Treating Diabetic Foot Osteomyelitis (DFO) in the forefoot is a daily battle in the trenches of limb preservation. It is the most common location for DFU, DFI, and DFO, occurring in up to 90% of cases. While we often lean on conservative standard care, it frequently fails when the bone is involved.
Our colleagues in Lebanon, led by Dr. Kaissar Yammine, have just released a preliminary report that hits the sweet spot between aggressive resection and functional preservation. They are looking at Internal Pedal Amputation combined with antibiotic-impregnated cement.
This isn’t just about cutting bone; it’s about managing dead space and infection simultaneously to get the patient back to “toe and flow.”
The Protocol: Clean House, Fill the Void
The study looked at acute-on-chronic DFO cases where the goal was a toe-sparing resection. Here is the playbook they used:
- Aggressive Resection: They performed an “internal pedal amputation”—total metatarsectomy or phalangectomy combined with partial bone excision.
- The Margins: The resection level was strictly defined as 1 cm away from the contrast enhancement shown on MRI.
- The Cement: They used PMMA cement mixed with 2g of vancomycin.
- Volume Control: Crucially, they filled the defect with cement volume estimated at only half the void volume to ensure easy skin closure without tension.
The Results: 100% Healing
While this is a preliminary series ($n=6$), the data is incredibly encouraging for those of us looking for better remission tools:
- Perfect Clearance: All patients demonstrated wound healing at the last follow-up with normalized CRP.
- No Recurrence: There were zero clinical signs of osteomyelitis recurrence.
- Durability: None of the cement spacers had to be removed or exchanged.
- Function: All patients were walking with full weight using insoles post-recovery.
Why It Matters: Form and Function
This approach tackles two massive headaches in limb salvage: dead space management and patient psychology.
- Structural Integrity: The cement acts as a spacer that provides enough stiffness to handle load transfer, potentially functioning as a “pseudo-joint”.
- Patient Satisfaction: Subjectively, patients were extremely satisfied (scoring 5/5 on the Likert scale) because the esthetic result of the toe was preserved.
The Takeaway
This is a team sport. Whether we are in Los Angeles or Beirut, the goal is the same: eliminate preventable amputation. This technique offers a viable option to locally control infection while maintaining the foot’s architecture. It’s a solid reminder that sometimes, to build a bridge to healing, you need a little cement.
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