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Effect of Sensory Neuropathy on the Predictive Value of Inflammatory Biomarkers for Osteomyelitis in Diabetic and Nondiabetic Patients with Foot Infections

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  • 1 Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
  • | 2 Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX.
  • | 3 South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney Local Health District, Sydney, Australia.
  • | 4 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX.
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Objective: To investigate the predictive value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in persons with and without diabetes with osteomyelitis (OM).

Methods: We evaluated 455 patients in a retrospective cohort study of patients admitted to the hospital with diabetic foot OM (n = 177), diabetic foot soft-tissue infections (STIs) (n = 176), nondiabetic OM (n = 51), and nondiabetic STIs (n = 51). Infection diagnosis was determined through bone culture, histopathologic examination for OM, and/or imaging (magnetic resonance imaging/single-photon emission computed tomography) for STI. The optimal cutoff values of ESR and CRP in predicting OM were determined by receiver operating characteristic curve analysis. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were determined through contingency tables.

Results: In persons without diabetes with STI or OM, the mean ESR and CRP differences were 10.0 mm/h and 2.6 mg/dL, respectively. In contrast, persons with diabetes had higher levels of each: 24.8 mm/h and 6.8 mg/dL, respectively. As a result, ESR and CRP predicted OM better in patients with diabetes. However, when patients were stratified by neuropathy status, ESR remained predictive of OM in diabetic patients with neuropathy (75% sensitivity, 58% specificity) but not in diabetic patients without neuropathy (50% sensitivity, 44% specificity). Also, CRP remained predictive irrespective of neuropathy status. A similar trend was observed in patients without diabetes.

Conclusions: Previous studies have reported that ESR and CRP are predictive of OM. However, this study suggests that neuropathy influences the predictive value of inflammatory biomarkers. The underlying mechanisms require further study.

Corresponding author: Easton Ryan, BS, Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390. (E-mail: easton.ryan@utsouthwestern.edu)