Case 43: Californians Could Not Treat Osteomyelitis?

The osteomyelitis in the first toe and metatarsal head of this 47 year old lady, a diabetic since age 15, had failed to heal in spite of two hospitalizations in California for debridements and parenteral antibiotic therapy. She came to Bryn Mawr to be treated as an outpatient largely with local measures. First, small punctures were made with a scalpel over the dorsal-medial aspect of the swollen area and in the scab between the first and second toes (first photograph). Appropriate cultures were made (second photograph)..

Swollen Right First Metatarsal-Phalangeal Joint on Presentation

Deep Culture into Joint

Destruction of First Metatarsal Head and Proximal Phalanx

The puncture sites were irrigated with multi-electrolyte solution (Sea Soaks) containing gentamicin removing modest amounts of clot and debris. A similar irrigation was performed day #2. Each day for the rest of her stay, the infected area was injected with 40 mg ( one ml) gentamicin particularly targeting the swollen areas with an attempt to well infiltrate the infected joint below. She was given oral Cipro for systemic coverage. The injections were followed by Mini-Boot therapy . A month later, her sedimentation rate was normal, her drainage long-gone and her fistulas closed. A post-inflammatory rubor persisted and she was discharged. Four years later, she was kind enough to send us some follow-up photographs.

Foot at Time of Discharge to Home

Four Year Follow-up and Doing Well

Four Year Follow-up: Walking and Hiking Daily

Comments: While we have many Circulator Boot centers in the East, we had none in California when this lady presented. The technique described here has been very helpful for us in curing most of the cases of osteomyelitis referred to us. It should be noted that we did not do extensive debridements. We did not do a ray resection. We did irrigate out loose bodies. We did get the antibiotics where they were needed. We did not require hospitalization. We did not require home visiting nurses. We did not put the lady at the risk of complications from central catheters. We did eventually restore a functional and relatively handsome foot. Maybe, Californians will catch up someday???.