Clinical practice

Osteomyelitis in diabetic foot ulcers: the Malaysian experience

Osteomyelitis is defined as an inflammation of the bone marrow. Approximately 20% of patients with diabetes will develop osteomyelitis and it is linked to high rates of mortality, morbidity and amputation. Diagnosing osteomyelitis associated with a diabetic foot can be challenging as it is difficult to identify the infection in its initial phase and there is often Authors: symptom and clinical manifestation variability. As there are no standardised Harikrishna KR Nair, Sylvia SY Chong tests or criteria for diagnosing osteomyelitis, it may be helpful to obtain a patient’s complete history of symptoms, including physiological state (risk factors) with clinical manifestation, laboratory tests, imaging and blood or bone cultures to come to a final diagnosis. This article looks at some of the tests that can be used in the diagnosis process.

he importance of wound irrigation and As seen below, Lew and Waldvogel (Figure 1) cleansing solutions is often ignored, with Cierny and Mader are two major clinical TWAs Malhotra et al (2014) have shown, classifications for osteomyelitis. According to osteomyelitis is defined as an inflammation Lew and Waldvogel in 1970, osteomyelitis is of the bone marrow. A bacterial infection can classified based (Table 1) on the length of cause inflammation of the bone tissue, which evolution and pathophysiology. can result in inflammatory destruction, necrosis, Cierny and Mader (1984) attempted to bone neoformation, and it can progress into a address some aspects that were not covered chronic or persistent stage (Smith et al, 2006). by Lew and Walvogel’s classification . They Staphylococcus aureus is the most common classified osteomyelitis by anatomical stages pathogenic organism isolated in osteomyelitis, according to bone infection and the type of although a variety of organisms can cause this host health status, depending on the patient’s disease, as outlined by Lew and Woldvogel (2015). clinical conditions (Table 2).

Harikrishna KR Nair is Head of Wound Care Unit, Department of Internal Medicine, Hospital Kuala Lumpur; Sylvia SY Chong is a Research Assistant, Wound Care Unit, Department Figure 1. Lew and Waldvogel with Cierny and Mader are two major clinical classifications of Internal for osteomyelitis

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Table 1. The Lew and Waldvogel osteomyelitis classification system Duration of infection Description Acute Initial episodes of osteomyelitis with the presence of oedema, pus formation, vascular congestion and thrombosis of the small vessels Chronic Recurrence of acute cases with large areas of ischemia, necrosis and bone sequestra

Mechanism of bone infection Description Hematogenous Commonly seen in children and occurs through secondary infection when bacterial is transported through the blood Contiguous Bacterial inoculation from an adjacent focus, e.g. post-traumatic osteomyelitis, or infections related to prosthetic devices Associated with vascular insufficiency Infections affecting the feet in patients with diabetes, hanseniasis or peripheral vascular insufficiency

Table 2. The Cierny and Mader osteomyelitis classification system Anatomical stage Description 1 Medullary Infection restricted to the bone marrow 2 Superficial Infection restricted to cortical bone 3 Localised Infection with clearly defined edges and bone stability preserved 4 Diffuse Infection spread to the entire bone circumference, with stability before or after debridement Host health status Description A Host healthy Patients without comorbidities Bl Local Smoking, chronic lymphedema, venous stasis, arthritis, large scars, fibrosis compromise by radiotherapy Bs Systemic Diabetes mellitus, malnutrition, renal or hepatic failure, chronic hypoxia, compromise neoplasms, extremes of age C Poor clinical Surgical treatment will have a higher risk than the osteomyelitis itself conditions

