Case 190: No, No, A Ray Amputation Is Not Necessary Because of Osteomyelitis in a Metatarsal Head

Born June 19th, 1953, this man had diabetes for 25 years. For the last five years he made more effort to control his diabetes and began taking 4-5 insulin injections a day. Having walked perhaps 15 miles, he developed his first foot lesion in 1995; a blister which healed with conservative therapy. Subsequently, in 1995 he developed ulcers he attributes to his treadmill. These took 7-8 months to heal. In February 1998, he broke his left ankle. Once the fracture healed, he again took to his treadmill only to develop a blister and an ulcer that was eventually led to his referral for boot therapy on April 8th, 1999. The lesions did not respond to the debridements, oral antibiotics and topical medications of the Foot and Ankle Group specialists he consulted. Swelling and drainage from the foot led to his hospitalization on January 15th, 1999. A local debridement released pus from which methicillin-resistant Staphylococcus aureus and Enterococcus were cultured. An MRI revealed osteomyelitis of his right 5th metatarsal bone and proximal metatarsal bone. His surgeons advised resection of the infected bone but the patient refused preferring first to try more antibiotics. He was continued on intravenous Vancomycin and Levaquin and an infectious disease specialist was consulted. The latter noted the osteomyelitis and an accompanying cellulitis. He recommended stopping the Levaquin, continuing the Vancomycin until the cellulitis abated, then stopping the Vancomycin and biopsying the bone to identify the bacteria actually infecting the bone. On February 2nd, such a biopsy was obtained but no bacteria were seen on gram stain or recovered on culture. However, by February 28th a heavy growth of Staphylococcus aureus was again recovered and his foot x-rays were interpreted as showing progression of his osteomyelitis. A repeat MRI on April 6th again was interpreted as consistent with osteomyelitis of the head of the 5th metatarsal and edema in the marrow of the shaft of the 5th metatarsal. Again, surgery was recommended.

April 9th, 1999

He presented for consideration of boot therapy. His dorsalis pedis pulse was palpable with light touch (3+). His posterior tibial pulse was easily palpable with firm finger-pressure (2+). He was unable to feel the vibration of the Bio-thesiometer with the instrument turned up to its maximum voltage (50 volts). On the basis of the culture data of his previous physicians, he was prescribed oral Bactrim-DS twice daily, local injections of vancomycin, gentamicin and Urecholine into the area of his lesions and Mini-Boot therapy.

May 12th, 1999

Now a month into his therapy, his redness was reduced, but his sedimentation rate remained elevated at 56 mm/hr. His foot x-ray showed partial destruction of the 5th metatarsal head and slight destruction of the lateral proximal phalanx. Soft tissue swelling around the 5th metatarsal head and vascular calcifications were noted.

June 18th, 1999

He was treated 5-6 days a week until June 8th when his sedimentation rate was reduced to 17mm/hr. He continued on oral antibiotics (Bactrim-DS twice daily and Cleocin 300 mg four times a day). He returned June 18th for a checkup (picture); his sed rate was 20 mm/hr. On June 30th, his sed rate was 9 mm/hr and has remained in the 9-17 range up to his discharge date, August 1st, 1999 when his foot appeared to be normal.

June 18th, 1999

Concerned because of the misgivings of his surgeons, he was interested in the x-ray progression of his osteomyelitis. Here the radiologist noted again the resorption of the head of the right 5th metatarsal and a suggestion of resorption of the proximal phalanx of the right 5th toe compatible with osteomyelitis. Both areas appeared to have a slight increase in mineralization leading him to conclude that there was interval improvement in the osteomyelitic process. As his ulcer was healed, his sedimentation rate normal and his x-rays improving, his antibiotics were discontinued. When last seen for follow-up on September 1st, 1999, he was doing well. He was advised that his x-ray changes will continue to improve over a year as the bone remodels and repairs itself... much like a fracture. Again, in view of his insensate feet, he was advised he is at very high risk for new ulcers. Proper extra depth shoes with box toes and molded inserts were prescribed.

September 1st, 1999

At time of his discharge, his x-rays showed further improvement in the outline of the 5th metatarsal head.

Comments: In previous cases of osteomyelitis, we have shown follow-up x-rays over several years time. The story of this man is shorter. He is included because his treatment was new to his current physicians, who have been referred to this website. He is included also to exhibit the unnecessary costs of "standard care". His initial treatments were unsuccessful and a waste of medical resources (doctors visits, antibiotics, x-rays and debridements). His MRI's were a waste; they certainly are not treatments. Clinical signs like probing his ulcer to bone and standard x-rays of the toe are cheaper. We have yet to have a patient whose outcome has been changed by an MRI or a bone scan. Rather, such studies seem to be markers of failure in treatment and, when abnormal, used as evidence that surgery must be done. Simply stated, unsuccessful therapy leads to additional costs: new consultations, new tests, hospitalizations, unnecessary surgery, lost time from work, alteration in the normal anatomy of the foot and increased risk for future ulcerations. In this man's case, much time from work was lost during our treatments also: he commuted to our office perhaps 60 miles a day and his job was a 45-mile commute in the opposite direction. We do have some Circulator Boot Centers closer to his home. However, the physicians there have not embraced the use of local antibiotics which this man felt correctly he needed.