Case 4: Refractory Osteomyelitis Healed and "Dead" Toe Restored
Fifty-five year old male with history of insulin-dependent diabetes for ten years, a lawn-mower accident several months ago with subsequent outpatient podiatry care and debridements, hospitalization for further debridements and intravenous antibiotics, continued outpatient antibiotics, additional MRI's and imaging studies showing progressive neuropathic changes of the tarso-metatarsal joints and osteomyelitis of the left 5th toe and metatarsal head.
Consultation three days previously with a nearby academic wound healing center where he was advised that healing of his ulcer and osteomyelitis was unlikely and that his 5th metatarsal head should be removed.
Findings on Presentation to Boot Center: 2.5x2.0 cm penetrating ulcer under the lateral aspect of his 5th metatarsal head; questionable pedal pulses by palpation; broad monophasic Doppler waveform in his left posterior tibial, anterior tibial and 4th dorsal metatarsal arteries; transcutaneous PO2 of 2mm and CO2 of 67mm Hg on the dorsum of his foot; flat photoelectricplethysmography waveforms in the left toes; especially prominent falloff in his pulse volume curves from his ankle to his mid-foot; absent sensation to vibration and light and firm touch; and reddening of the distal lateral foot compatible with his presenting diagnosis of cellulitis.
Healing of his foot with following outpatient therapy: walking air cast and crutches to rest the foot; an initial cleansing soak with multielectrolyte solution (Sea Soaks) and dilute peroxide; local injections of antibiotics into the base of his ulcer; Miniboot therapy with his foot immersed in Sea Soaks, dilute Urecholine and antibiotics.
November 29, 1995, 8 months later on return from a four day hunting trip in the Pennsylvania mountains: recurrent callus and ulcer at his previous plantar ulcer site and a swollen, oozing, purple 4th left toe... the latter thought to be dead by the patient and his doctor.
Resumption of previous outpatient care with local injection of antibiotics now directed into the 4th toe.
Four Days in Hunting Boots - Lateral View of 4th Toe
Plantar View of 4th Toe
Sixty-five Days Later.
Comments: His previous expert consultants thought his initial osteomyelitis and 5th toe could not be saved. His initial boot laboratory vascular data likewise suggested healing would be impossible: toes with flat PPG's do not heal and feet with transcutaneous PO2 values under 20 are said not to heal. Indeed he had not healed after months of standard therapies. With our standard boot protocol for such feet (local injection of appropriate antibiotics and boot therapy), he did heal; the local injections insure that high concentrations of antibiotics do reach the infected area and the boot therapy increases the local blood flow). Like many diabetic patients with neuropathy, he did not appreciate the susceptibility of his feet to new problems and he foolishly embarked on his hunting trip in the wilderness. His toe might have indeed died. The local antibiotics injected into the toe immediately sterilized the toe and his boot therapy kept his local circulation open. His toe recovered. He has regained some sensation in his foot with his therapies. Hopefully, he can be taught how to avoid further problems and his HMO will provide needed shoewear. Again, this case represents a few more "kicks to the moon". Perhaps, he would do better if he recognized his good fortune.
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