Hematogenous osteomyelitis is most are Staphylococcus aureus (Asmar, 1992). As commonly seen in infants and children, and reported by Ramsey et al (1999) and Lavery et usually involves the metaphysis of long bones, al (2009), about 20% of osteomyelitis cases are particularly the femur and tibia. Metaphyseal acute hematogenous osteomyelitis. Of these, spongiosa contains abundant blood vessels children under the age of 5 account for 50%. with leaky endothelium and a sluggish flow This accumulates up to 85% for cases involving that ends in capillary loops and provides a children under the age of 17, as stated by suitable environment for bacteria growth, Cierny and Mader (1984). as reported by Whyte and Bielski (2016). In The most common infection site is the children under the age of one, there have vertebrae, but it can also occur in the pelvis, been cases of osteomyelitis affecting the clavicle and long bones, and, as reported by epiphysis due to the connection of blood Arciola et al (2005), only 2–7% of adults have vessels passing through the metaphysis to this condition. As Rao et al (2011) have shown, the epiphysis. As shown by McPherson (2002), hematogenous osteomyelitis is usually an acute Liao et al (2005), and Qadir et al (2010), in disorder and primarily treated conservatively. new-borns the most common pathogens are On the other hand, as stated by Lew and Streptococcus agalactiae, Escherichia coli and Waldvogel in 1970, chronic osteomyelitis is Klebsiella pneumonia, while in children the characterised by progressive reoccurrence or common pathogens across all age groups multiple episodes of acute osteomyelitis at the

20 Wounds Asia 2021 | Vol 4 Issue 1 | ©Wounds Asia 2021 | www.woundsasia.com Figure 2. X Rays with bony erosions, subluxations, soft tissue swellings etc and pictures of the wounds with bone exposed or probe test positive with osteomyelitis are shown in a–c a. Patients with osteomyelitis and chronic wounds currently undergoing treatment under the Wound Care Unit, Hospital Kuala Lumpur

b. Patients with osteomyelitis and chronic wounds currently undergoing treatment under the Wound Care Unit, Hospital Kuala Lumpur

c. Patients with osteomyelitis and chronic wounds currently undergoing treatment under the Wound Care Unit, Hospital Kuala Lumpur

same site, which can lead to bone necrosis (Lew in patients with diabetes, as stated by Sia and and Waldvogel, 2004). Berbari (2006). In elective trauma surgery, Other entry routes of infection are secondary close fractures and first- to third-degree open to the direct inoculation of bacteria into fractures had 1–5% and 3–50% of contagious the bone tissue. The can occur in acute infection respectively, as reported by Gustilo trauma (an open fracture) and surgery (with et al (1990). As Parvazi et al (2008) have shown, or without implantation), as well as poor early infections are expected in 0.5% to 2% peripheral vascular supply with infection of of primary hip and knee replacement cases, the surrounding tissues. This is especially seen and more than 20% of septic revisions and

