Osteomyelitis surgery: removing infected bone to save the foot

What the operation does

The operation targets bone that an ulcer has reached and infected. Taking out infected bone has long been the standard treatment, though in carefully selected people, mostly with forefoot infections, antibiotics alone can work as well. When bone does need to come out, the 2023 international guideline favors a conservative approach: removing a limited amount of bone and avoiding amputation where possible.⁠^[1]

See also bone infection of the foot, how a foot wound is evaluated and limb salvage surgery.

Who it helps

In the guideline authors’ view, surgery should at least be considered for any severe foot infection and whenever antibiotics alone are unlikely to work. Studies supporting antibiotics alone mostly left out people who clearly needed an operation, such as those with exposed bone or an undrained abscess.⁠^[1] A deep abscess or a fast-spreading necrotizing infection needs a surgeon urgently.⁠^[1] See surgery for diabetic foot infection.

Antibiotics without surgery can be considered for a forefoot bone infection with no artery disease, no exposed bone and no immediate need for drainage.⁠^[1] In a randomized trial of such patients, 86% healed after bone-sparing surgery and 10 days of antibiotics, and 75% after 90 days of antibiotics alone, not a statistically significant difference. Four of the 24 given antibiotics alone got worse and went on to surgery, and 3 of the 22 in the surgery group needed a second operation; the authors judged the outcomes similar.⁠^[4]

Badly reduced blood flow should be restored before or after the bone is removed, since an operation on a foot without enough circulation can leave a wound that won’t heal.⁠^[1] We start with noninvasive circulation testing at our practice and work with vascular specialists who restore blood flow.

The operations, from toe to heel

The operation is matched to where the infected bone sits.

• Toe. Removing part or all of the infected end bone, or trimming away an infected toe joint, keeps the rest of the toe.⁠^[2] For an ulcer at the tip of a flexible bent toe, releasing the tendon that curls the toe, through a tiny cut, can take pressure off the tip.⁠^[5,2]
• Big-toe joint. An infected sesamoid (one of two small bones under the joint) can be removed, or the infected joint surfaces trimmed away.⁠^[2]
• Ball of the foot. A metatarsal head resection removes the infected end of the long bone beneath the ulcer.⁠^[2]
• Heel. A partial calcanectomy removes the infected part of the heel bone. Across 20 studies of 300 heel-bone operations, mostly partial, the bone infection healed in 80%; about one in six people later needed a below-knee amputation.⁠^[6] See heel ulcers.
• When too much bone is damaged. A planned toe or partial foot amputation that keeps as much length as possible is itself limb preservation. A limb salvage second opinion can show whether a smaller operation is possible.

A review judged bone-sparing forefoot surgery, when indicated, safe and effective, improving the chance of healing compared with more radical amputation, though randomized trials are still needed.⁠^[2]

When surgery is the right step, Dr. Efe Ozturk, a Foot and Ankle Surgeon board certified in wound care (FAPWH), performs these operations, choosing the smallest one that clears the infected bone and keeps a foot you can walk on.

What happens during the operation

• Removing the bone. The surgeon takes out the infected bone along with any dead or infected tissue around it.⁠^[1]
• Testing the bone. Bone samples go to the laboratory, because a bone culture identifies the germ more reliably than a sample from the wound; in most studies the two agree less than half the time.⁠^[1] We choose antibiotics from those results, and when the diagnosis is uncertain before surgery, Dr. Ozturk performs a bone biopsy to confirm it.
• Checking the edge. The remaining bone, called the margin, can be tested too; in several studies, one- to two-thirds of healthy-looking margins showed some infection, though many may be false alarms.⁠^[1] Whether this matters is debated: a 2024 review of 530 people linked leftover infection with about twice the odds of reinfection and higher odds of amputation,⁠^[7] while a 2023 study of 93 people found no link with infection returning.⁠^[8]
• Closing the wound. The wound may be left open to heal from its base; in the series of 81 people, wounds healed this way in a median of 8 weeks.⁠^[3] Once the infection is under control, we use negative-pressure wound therapy or a skin graft or local flap for the wounds that need help closing.
• Antibiotic beads. Some surgeons pack antibiotic-loaded beads or cement into the space left by the bone; the guideline suggests not adding these to antibiotics by mouth or vein, as studies haven’t shown a clear benefit.⁠^[1]

Antibiotics afterward

The margin result helps set how long you take antibiotics. The guideline suggests these courses, based on limited evidence:⁠^[1]

In a randomized pilot trial of 93 people after surgical debridement of a diabetic foot bone infection, 3 weeks of antibiotics did as well as 6 (remission in 84% and 73%), with similar side effects.⁠^[9] Many people can take antibiotics by mouth, sometimes after starting through a vein.⁠^[1]

What the results show

In a prospective series of 81 people with diabetes having surgery for foot bone infection, 59% had bone-sparing surgery and 40% a minor (foot-level) amputation. About one in four (24.7%) needed another operation for persistent infection. Over a median of about two years, 16.9% of the 65 people followed after healing had a new episode of bone infection.⁠^[3]

Recovery

You keep pressure off the area while it heals, and we see you every week or two to clean, measure and dress the wound. Hyperbaric oxygen isn’t advised for the infection itself,⁠^[1] but for a wound with reduced blood flow that heals slowly despite good care, a guideline suggests considering hyperbaric oxygen therapy, and we can refer you.⁠^[10] Because bone infection can come back, doctors judge success, called remission, at least 6 months after antibiotics end.⁠^[1]

An uncorrected deformity or pressure point can let a new infection start in the same spot, and lifelong foot checks are advised after a diabetic foot infection.⁠^[1] In the series above, 43% of those followed after healing developed a new ulcer.⁠^[3] See surgery that takes pressure off ulcers, recovery after limb salvage surgery and keeping your foot in remission.

Risks and limits

The guideline’s suggestion to operate rests on low-certainty evidence, and studies comparing surgery with antibiotics alone have reached different results.⁠^[1] Some people need more than one operation before the infection clears.⁠^[3]

Infection of the surgical wound is more common with diabetes: 9.5% versus 2.4% in a study of 1,465 foot and ankle operations, with nerve damage, Charcot foot, smoking and longer operations as risk factors.⁠^[11] Read about peripheral neuropathy (external site) and, if you smoke, smoking and foot surgery healing (external site).

Questions to ask

• How much bone will you remove, and will the edge be tested?
• Is a bone-sparing operation possible instead of an amputation?
• How long will I take antibiotics, and can they be pills?
• Is my circulation good enough for the wound to heal?
• What will prevent a new ulcer afterward?

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. With diabetes or poor circulation, call us the same day for new redness, warmth, swelling or drainage, a red, hot, swollen foot, or new foot pain at rest or at night.