Replicating Success in Conservative Surgery for Diabetes-Related Forefoot Osteomyelitis: A Comparative Study Between Two Diabetic Foot Units in Spain and Costa Rica

To evaluate whether the adoption of conservative surgical techniques in Costa Rica, facilitated by international collaboration and training, achieved outcomes comparable to those in a reference unit in Spain. This retrospective study included 199 patients with histologically confirmed diabetes-related forefoot osteomyelitis: 110 from Costa Rica and 89 from Spain. Data were extracted from two standardized databases. Infection severity was classified according to IWGDF/IDSA criteria. Surgical procedures were categorized as conservative surgery, minor amputation, or major amputation. Antibiotic use and hospitalization rates were compared between cohorts. Statistical analyses included Chi-squared and Mann-Whitney U tests. Patients in Costa Rica were younger and exhibited poorer metabolic control, while patients in Spain had higher rates of comorbidities. Despite more severe infections in Costa Rica, characterized by higher inflammatory markers and soft tissue involvement, 39.1% of Costa Rican patients were treated without postoperative antibiotics, and the median antibiotic duration was significantly shorter (14 vs 30 days, p < 0.001). The rates of conservative surgery were similar in both groups (62.7% in Costa Rica vs 65.2% in Spain, p = 0.63). When excluding cases with soft tissue involvement, conservative surgery was performed in 86.0% of Costa Rican cases and 96.0% of Spanish cases (p = 0.167). This study demonstrates that structured training and international collaboration enabled the adoption of surgical strategies comparable to those in a reference unit in Spain, achieving similar clinical outcomes. The findings highlight the potential for conservative surgery and antibiotic stewardship to optimize care in resource-limited settings while reducing unnecessary interventions.