Case 179: Boot Therapy Contributes to the Cures of Osteomyelitis in Both Feet When Other Methods Prove Ineffective.

RS was born September 15, 1945. He was hospitalized in Bryn Mawr by his family physician on December 26, 1990 with a 20 year history of insulin-dependent diabetes and a five month history of plantar ulcers. The latter had been periodically trimmed by his podiatrist who had given him prescriptions for erythromycin and Cipro for the three previous months. Feeling septic, he had presented to the emergency room where his temperature was found to be 101.8 degrees F. He had a ulcer on the dorsum of his foot and two plantar ulcers. He was treated with intravenous Clindamycin and various foot soaks and ulcer irrigations. An infectious disease consultant added intravenous Vancomycin on January 5th, 1991. A general surgery consultant recommended amputation of the 5th toe, debridement of infected tissue and bone and possible hyperbaric oxygen therapy. A bone scan showed hot spots at the 4th and 5th metatarsal heads along with the 5th toe. The x-ray of his foot showed destructive changes in the 4th and 5th metatarsals and the 5th toe documenting significant osteomyelitis. A boot consultation was requested January 8th and the boot program replaced his previous therapies and planned surgical procedures; Vancomycin and methacholine were injected locally into his lesions prior to Mini-Boot therapy which was performed with his foot immersed in Sea Soaks also containing Vancomycin and methacholine. His foot markedly improved. He was provided with a walking cast and a prescription for Keflex 250mg to be taken four times daily and discharged on January 13th to continue his boot treatments in the boot clinic. He went to work daily after his morning treatments. His sedimentation rate had fallen from 50mm at the time of discharge to 12 mm/hr and his foot appeared to be healed on February 10th, 1991. During the spring of 1991, he was seen by an orthopedic consultant who noted the multiple changes in his left foot, which, without his history of previous infection, suggested Charcot changes. He prescribed extra depth shoes with arch supports for his fallen arches.

He returned to the care of his family doctor who again hospitalized him in Bryn Mawr in April of 1995, this time with a history of plantar ulcers of the right foot since September 1994. A podiatry consultant recommended incision and drainage procedures along with bone resections. A boot consultation was again requested and our usual therapeutic program was recommended and eventually carried out: initial cleansing foot soaks in Sea Soaks and dilute peroxide, local antibiotic injections into and around the infected bone and soft tissue and Mini-Boot treatments.

His 5th toe had a callus on its lateral side where a focal ulcer penetrated into the proximal interphlangeal joint. Antibiotics (Vancomycin and gentamicin) were injected into this cavity. Skin had been lost over the dorsum of the middle phalanx. The distal toe was a sallow blue.

The plantar ulcer under the 3rd metatarsal penetrated deep into the foot. X-rays suggested osteomyelitis of the 4th and 5th metatarsals and the 5th toe.

Now after two weeks of outpatient treatments, the ulcer to his IP joint is closed and skin is closing over the dorsum of the toe.

The plantar ulcer was also improved in spite of his ambulation.

His fifth toe did well....

...as did his plantar ulcer . The brown spots are old needle tracts where his antibiotics were recently injected.

In cases with proven osteomyelitis, we follow the sed rate and continue both oral and local antibiotics until it is normal and the foot appears to be clear of infection. He was dismissed in September 1995 and found a new primary care physician and a new job-acquired HMO.

In spite of the care provided, he found himself hospitalized for a week in March of 1997 by his primary care physician in a hospital perhaps 20 miles from Bryn Mawr with cellulitis of his right foot again and osteomyelitis of his 5th metatarsal head. A sed rate of 60 mm/hr, a serum albumen of 2.8 and foot cultures growing Beta-hemolytic streptococci and Streptococcus viridans were noted. He was discharged on March 24th with a prescription for Keflex and came straight to our boot clinic on his own initiative for evaluation and possible boot therapy.

The lateral margin of his foot from the base of his toes to the ankle was erythematous.

His accompanying x-rays showed osteomyelitis of his 5th MT head and partial ankylosis of the right 1st metatarsal-tarsal joint.

His primary physician and HMO allowed boot treatments with our local antibiotic treatments. He continued this time and thereafter on the program of the infectious disease consultant and the primary care physician. He was again hospitalized by his family physician 7/24-7/31. He returned to the boot clinic August 1st, 1997 again in trouble. He had been receiving intravenous Rocephin since April 27th and it was still being administered now by the home nurse. The 4th toe and MP joint were infected.

We dilated up the opening on the dorsum of his foot with a hemostat and irrigated the cavity with Sea Soaks and gentamicin. A modest amount of clot and necrotic tissue was obtained and the toe was left somewhat less swollen.

His accompanying hospital x-rays showed osteomyelitis of his 4th MT joint along with significant soft tissue swelling.

We returned to our usual boot program adding for a few days an initial irrigation of his abscess cavity. Then we injected local ceftazidime and Vancomycin and pumped his foot in the Mini-Boot. After his infection was obviously controlled , he received two to three treatments a week until he appeared to be healed. The extensor tendons on the dorsum of his feet were cut to release his hammer toes and flatten the tissue over his metatarsal heads.

The overall shape of his foot was close to normal when he was discharged. His toes were all present. Plantar callus remained a problem.

He was instructed in skin care intermittently. He was ambulatory during his therapy. His intravenous antibiotics were discontinued and oral antibiotics substituted by his infections disease consultant, who continued to follow him after he left the boot clinic. Hopefully, he is doing well presumably again under the eye of his primary care physician.

Comments: Patients like this bother insurance companies; they have multiple expensive illnesses. This man had multiple hospitalizations, x-rays and scans ordered by other doctors. Many of these procedures are expensive and offer frequently nothing more than tangible legal proof of the status of the patient's foot. In each episode, his definitive care involved boot therapy and local measures that were carried out with the physical findings at hand at the bedside. His hospitalizations were not effective and had he agreed to have foot surgery, he likely now would not have a foot. Boot therapy may be more effective in the hospital than in the outpatient clinic, however, for many reasons: multiple boot therapies are possible; bedrest may be achieved; the diet and insulin program of the patient is readily controlled; and other medical problems are more readily attended. If the insurance company really wants to avoid these illnesses, they must allow the patients to seek effective care of their diabetes. Some HMO's provide their physicians with checklists of tests. Hopefully, they will take steps to correct these tests when they are found to be abnormal. We did not comment on his diabetic neuropathy which likely was the cause of his hammer toe deformaties and his ulcers.