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5% of aseptic revisions have deep infections. clinical manifestation variability. As Arias et Generally, infectious complications occur in al (2019) have shown, because there are no 5% of traumatic and orthopaedic implants standardised tests or criteria for diagnosing during the lifetime of the implant (Trampuz and osteomyelitis, it may be helpful to see a patient’s Zimmerli, 2006). complete history of symptoms, including Contiguous spread of pathogens from physiological state (risk factors) with clinical infected diabetic foot ulcers (DFU) to the manifestation, laboratory tests, imaging, and bone is the pathogenesis of osteomyelitis blood or bone cultures to come to a final in a diabetic foot. Bacteria induce an acute diagnosis. Furthermore, patients with diabetes inflammatory reaction during infection of the and peripheral neuropathy are also prone to bone and the bacteria and inflammation affect developing Charcot neuro-osteoarthropathy, the periosteum and spread in the bone, causing which closely resembles and may co-exist with bone necrosis. Lifting of the periosteum further diabetic foot-associated osteomyelitis (Berendt impairs the blood supply to the affected bone, et al, 2008). causing segmental bone necrosis known as a Clinical suspicion is very important when sequestrum. In the chronic stage, numerous commencing a medical investigation for inflammatory cells and their release of cytokines osteomyelitis. A thorough assessment of the stimulate osteoclastic bone resorption, foot or lower extremity should be performed, ingrowth of fibrous tissue, and the deposition including examination of the ulcer, presence of of reactive new bone in the periphery. When peripheral neuropathy (present in 88% of DFUs), the newly deposited bone forms a sleeve of peripheral vascular disease (present in 45–65% living tissue around the segment of devitalised of DFUs), and the extent of any underlying infected bone, it is known as an involucrum. infection (Nair, 2017). Infected DFUs usually As Rosenberg (2010) has shown, a rupture of have purulent secretions or at least two signs of a subperiosteal abscess may lead to a soft- inflammation, as stated by Giurato et al (2017) tissue abscess and the eventual formation of a and Jeffcoate and Lipsky (2004), yet diabetic draining sinus. foot-associated osteomyelitis can occur without As reported in several publications Lipsky any local signs of infection. Systemic symptoms (2014), Lázaro-Martínez (2019) Optimal are rare due to the presence of diabetic- management of diabetic foot osteomyelitis: immunopathy, which impairs the patient’s challenges and solutions. Diabetes Metab Syndr response to inflammation and infection. Obes12:947–59. https://doi.org/10.2147/dmso. As Nair (2017) has shown, a simple clinical test s181198 et al (2019) and Bond et al (2019), commonly used for osteomyelitis is a probe-to- approximately 20% of patients with diabetes bone (PTB) test. This test evaluates the ability will develop osteomyelitis, and it is linked to a to contact a bone in the depth of an ulcer and high burden of mortality and morbidity - and it is performed by probing the ulcer area with especially high rates of amputation. Of these a sterile blunt metal probe. It is considered 10–20% account for moderate infection and positive if the probe reaches the bone surface. A 50–60% of the remaining account for severe study by Lavery et al (2007) showed a sensitivity infections, as shown by Giurato et al (2017), 87% and specificity 91%, positive predictive Berendt et al (2008) and Thomas-Ramoutar et value of only 57%, and a negative predictive al (2010). Diabetic foot osteomyelitis usually value 98% for the PTB test, which concluded develops by contiguous spread of bacteria from that it is a better tool to use to exclude overlying soft-tissue, infiltrating the cortex and osteomyelitis. In contrast, Morales et al (2010) eventually the bone marrow. In osteomyelitis, and Aragon-Sanchez et al (2011), support it as the pathogens found are more frequently poly- a reliable test for osteomyelitis, with sensitivity microbial. Staphylococcus aureus is the most 98%, specificity 79%, and sensitivity 95%, commonly detected (up to 50%), followed by specificity 93% respectively. Clinical signs that Enterobacteriaceae (up to 40%), Streptococci predict osteomyelitis are: an ulcer larger than (~30%), and Staphylococcus epidermidis (~25%). 2cm2; ulcer depth >3mm; visible exposed bone; This is stated by several publications (Jeffcoate positive PTB test; presence of ‘sausage; toe; an and Lipsky, 2004) Hartemann-Heurtier and ulcer that fails to heal or is located over the bony Sennivel, 2008; Nair, 2017). prominence, and the presence of soft-tissue Diagnosing osteomyelitis associated with sinus with purulent discharge. Leucocytosis and a diabetic foot can be challenging, as it is high CRP levels are a poor indicator for diabetic difficult to identify the infection in its initial foot-associated osteomyelitis, as they can be phase, and there is often symptom and negative in osteomyelitis, but ESR>70mm/h

