The Diagnosis of Osteomyelitis in Diabetes Using Erythrocyte Sedimentation Rate

To the Editor:

I thoroughly enjoyed the article in the October 2001 issue of the Journal titled “The Diagnosis of Osteomyelitis in Diabetes Using Erythrocyte Sedimentation Rate: A Pilot Study.” Although there is a significant correlation between diabetes and the development of osteomyelitis, was there any reason nondiabetic patients with osteomyelitis were not included in the study? I believe the pilot study would be further validated by a similar optimal sedimentation rate cutoff value for nondiabetic patients with osteomyelitis. The article states that this is a pilot study, but there is no mention that a larger study is warranted or currently under way by the authors or their institution, although the authors mention in the “Discussion” section that further investigations are warranted.

In addition, there is no mention of what type of osteomyelitis the authors were evaluating. It would be of clinical value to differentiate between acute and chronic osteomyelitis. Further differentiation between chronic osteomyelitis with a draining sinus tract and chronic osteomyelitis with an acute flareup needs to be made. There also needs to be some mention of osteomyelitis location with classification using an acceptable system, eg, the Cierny-Wager classification system.

These comments are not meant to detract from the article but merely to stimulate dialogue on this subject.

JEFFREY C. KARR, DPM

Karr Foot Kare 1045 East Rd 540A Lakeland, FL 33813

Author’s Response

To the Editor:

I appreciate Dr. Karr’s commentary on our article. With regard to the nondiabetic patient population,

this was not the focus of our study. Diabetes is the leading cause of nontraumatic amputation in the United States [1]. It has been well demonstrated that the diabetic patient often fails to respond to infection in the same manner as the nondiabetic patient [2]. Therefore, any test that a clinician might use to aid in the diagnosis of osteomyelitis would be beneficial.

As stated in the article, this was a pilot study, which by definition is a small initial investigation of a particular topic. It is customary to publish pilot data prior to performing a larger investigation. As Dr. Karr pointed out, it is mentioned in the “Discussion” section that further investigations are warranted.

This being a pilot study, it would be difficult to further divide these patients into groups such as acute and chronic osteomyelitis, and we believe this would not change the results. Once again, the erythrocyte sedimentation rate is to be used as a screening tool, an adjunct to aid the clinician in the diagnosis of osteomyelitis in the diabetic foot. In the clinical setting, a classification system such as the University of Texas classification system for diabetic wounds is a useful tool and has been validated [3,4,5,6,7]. However, our aim was to evaluate a nonclinical test to aid the physician in the treatment of the diabetic patient. The use of a classification system is not needed here.

The purpose of our study was to evaluate a relatively noninvasive test, the erythrocyte sedimentation rate, for its value in the early diagnosis of osteomyelitis in diabetic foot infections. Once again, the results of our pilot study demonstrate with a high degree of specificity and sensitivity that the erythrocyte sedimentation rate, when coupled with clinical signs of infection, can be an effective tool for predicting the presence or absence of bone infection in the diabetic patient population. Most important, this information can then lead to prompt management of these limbthreatening infections.

JENNIFER L. KALETA, DPM

Illinois Masonic Medical Center 3000 N Halsted, Ste 500 Chicago, IL 60657