Ahmed AH, Ahmed S, Barakat A, Mangwani J, White H. Inflammatory response in confirmed non-diabetic foot and ankle infections: A case series with normal inflammatory markers. World J Orthop 2023; 14(3): 136-145 [PMID: 36998381 DOI: 10.5312/wjo.v14.i3.136]
Corresponding Author of This Article
Ahmed Barakat, MBChB, MSc, Surgeon, Department of Trauma and Orthopedics, Leicester University Hospitals-NHS Trust, University Hospitals of Leicester Headquarters, Level 3, Balmoral Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, Leicestershire, United Kingdom. ahmedharoonbarakat@gmail.com
Research Domain of This Article
Orthopedics
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Orthop. Mar 18, 2023; 14(3): 136-145 Published online Mar 18, 2023. doi: 10.5312/wjo.v14.i3.136
Inflammatory response in confirmed non-diabetic foot and ankle infections: A case series with normal inflammatory markers
Amr Hassan Ahmed, Shah Ahmed, Ahmed Barakat, Jitendra Mangwani, Helena White
Amr Hassan Ahmed, Shah Ahmed, Ahmed Barakat, Jitendra Mangwani, Department of Trauma and Orthopedics, Leicester University Hospitals-NHS Trust, Leicester LE1 5WW, Leicestershire, United Kingdom
Helena White, Department of Infectious Diseases and Tropical Medicine, Leicester Royal Infirm, Leicester LE1 5WW, Leicestershire, United Kingdom
Author contributions: Mangwani J and White H conceptualized the study design and aim; Ahmed AH and Ahmed S completed data collection and statistical analysis; Barakat A drafted the manuscript and reviewed it for final submission.
Institutional review board statement: This study was reviewed by the Leicester University Hospitals-NHS Trust research ethics committee. No ethical approval was required due to the de-identified anonymous retrospective nature of the published laboratory data.
Informed consent statement: There was no direct or even indirect contact between researchers and patients, with no necessity for "Signed Informed Consent Form" to carry out our study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ahmed Barakat, MBChB, MSc, Surgeon, Department of Trauma and Orthopedics, Leicester University Hospitals-NHS Trust, University Hospitals of Leicester Headquarters, Level 3, Balmoral Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, Leicestershire, United Kingdom. ahmedharoonbarakat@gmail.com
Received: July 9, 2022 Peer-review started: July 9, 2022 First decision: September 26, 2022 Revised: October 23, 2022 Accepted: January 31, 2023 Article in press: January 31, 2023 Published online: March 18, 2023
ARTICLE HIGHLIGHTS
Research background
Non-diabetic foot and ankle infections are not uncommon. Despite this, there is a paucity of the literature investigating the diagnostic accuracy of different inflammatory markers in the diagnosis of these infections as opposed to the diabetic population.
Research motivation
Defining the reliability of inflammatory markers in the diagnosis of non-diabetic foot and ankle infections can aid in early diagnosis and mitigate associated healthcare costs for delayed treatments.
Research objectives
Our aim was to define the reliability of the commonly utilized inflammatory markers such as white cell count (WCC) and C-reactive protein (CRP) in the diagnosis of non-diabetic foot and ankle infections as well as to highlight the shortcomings of those markers in a small subset of patients with normal inflammatory markers despite a microbiologically confirmed diagnosis of infection.
Research methods
This was a retrospective cohort study looking into microbiologically confirmed foot and ankle infections in the non-diabetic population presenting to our hospital (University Hospitals Leicester-United Kingdom) over the period of 6 years (2014-2020).
Research results
A total of 25 non-diabetic patients with confirmed foot or ankle infections were identified. Previous bony surgery was identified in 13 (52%) patients. Inflammatory markers were raised in 21 (84%) patients while 4 (16%) patients did not mount an inflammatory response even with subsequent surgical procedures. CRP sensitivity was shown to be 84%, while WCC sensitivity was only 28%.
Research conclusions
CRP had a relatively good sensitivity whereas WCC is a poor inflammatory marker in the detection of non-diabetic foot and ankle infections. In a subset of non-diabetic foot and ankle infections, inflammatory markers will not be raised, and a normal CRP should not rule out the diagnosis of osteomyelitis. In these cases where a high level of suspicion persists despite normal CRP, further advanced radiological and laboratory investigations should be performed.
Research perspectives
Further evaluation of different inflammatory markers in the non-diabetic foot and ankle infections (erythrocyte sedimentation rate, pro-calcitonin and interleukin-6) could improve diagnostic accuracy and avoid more expensive investigative procedures.