22 Wounds Asia 2021 | Vol 4 Issue 1 | ©Wounds Asia 2021 | www.woundsasia.com is highly suggestive of osteomyelitis, with a attain limb salvage wherever possible. Current positive predictive value of 100%. management of diabetic foot osteomyelitis Laboratory tests such as whit blood cell is evaluated by case basis with guidelines (WBC), erythrocyte sedimentation rate (ESR), to advocate the specific conditions for and C-reactive proteins detect the presence of surgical or medical approaches combined inflammation and are generally raised in acute with conservative surgery. Antibiotic therapy hematogenous osteomyelitis, but they lack alone can work for selected cases, particularly specificity as other sources of inflammation uncomplicated forefoot osteomyelitis with no might also raise the readings. However, as other indications for surgery, as stated by the stated by Saavedra-Lozano et al (2008), these International Working Group on the Diabetic inflammatory markers are better used as a Foot (2019). The antibiotic regimens are based monitor during treatment. on the likely causative pathogens and guided by Radiological investigations are useful to culture results preferably from the bone, with a confirm a suspected case of osteomyelitis, to treatment duration of 6 weeks or shorter if the detect bone involvement and to distinguish infected bone is resected. As shown by Berendt a diabetic foot-associated osteomyelitis from et al (2008) and Mutluoglu and Lipsky (2016), soft-tissue infection (Giurato et al, 2017). Plain the patient’s clinical symptoms, abnormal lab radiography, although not as effective in the tests, and imaging studies should be monitored early stages or in distinguishing osteomyelitis for at least a year, and the case should be from Charcot neuro-osteoarthropathy, is still evaluated by a surgeon if it is not improving. The helpful as a baseline to assess the development major benefits of medically-treated diabetic foot of osteomyelitis, as stated by Jeffcoate and osteomyelitis are the absence of biomechanical Lipsky (2004). The classic radiographic triad of changes, which increase recurrent ulceration osteomyelitis is demineralisation, periosteal rates that may occur after surgical procedures. reaction, and bone destruction, which normally It is a more cost-effective option as it reduces manifests after 2–3 weeks or when 30–50% of risk and hospitalisation associated with bone loss occurs. surgical procedures. As stated by Mutluoglu and Lipsky (2016), A study by Senneville et al (2008) reviewed advanced imaging is necessary for early the outcome of osteomyelitis in a patients diagnosis, delineation of deep soft-tissue with diabetes who was treated non-surgically infection, differentiation of osteomyelitis from and at the same time compared the results of Charcot neuro-osteoarthropathy or to plan bone versus swab culture-based. There were surgery. MRI is preferable in the diagnosis 50 patients included, who had underlying of diabetic foot-associated osteomyelitis, type 2 diabetes with osteomyelitis of a non- while radionuclide scanning, leukocyte ischaemic foot. At the end of the study, 32 of scan, SPECT/CT, and PET/CT are only used the 50 patients (64%) achieved remission, 18 of if MRI is contraindicated. MRI provides high 22 patients (81%) who were treated with bone sensitivity 90% and specificty 85%, which can cultured-based antibiotics achieved remission distinguish osteomyelitis and chronic Charcot and 14 of 28 patients (50%) achieved remission neuro-osteoarthropathy, but problems arise who were treated with a swab-based antibiotic. when other entities that cause marrow oedema Although bone culture provides a better such as recent surgery or a resolving fracture remission rate, it is not widely undertaken in are present. many facilities. An article by Tone et al (2014) The gold standard for diagnosing discussed the duration of antibiotics to be given osteomyelitis is bone biopsy, collected to the patient with osteomyelitis in diabetic aseptically via a percutaneous approach foot patients treated non-surgically. A 6-week through uninfected skin or via an open surgical course was compared with a 12-week course in procedure for culture and histopathology. the case of a patient who was diagnosed with Histologic features of osteomyelitis are specific, osteomyelitis of a non-ischaemic foot and had i.e. bone erosion, marrow oedema, fibrosis, not received prior surgical treatment. The result necrosis, and the presence of inflammatory cells, showed that the 6-week antibiotic course has which are rarely seen in normal bone. Reliable a similar outcome to the 12-week course, with cultures are the key to successful antibiotic reduced gastrointestinal side effects. therapy and can be obtained by discontinuing As stated by the International Working antibiotics 2–4 weeks before the bone biopsy. Group on the Diabetic Foot (2019), surgical As Nair (2017) has shown, the ultimate goal intervention is considered in cases of diabetic in managing diabetic foot osteomyelitis is to foot osteomyelitis when it is accompanied by

