Case 156: Diabetic Foot: Osteomyelitis of Exposed First MP Joint and Extensive Plantar Cellulitis Treated without Distal Bypass or Major Incision and Drainage Procedures

Patient MM was born February 23, 1922. She was known to have diabetes and hypertension since 1966. Standing 60 3/4 inches tall, she weighed less than 112 lbs until age 25. By age 53, she had reached 194 lbs and was advised her cholesterol was also high. She dates her first right big toe lesion to July 1995. Abnormal Doppler studies were noted in September and November 1995. As conservative measures were unsuccessful in healing her foot, she was admitted to a nearby hospital for an arteriogram. The latter showed extensive obstructive disease below the right knee: moderate stenosis of the proximal popliteal, complete occlusion of the distal popliteal at the level of the anterior tibial artery, occlusion of the anterior tibial just distal to its origin, complete occlusion of the tibioperoneal trunk and collaterals in the calf that reconstituted above the ankle into both a posterior tibial which ran off into the plantar arch and into the anterior tibial which ran off into the dorsalis pedis. She was given intravenous antibiotics and whirlpool treatments. She was discharged from the hospital little improved. On April 26th, 1996, she consulted a medical peripheral medicine specialist at a Philadelphia university center. He recovered Pseudomonas maltophilia, Klebsiella pneumoniae, Alpha-hemolytic streptococcus and a few staphylococcal species from her ulcers. He considered the possibility of attempting a distal bypass to the dorsalis pedis, but the presence of multiple foot ulcers and her questionable cardiac status led him to believe that treatment with the Circulator Boot was a better option. On May 20th, 1996, she was referred to Bryn Mawr. She was wheelchair-bound and complained of a tingling pain in the foot that prevented sleep.

Her most prominent lesion involved the tissue beneath and medial to the first MP joint. The latter was exposed and easily probed with a culturette obtaining the Klebsiella and Xanthomonas as above but, in addition, a heavy growth of Staphylococcus aureus and Streptococcus viridans. The distal foot and arch were ruborous.

She was given Bactrim-DS an an oral antibiotic. Our usual program was commenced: an initial cleansing foot soak to remove loose pus and debris, local injections of antibiotics (in her case, gentamicin) and Mini-Boot treatments with her foot immersed in Sea Soaks and Fortaz. She was initially maintained on her usual medications which included Micronase, Glucophage, Trental, Darvocet and Tylenol. The locally injected areas of her distal foot quickly stabilized but the infection in the midfoot and the purplish areas on her lateral heel and around her internal malleolus became more prominent. She appeared to have a wide tract of infection in her foot beginning at the first MP joint, continuing across the arch to the heel pad, dissecting laterally under the heel pad to surface on the lateral heel and rising medially to exit above and below the medial malleolus. She was advised that standard practice commonly led the surgeon to open up the entire length of the tract and debride any necrotic and infected tissue. She was hospitalized at Bryn Mawr and started on intravenous antibiotics in addition to the usual program listed above. Her oral diabetes drugs were discontinued and insulin therapy begun significantly improving her glycemic control. The purplish areas at her heel and internal malleolus along with areas of the infection tract were also injected with local antibiotics (gentamicin and vancomycin) and did well. Her foot was sterilized but the scar tissue from her infection persisted. She was discharged stable to outpatient care.

Her skin color is normal except over her malleolus. Her lesions are closing.

The lateral heel eschar represented a plug of necrotic tissue which was debrided away slowly.

She has had occasional chest pain and dypsnea taking her to her longtime cardiologist who hospitalized her for a week in February 1997. Her rest pain has disappeared. She has been given an orthopedic shoe with a steel brace to support her ankle. She is ambulatory and generally happy.

Slow progress receiving but two to three treatments a week.

Antibiotic is injected into the her lesions at the time of her visit.

A little soft fibrous material remains in the area of the plantar fat pad...

...and again at her heel.

Comments: There are many who would have insisted that this lady had to have a bypass to her dorsalis pedis and that otherwise her obvious osteomyelitis was incurable. Again, there are many who would have insisted that she have an open debridement of her foot opening up the tract from her big toe to her medial malleolus. Both would have required considerable hospital time and modest risk to the patient. It is obvious that insistence for such courses of action just was not justified. It is also obvious we have been slow to cure her lesion... but she had it ten months and significant pathology was well established before we started therapy. Her longest hospitalizations for her foot were for standard therapies that failed and preceded our treatments. Medicare would have been spared considerable expense and our patient considerable pain if our treatments had been instituted ten months earlier.