Case 110: Osteomyelitis Healed by Boot and Local Antibiotics and Surgery and Prolonged IV therapies Avoided

This man presented at age 58 with a sore left third toe and type 2 diabetes on the service of his orthopedic specialist on August 12th, 1986. He had had a previous right BK amputation. He had palpable pedal pulses and minimal sensory loss. Abundant Staphylococcus aureus, Beta-streptococcus Group A and a few Pseudomonas aeruginosa were cultured and all were found to be sensitive to gentamicin and the combination of clindamycin and ceftazidime prescribed by the infectious disease consultant. The latter recommended a three month course of intravenous antibiotics or a toe amputation. While the first orthopod was on vacation, a second orthopod called for a boot consultation. The "boot team" provided its usual routine for such patients: a cleansing foot soak, local injection of appropriate antibiotic into the toe (here gentamicin) and subsequent Miniboot therapy. Four injections were delivered, three in the hospital a few days apart, and one was given as an outpatient. His drainage stopped. His ulcer epithelized and the boot team declared him healed. His family physician returned from vacation to find that the recommendations of the infectious disease consultant had been ignored and again hospitalized the patient. Serial sedimentation rates had been done: August 13th, 57 mm/hr; August 15th, 69 mm/hr; August 21st, 44 mm/hr; and August 29th, 25 mm/hr. It was found to be normal at 15 mm/hr and the toe appeared to be intact albeit slightly swollen and reddened when he was readmitted on September 5th. Again, the "boot team" recommended no treatment while his orthopod and the infectious disease consultant were swayed by his x-rays and recommended further IV antibiotics or toe amputation. A third orthopod was consulted and recommended that a ray resection of the toe and metatarsal head was indicated. The patient was impressed that his toe looked and felt normal. He declined further therapy and went home; he did well. The decisions of the orthopod and the infectious disease specialists were dependent on his x-rays. The following show what they saw:

On the 19th, the roentgenologist reported destruction of the 3rd distal phalanx, soft tissue swelling, osteoporosis and probable osteomyelitis. On the 29th, resorption of the distal phalangeal tuft and periosteal reaction were noted. On September 7th, resorption of the distal phalanx with slight increase in periosteal cloaking about the distal IP joint, increased resorption of the distal middle phalanx and a pathologic fracture through the medial cortex of the distal end of the middle phalanx were reported.

On September 14th, the roentgenologist reported slightly more destruction of the distal end of the middle phalanx. On July 15th, 1987 the roentgenologist noted improved mineralization of the 3rd digit, some quiescent destruction of the terminal phalanx and no evidence of destruction of the distal end of the middle phalanx. On February 3rd, 1989 Healing of the third distal phalanx and remineralization of the middle phalanx were noted.

The patient was kind enough to obtain the follow-up x-rays above and pose for this picture on February 3rd, 1989. His foot had remained intact in spite of his hammer toes.

He returned November 20th with a new ulcer on his left second toe; the third toe remained intact. This ulcer was treated with local antibiotics and the Mini-Boot as an outpatient and did well.

Comments: This patient along with 34 others was reported in Vascular Surgery 24:683-696, 1990. He was chosen then and now to report because of the dependence of many physicians on x-ray reports. Many patients damage bone in accidents and the bone undergoes subsequent continual remodeling until it has returned to approximately its normal shape. Bone damaged by infection likewise undergoes remodeling. However, such change in osteomyelitic bone is usually taken as evidence of continued infection and justification for operative procedures. Here we see that the patient was wise to go home and ignore his doctors. The patient did well until August 1997 when he presented again with a foot infection. He now has joined a local HMO who are willing to approve but two weeks of outpatient boot therapy. Crazy!