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spreading soft-tissue infection, progressive bone Retrospective analysis of diabetic foot osteomyelitis destruction or bone exposure. The operative management and outcome at a tertiary care hospital in the UK. PLoS ONE 14(5):e0216701. https://doi. aim is to reset the affected bone, avoid leaving org/10.1371/journal.pone.0216701 residual disease and to insert antibiotic cement/ Asmar BI (1992) Osteomyelitis in the neonate. Infect Dis Clin spacer beads. As Lázaro-Martínez et al (2014; North Am 6(1): 117–32 2019) have shown, on top of preventing minor Berendt AR, Peters EJG, Embil JM, Eneroth M et al (2008) and major amputations, conservative surgery Diabetic foot osteomyelitis: a progress report on diagnosis and a systemic review of treatment. Diabetes also leads to a reduction in the duration of Metab Res Rev 24(1):145–161. https://doi.org/10.1002/ antibiotic therapy. Other advantages of surgical dmrr.836 management are a high rate of limb salvage, low Bond H, Metcalf L, Gouni R, Snape S (2019) Diabetic foot risk of recurrence through surgical offloading osteomyelitis treatment: an audit of success rates in differing circumstances.Diabetic Foot Journal 22(4): and obtaining samples for culture and 17–21 histological analysis. The downside of surgical Cierny G, Mader JT (1984) Adult chronic osteomyelitis. interventions are biomechanical changes, re- Orthopedics 7:1557–64. https://doi.org/10.3928/0147- ulceration due to pressure transfer syndrome, 7447-19841001-07 foot instability, higher costs and increased Cierny G, Mader JT, Penninck JJ (1985) A clinical stage system for adult osteomyelitis. Contemp Orthop 10: operative morbidity. As for adjuvant therapies, 17–37 there is no conclusive evidence to support the Giurato L, Meloi M, Izzo V, Uccilio L (2017) Osteomyelitis use of hyperbaric oxygen therapy, granulocyte in diabetic foot: a comprehensive overview. World J growth factors, local antibiotic-delivery systems, Diabetes 8(4):135–42. https://doi.org/10.4239/wjd. or maggot therapy. v8.i4.135 Gold RH, Hawkins RA, Katz RD (1991) Bacterial As Gold et al (1991) have shown, conservative osteomyelitis: findings on plain radiography, CT, MR, surgery is being practiced where there is a and scintigraphy. AJR Am J Roentgenol 157(2):365–70. high percentage of healing rate (78%) and less https://doi.org/10.2214/ajr.157.2.1853823 recovery time needed compared with medical Gustilo RB, Merkow RL, Templeman D (1990) The treatment alone (57%) and some of the findings management of open fractures. J Bone Joint Surg Am 72: 299–304. claim that medical therapy alone could also Hartemann-Heurtier A, Sennivel E (2008) Diabetic foot achieve good results of remission. Otherwise, osteomyelitis. Diabetes Metab 34:87–95. https://doi. surgery in chronic osteomyelitis mainly org/10.1016/j.diabet.2007.09.005 focuses on a few procedures such as radical The International Working Group on the Diabetic Foot sequestrectomy, dead space management (2019) IWGDF Guideline on offloading foot ulcers in persons with diabetes. http://www.iwgdfguidelines.org (antibiotic-impregnated cement spacers with (assessed 20J anuary 2021) vancomycin), soft tissue reconstruction and Jeffcoate WJ, Lipsky BA (2004) Controversies in diagnosing restoration of bone stability to stop the infection and managing osteomyelitis of the foot in diabetes. Clin and retain limb and function. It is believed Infect Dis 39(2):S115–20. https://doi.org/10.1086/383272 Lew DP, Waldvogel FA (2004) Osteomyelitis. Lancet both medical and surgical treatment play their 364(9431):369–79. https://doi.org/10.1016/s0140- respective roles and it depends on the patient’s 6736(04)16727-5 condition, physiological state and support to Liao SL, Lai SH, Lin TY, Chou YH et al (2005). Premature decide which option is better. rupture of the membranes: a cause for neonatal In summary, although complex, early diagnosis osteomyelitis? Am J Perinatol 22(2):63–6 Lavery LA, Armstrong DG, Peters EJG, Lipsky BA (2007) and timely management of diabetic foot Probe-to-bone test for diagnosing diabetic foot osteomyelitis is crucial to avoid potential limb osteomyelitis. Diabetes Care 30(2):270–274. https://doi. loss. Foot care education also plays a major role org/10.2337/dc06-1572 in prevention, as diabetic foot osteomyelitis can Lavery LA, Peters EJ, Armstrong DG, Wendel CS et al (2009) normally be prevented by footwear, footcare, and Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Res Clin Pract 83(3):347– prompt treatment to any wounds of the foot. WAS 52. https://doi.org/10.1016/j.diabres.2008.11.030 Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales References E (2014) antibiotics versus conservative surgery for Aragón-Sánchez J, Lipsky BA, Lázaro-Martínez JL treating diabetic foot osteomyelitis: A randomized (2011) Diagnosing diabetic foot osteomyelitis: is comparative trial. Diabetes Care 34: 789–95. https://doi. the combination of probe-to-bone test and plain org/10.2337/dc13-1526 radiography sufficient for high-risk inpatients? Lázaro-Martínez JL, Álvarez YG, Tardáguila-Garcia A, Diabet Med 28:191–4. https://doi.org/10.1111/j.1464- Morales EG (2019) Optimal management of diabetic 5491.2010.03150.x foot osteomyelitis: challenges and solutions. Diabetes Arciola CR, An Y, Campoccia D, Donati M et al (2005) Metab Syndr Obes12:947–59. https://doi.org/10.2147/ Etiology of implant orthopedic infections: a survey on dmso.s181198 1027 clinical isolates. Int J Artif Organs 28:1091–1100. Lipsky BA (2014) Treating diabetic foot osteomyelitis https://doi.org/10.1177/039139880502801106 primarily with surgery or antibiotics: Have we answered Arias M, Hassan-Reshat S, Newsholme W (2019) the question? Diabetes Care 34(3):593–95. https://doi.

