor of lower extremity amputation.
糖尿病足溃疡中骨髓炎的患病率尚不清楚。早期诊断这种感染至关重要，因为及时的抗生素治疗可降低截肢率。因此，我们评估了35例患有41处足部溃疡的糖尿病患者中骨髓炎的患病率。我们将X线片、用铟In 111氧喹啉进行的白细胞扫描以及骨扫描的结果与骨组织学和培养结果的诊断标准进行了比较。在抗生素治疗期间，每隔2至3周重复进行白细胞扫描。
队列研究。
机构和私人机构的门诊及住院患者。
54例糖尿病患者的连续样本。纳入了35例患有41处足部溃疡的患者。
通过骨活检和培养确定，41处糖尿病足溃疡中有28处（68%）存在骨髓炎为其病因。在这28例病例中，只有9例（32%）由转诊医生临床诊断。强调这些溃疡中骨髓炎在临床上无症状的特点，28例中有19例（68%）发生在门诊患者中，28例中有19例（68%）发生在未暴露骨质的溃疡中，28例中有18例（64%）在体格检查中无炎症迹象。所有暴露骨质的溃疡患者均患有骨髓炎。在影像学检查中，白细胞扫描的敏感性最高，为89%。在患有骨髓炎的患者中，白细胞扫描图像强度在抗生素治疗16至34天时降低，在36至54天时恢复正常。
大多数糖尿病足溃疡都存在临床上未被怀疑的潜在骨髓炎。白细胞扫描对诊断糖尿病足溃疡中的骨髓炎高度敏感，可能有助于监测抗生素治疗的疗效。我们建议，对于骨质暴露的糖尿病足溃疡患者应进行骨髓炎治疗。对于骨质未暴露的糖尿病足溃疡患者应进行白细胞扫描，这可消除在诊断骨髓炎时进行骨活检的风险，并有助于诊断和治疗这种众所周知但往往无症状的下肢截肢先兆疾病。
