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Three Part Question

In a [diabetic patient with a wound to the foot] is [immediate or delayed debridement] the [most likely to prevent osteomyelitis?]

Clinical Scenario

A 69 year old female patient with diabetes and peripheral neuropathy presents to the emergency department with a wound to her left foot. On inspection there is an ulcerated area surrounded by callus. There are local signs of infection (swelling and erythema) requiring an antibiotic, but the patient is systemically well and fit for discharge to follow-up. You wonder if the wound can wait to be debrided by the diabetes team the next day or if there would be any benefit to sharp-debridement performed immediatly.

Search Strategy

(exp diabetes mellitus OR exp diabetic neuropathies OR exp diabetic foot) AND (exp wounds and injuries OR debride$.mp. OR exp debridement) LIMIT to humans and English language.
Medline from 1950 to June 2007 using the Ovid interface and Embase 1996 to week 25 2007

Search Outcome

The search located 84 papers only 1 of which was relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Lavery LA, Harkness LB, Ashry HR,Felder-Johnson KF. 1994 USA	66 adult patients with diabetes admitted to hospital for a foot infection precipitated by a puncture wound. Medical records, operative reports, and pathology reports weere reviewed for each patient. Subjects were subdivided into two diagnostic groups (with and without osteomyelitis)	Cohort study	Diagnosis of osteomyelitis based on either a positive bone culture or pathology report	Debridement was performed in an average of 20.5 days after the puncture injury in patients with osteomyelitis and 11.1 days in patients with soft tissue infections (P<0.03)	This is a small study. There was no blinding or randomisation used. The groups were identified retrospectively as the time lag between injury and debridement was determined from the date of injury.

Comment(s)

This study alone is not sufficient to make definite recommendations from, however it does suggest that the later that debridement takes place the more likely a patient is to have osteomyelitis.

Clinical Bottom Line

The emergency department clinician should debride the wound as thouroughly as their clinical competancy allows taking care not to damage viable tissues.

References

1. Lavery LA, Harkness LB, Ashry HR,Felder-Johnson KF Infected Puncture Wounds in Adults with Diabetes: Risk factors for Osteomyelitis American Journal of Foot and Ankle surgery 1994;33(6):561-6