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org/10.2337/dc13-2510 Philadelphia Malhotra R, Chan CS, Nather A (2014) Osteomyelitis in the Saavedra-Lozano J, Mejías A, Ahmad N, et al (2008) diabetic foot. Diabetic Foot & Ankle. 5:1. https://doi. Changing trends in acute osteomyelitis in children: org/10.3402/dfa.v5.24445 impact of methicillin-resistant Staphylococcus aureus McPherson DM (2002) Osteomyelitis in the neonate. infections. J Pediatr Orthop 28(5):569–75. https://doi. Neonatal Netw 21(1):9–22. https://doi.org/10.1891/0730- org/10.1097/bpo.0b013e31817bb816 0832.21.1.9 Senneville E, Lombart A, Beltrand E et al (2008) Outcome Morales Lozano R, González Fernández ML, Martinez of diabetic foot osteomyelitis treated nonsurgically: a Hernández D et al (2010) Validating the probe-to-bone retrospective cohort study. Diabetes Care 31: 637–42. test and other tests for diagnosing chronic osteomyelitis 10.2337/dc07-1744. https://doi.org/10.2337/dc07-1744 in the diabetic foot. Diabetes Care 33:2140–5. https:// Sia IG, Berbari EF (2006) Osteomyelitis. Best Pract Res Clin doi.org/10.2337/dc09-2309 Rheumatol 20(6):1065–81 Mutluoglu M, Lipsky BA (2016) Five things to kn0ow about Smith IM, Austin OMB, Batchelor AG (2006) The treatment diabetic foot osteomyelitis. CMAJ, 118(17–18):E535 of chronic osteomyelitis: A 10 year audit. J Plast https://doi.org/10.1503/cmaj.160228 Reconstr Aesthet Surg 59:11–5. https://doi.org/10.1016/j. Nair HKR (2017) Diabetic foot infection. In: Nathen A (ed) bjps.2005.07.002 Diabetic foot: The Asian perspective, 2nd ed. Selangor: Thomas-Ramoutar C, Tierney E, Frykberg R (2010) Uniquelink dot print Sdn Bhd: 58-67 Osteomyelitis and Lower Extremity Amputations in Parvizi J, Ghanem E, Azzam K, Davis E et al (2008) the Diabetic Population. The Journal of Diabetic Foot Periprosthetic infection: are current treatment strategies Complications 2(1):18–24 adequate? Acta Orthop Belg 74(6):793–800 Tone A, Nguyen S, Devemy F et al (2014) Six-week versus Qadir M, Ali SR, Lakhani M, Hashmi P et al (2010) twelve-week antibiotic therapy for nonsurgically treated Osteomyelitis of the right humerus involving the right diabetic foot osteomyelitis: A multicenter open-label shoulder joint in an infant. J Pak Med Assoc 60(9):769–71 controlled randomized study. Diabetes Care 38(2):302–7. Ramsey SD, Newton K, Blough D, McCulloch DK et al (1999) https://doi.org/10.2337/dc14-1514 Incidence, outcomes, and cost of foot ulcers in patients Trampuz A, Zimmerli W (2006) Diagnosis and treatment with diabetes. Diabetes Care 22(3):382–7. https://doi. of infections associated with fracture-fixation devices. org/10.2337/diacare.22.3.382 Injury 37(2):S59–66. https://doi.org/10.1016/j. Rao N, Ziran BH, Lipsky BA (2011) Treating osteomyelitis: injury.2006.04.010 antibiotics and surgery. Plast Reconstr Surg Waldvogel FA, Medoff G, Swartz MN (1970) Osteomyelitis: 127(1): 177S–87S. https://doi.org/10.1097/ a review of clinical features, therapeutic considerations, prs.0b013e3182001f0f and unusual aspects. N Engl J Med 282(4):198–206. Rosenberg AE (2010) Bones, joints, and soft-tissue https://doi.org/10.1056/nejm197001222820406 tumors. In: Kumar V, Abbas AK, Fausto N et al. (eds) Whyte NS, Bielski RJ (2016) Acute hematogenous Pathologic Basis of Disease. (8th edn) Saunders Elsevier, osteomyelitis in children. Pediatr Ann 45(6): 204–208

