Case 102: Leg Amputation Averted in Elderly Diabetic Lady with Osteomyelitis of the First Metatarsal and Gangrene of Two Toes

This 76 year old diabetic Florida lady had had an excisional arthroplasty of the second and third toes and a Mitchell bunionectomy of the first metatarsal performed September 30th, 1987. Her toes became infected and gangrenous. Her physicians prescribed topical oxygen, systemic antibiotics and whirlpool treatments to no avail. Her foot x-ray showed a transverse fracture through the distal shaft of the first metatarsal, the site of her bunionectomy. She developed a C-Difficile diarrhea. The possibility of leg amputation was raised. Distressed, she transferred from the Florida hospital to Bryn Mawr. .

October 25th, 1987: She arrived from Florida with two dead toes and a draining fistula at the bunionectomy site.

She was treated with oral Vancomycin for her C-Difficile colitis. Her therapeutic foot routine included an initial daily cleansing foot soak with Sea Soaks and dilute Betadine. Gentamicin and clindamycin were reported as appropriate for her cultures and were injected locally into the toes and first metatarsal fistula. Her foot was then placed in a clean plastic bag containing Sea Soaks and 0.1% Neomycin and foot, bag and all were then placed in the Mini-Boot and pumped. The Mini-Boot treatment was performed three to four times a day while she was in the hospital. Her second and third toes sharply demarcated leaving the options of spontaneous amputation or surgical amputation with primary closure. The latter was chosen to speed her return to Florida. She was discharged to heal as an outpatient and was continued with local antibiotic injections into the area of the first metatarsal fracture and Mini-Boot therapy until the drainage (Staphylococcus aureus) ceased and the fistula closed. She healed and returned to Florida.

March 16th, 1988: Fully ambulatory and ready to return to Florida

Comments: The patient thought our care in Bryn Mawr was rather straight forward... and obviously effective. Over the next few years she returned with other small lesions and was treated successfully as an outpatient. Her biggest expense: the commute between Florida and Philadelphia.