The Clean Margin in Diabetic Foot Osteomyelitis: Conceptual Appeal, Practical Uncertainty

Abstract Updated guidelines endorse tailoring antimicrobial treatment for diabetic foot osteomyelitis (DFO) based on resection margins, representing a shift toward more individualized therapy. While conceptually appealing, this approach relies on a construct that remains ill-defined and inconsistently measured. Historically, infectious diseases management has emphasized source control without formal operationalization of resection margins. In DFO, the concept has evolved from descriptive assessments of residual infected bone to categorical designations of “positive” or “negative” margins, largely without prospective validation. Current recommendations are informed in part by limited trial data with uncertain ascertainment of residual infection. At the bedside, resection margin assessment varies across surgical, histopathological, and microbiological domains that are not interchangeable and often discordant, limiting reliability and complicating treatment decisions. Standardized definitions and prospective validation are needed before routine implementation.