Call for abstracts

Wounds UK are pleased to announce the call for abstracts for the 2021 Annual Conference, which we fully expect to be a face-to-face event this year. It will be held at the Harrogate Convention Centre on 8-10 November. Following such a challenging period, this will be a long awaited celebration of all that is good in Tissue Viability.

Entries for the e-poster exhibition require you to submit an abstract. Every entry received will automatically be considered for the Wounds UK Award for Excellence 2021.

All abstracts will be reviewed by our judging panel, who will be looking to accept submissions that display high levels of innovation, relevance to current and/or best practice and provide high-quality research/evidence.

To submit your abstract please use the following link This year’s categories are: www. surveymonkey.co.uk/r/ WUKH21 COVID-19, CASE STUDY, COST, DIABETIC FOOT, INFECTION, PHD PRESENTATION, PRACTICE, RESEARCH, SCIENCE, SKIN INTEGRITY, OTHER

THE WINNER OF THE WOUNDS UK AWARD FOR Deadline for submissions is EXCELLENCE WILL RECEIVE A FREE 3-DAY DELEGATE PASS WITH ENTRANCE TO THE GALA DINNER 1 AUGUST 2021 All successful entries will be notified by 30 SEPTEMBER 2021

Please contact the events team on [email protected] or 020 3735 8244 if you have any questions or require further information Poster presentations will be presented on electronic poster displays only, no hard copies will be on display

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