## 4 Discussion
A notable difference from this report is that the listed study included fewer patients who received the intervention, as well as the fact that in this case series, patients with Charcot neuroarthropathy were also included, and the intervention was applied in different joints of the foot; the 2019 study primarily focused on the first metatarsophalangeal joint and first ray preservation. A case series of six patients with diabetic foot bone and joint infection by [PERSON] et al. reported no residual infection after 24 months of follow-up. Healing and osteointegration was achieved in four patients; however, half suffered from postoperative complications, with two requiring reoperation due to vascular or soft tissue issues [16]. A case report by [PERSON] et al. detailed the multimodal treatment of a patient with Charcot arthropathy, including surgical debridement of the metatarsal bases, midfoot bones, and plantar calcanear prominence and BAG application. Here, the authors reported no recidivant osteomyelitisis or septic osteoarthritis. Of note, an appropriate range of motion and osteointegration of the inserted material were reported [15]. Another case report, published by [PERSON] et al., detailed particular benefits in treating osteomyelitisis limited to the forefoot but caused by multidrug resistant bacteria, reporting success in preventing bone and soft tissue infection recurrence with a conservative therapeutic approach [21]. In our case series, microbiology isolates in patients with a successful recovery have also included multi-drug-resistant bacteria. This clinical finding, combined with in-vitro results, suggests that the material does not induce drug resistance [17], opening the possibility of using such materials as a beneficial therapeutic approach in resilient infections. However, to the best of our knowledge, no other published study or paper has focused on the use of BAG in Charcot neuroarthropathy. The therapy of complicated infections of the diabetic foot remains a challenge. The International Working Group on the Diabetic Foot (IWGDF) provides guidance on options for conservative management and the necessity of a surgical consultation. Patients who are clinically stabile, are not systemically affected by infection, are not suffering from severe complications (such as widespread gangrene, gas gangrene, or compartment syndrome), and can be treated with an appropriate antibiotic do not necessarily require immediate surgical treatment. As per IWGDF guidelines, such patients can be treated with antibiotics for up to six weeks with regular reevaluation of the efficacy of treatment, and in case improvement is not noted within two to four weeks of optimal treatment, the therapeutic approach (surgical approach or substitution of antibiotic treatment) might have to be adjusted. The guidelines recommend consultation with a surgeon in cases of moderate to severe infection and complications [22]. If surgical treatment is employed, intraoperatively acquired samples can be used for guidance regarding appropriate choice of antibiotic as well as differentiation between contamination and significant infection. However, delayed surgical treatment in complicated infections or in the presence of necrotic tissue can cause additional exacerbation [22; 23]. Treatment is complex, and there is a lack of clear consensus or evidence on strategies and advantages of surgical treatment. Of additional concern is the finding that while we may be under the impression that treatment strategies are rapidly improving, a recent systematic review and meta-analysis by [PERSON] et al. showed that reamputation rates in patients with diabetes mellitus have not significantly decreased in the last 20 years, calling such beliefs into question [10]. In this retrospective case series, we detailed our experience with the use of S53P4 BAG in patients with septic osteoarthritis and osteomyelitisitis of the diabetic foot and complications related to Charcot neuroarthropathy in diabetes mellitus types I and II.