Antibiotic-loaded bone substitutes in the surgical management of diabetic foot osteomyelitis: Current evidence and clinical perspectives.

Diabetic foot osteomyelitis (DFO) represents a severe manifestation of diabetic foot syndrome and a leading cause of lower-limb amputation globally. Surgical intervention is frequently required, often leaving residual bone defects that can promote persistent infection and impair healing. In this context, bioabsorbable antibiotic-loaded bone substitutes have emerged as a potential adjunct in surgical management. These biomaterials enable high local antibiotic delivery within the surgical cavity, exceeding minimum inhibitory concentrations for common pathogens, while avoiding systemic toxicity. In parallel, they act as fillers of dead space and provide an osteoconductive scaffold that supports bone regeneration. This narrative review summarizes the pathophysiology of DFO, current surgical principles, and the properties of available antibiotic-loaded bone substitutes. We also critically appraise the clinical evidence supporting their use. Available studies suggest promising outcomes in terms of infection control, wound healing, and limb preservation. However, the current evidence base is largely limited to observational and heterogeneous studies, with variability in study design, patient selection, and biomaterial characteristics. Overall, while these technologies appear to be a valuable adjunct in selected cases, robust prospective and randomized trials are needed to better define their indications, comparative effectiveness, and long-term clinical impact in the management of diabetic foot osteomyelitis.