Case 31: Both Legs Intact and Functional after 10 Years in Spite of Multiple Episodes of Osteomyelitis and Cellulitis Along with an Episode of Frostbite

At age 56, this single ex-chauffeur presented with a history of poorly controlled diabetes over 15 years and of various foot problems for 10-15 years. He had been treating his sore right big toe for four months with sea weed foot soaks and had been taking Velocef for three weeks. He presented 3/21/86 with a swollen right foot and big toe, plantar callus and ulcers under both first metatarsal heads. The ulcer under the right foot admitted a finger allowing bone to be directly palpated and seen. Not shown well on the photographs below was the intertriginous ulcer of the right big toe and a 1cm black eschar over the lateral aspect of the left 5th metatarsal head.

Feet on Presentation 3/21/86

Swollen 1st Toe and Cellulitis of Distal Half of Right Foot

A bilateral decrease in position and vibratory sense and absent light touch sensation pointed to significant neuropathy. His leukocyte count (WBC), temperature ("T" = high temperature and "t" = low temperature in degrees F), and erythrocyte sedimentation rate (ESR or "E") are summarized in the first chart below and his culture reports and medications are summarized in the second chart.

On the Vertical Axis are plotted his daily high and low temperatures, his white count and sed rate. His white count was normal by the 10th day. On the bottom of the chart are shown the periods of time when his repeated foot x-rays were done and their results. While bone was seen and palpated on admission, the first x-ray abnormality was seen at three weeks.

The reports of his cultures, the injections of antibiotics given directly into his foot and his systemic medications are shown for his hospital stay. His initial bacteria were quickly eliminated. His cultures were negative after the 27th day in spite of his fever. Only with the addition of the prednisone at the end of his hospitalization did his temperature and sed rate become normal..

He had 86 polys, 4 lymphs, 9 monocytes and 1 eosinophil on admission, the cell distribution attesting to the seriousness of his infection. His cholesterol was reduced to 102 mg/dl. His cultures were easily obtained early in his hospitalization because of copious discharge. Later cultures were attempted because of his fever and were more difficult; squeezing his foot to express discharge and needle aspirations were attempted without gaining a positive culture. His treatments included those in the chart above and the following measures: (1) an initial daily foot soak with Sea Soaks and Betadine to cleanse his foot; (2) end-diastolic pumping with the Mini-Boot with his foot immersed in a Sea Soaks-gentamicin solution; (3) the local injections listed above into the swollen, reddened and fluctuant areas of his foot.

His white count was normal in 9 days, his morning basal temperature was normal in four days. His foot color improved, his drainage ceased and his ulcers were healed in two weeks. His evening temperature elevations persisted until the end of his hospitalization when caffeine was restricted. His hospitalization was complicated and its duration prolonged by an episode of influenza (pharyngitis, rhinorrhea and cough), the possibility of drug fever (rash and swollen left elbow) and a dispute over the significance of his serial foot x-rays.

On 3/22/86 a small lucency (arrow) marks his ulcer and soft tissue swelling is seen. On 3/28/86 the ulcer is gone and the swelling persists. On 4/22/86, the first metatarsal head and proximal phalanx are fragmented and active osteomyelitis is diagnosed. However, his foot appeared to be clinically healed. The osteomyelitis process is read as progressing on 4/27/86. The orthopedic service took the position that the involved bone should be removed. The boot service took the position that the foot appeared healed on the surface and that the damaged bone was merely healing as shown on the x-ray.

Over time the bone continued to solidify and "heal". The joint remained stiff and had little motion... but his foot was intact.

When his temperature was shown to be normal without caffeine and his swollen elbow and rash disappeared with a burst of prednisone, he felt well and lost interest in the dispute about his foot and went home. He returned to work then as a handyman. And he continued his favorite pastimes: modest alcohol, dancing the polka and playing the slot machines at Atlantic City. Controlling his diabetes was not included in his list.

He did well only a few months and returned 5/15/87 again with an ulcer penetrating to visible bone... an intertriginous lesion on the outer side of his left 4th toe. This responded nicely to a few injections of gentamicin locally followed by Mini-Boot treatments. Again, it was serial x-rays that showed the damage and healing of the bone.

Penetrating Ulcer in Purple 4th Toe

Toe Color Restored and Ulcer Healed

Normal 4th Toe X-ray 5/17/87

Resorption of Proximal Phalanx 7/7/87

Recalcification of Proximal 4th Phalanx and Fusion with 4th Middle Phalanx

He also had a small ulcer under his first metatarsal head in his left foot that healed at the same time the 4th toe was treated. He continued his casual approach to his diabetes and next developed a infected sebaceous cyst on his back that responded poorly to oral antibiotics; it cleared with incision and drainage, local gentamicin injections and Sea Soaks-gentamicin irrigations.

...tried Debrisan Beads

He disappeared from our clinic for a year, but had not been doing well. He developed an ulcer of his right first toe and applied some Debrisan beads under the care of a nurse. The beads found their way down various skin tracts where they accumulated like a thick paste. He presented 4/26/89 with a denuded toe. This too responded nicely to therapy with the Mini-Boot with his foot immersed in Sea Soaks, Urecholine and appropriate antibiotics.

In July, 1992, he infected and macerated his right heel in mowing grass.

In February, 1995, he tried shoveling snow.

The ulcer tunneled under the bunion.

His foot slowly got better allowing him in 1996 to venture again out in the snow wearing only his molded shoes. His shoes got wet. He sat in an unheated automobile repair shop for three hours. When he removed his socks that night, he removed the skin of his forefoot also. The next day he was admitted to the hospital with a temperature of 100.6 degrees F and a white count of 10.1. He was treated with intravenous antibiotics, wet-to-dry dressings with Sea Soaks, and Mini-Boot treatments with his foot immersed in Sea Soaks containing gentamicin, fungizone, Vancomycin and Urecholine. The pictures show the damaged foot and the healing process.

Damage Following Exposure to Cold and Water

Shiney Glistening New Skin Growing over the Granulations

Further Skin Closure

The man healed his foot and will likely continue to require intermittent therapy the rest of his life. He appears unable to look after himself..

Comments: This man breaks all of the rules commonly taught regarding diabetic feet. He shows that advanced osteomyelitis can be healed, at least with our methods. In most clinics, he would have had his first metatarsal resected with his initial illness. His purple 4th toe would have been declared lost especially when the bone disappeared in the proximal phalanx. His big toe would have been removed when he denuded it. His first episode and his last episode were treated initially in the hospital. The hospital stays were shortened somewhat by transferring him to a nursing home and doing outpatient boot therapy. Otherwise, his other illnesses were treated in the office where local antibiotic injections and oral antibiotics substituted for the antibiotics usually given intravenously. In spite of poor metabolic control in an uncooperative patient, he still has his feet intact... scarred perhaps but intact and functional.... and over a reasonably long follow-up period... ten years.