Case 120: Successful Treatment of Osteomyelitis and Arteriosclerosis Obliterans in Recalcitrant Smoker

This 68 year old non-diabetic ophthalmologist smoker was referred by his orthopedic surgeon for a "Charcot-like big toe". The distal phalanx of the big toe was fractured, loose, mobile and infected.

The distal phalanx was demineralized at the IP joint.

The toe was modestly swollen but only slightly painful. Pseudomonas stutzeri, resistant to the cephalexin that he was taking, was grown from the draining ulcer.

His systolic pressure was 210 in his brachial artery, 76 in his posterior tibial at the ankle, 64 in his anterior tibial, and a faint 67 in the peroneal. Only faint Doppler sounds were detected in his metatarsal arteries.

He was treated with both the Long-Boot and the Mini-Boot. Gentamicin was injected into his toe ulcer prior to his Mini-Boot therapy. He was treated as an outpatient while he continued his office and operating room practice. He remained asymptomatic and was grateful that he escaped standard therapy which he understood to include an arteriogram, consideration for vascular surgery, toe amputation (if healing could not be guaranteed) and leg amputation (if revascularization of his foot was impossible and his toe lesion had continued to worsen)..

His ulcer closed and the foot did well.

Comments: He unfortunately never did stop smoking... in spite of symptoms of both cerebrovascular and coronary disease... not a wise decision.