Case 55: Long-term Success in Treatment of Osteomyelitis and Neuropathic Ulcers

Born January 29th, 1949 and with known diabetes since 1975, this 1-1.5 pack/day twenty year smoker presented on May 7th, 1986 at the Bryn Mawr Hospital with a history of foot ulcers since August, 1985. His ulcers had not improved in spite of a three-week hospitalization elsewhere and the construction of special shoes at a nearby University Center. He had been on oral cephalexin three week prior to admission.

On May 7th, he presented with pus draining from callus under the right 3rd MT head and an ulcer under the left 2nd MT head. Note the intense cellulitis in the left arch.

He also had a intertriginous ulcer on the lateral aspect of the 4th left toe.

Xrays showed osteomyelitis of the proximal phalanx of the left 2nd toe. He was given local injections of gentamicin and ampicillin which were followed by Mini-Boot treatments. After several days in the hospital, he was transferred to a local nursing facility with a boot service where his treatments were continued another two weeks. His lesions healed and he appeared intact. He was discharged with molded shoes.

He returned December 31, 1986 with callus under the right 2nd-3rd MT heads...

and callus under the left 2nd MT head

His work required a lot of walking and his shoes did not offer sufficient protection. Again he had osteomyelitis.

Osteomyelitis had destroyed the distal portion of the proximal phalanx of the 5th toe.

Periosteal reaction was seen on the proximal phalanx of the right 1st toe.

He was treated as an outpatient with local antibiotics and Mini-Boot therapy. His callus was trimmed back. His foot again appeared to be doing well and returned to his active life. Unfortunately, he relapsed quickly with new lesions this time requiring hospitalization.

He returned April 21st, 1987 with cellulitis of the dorsum of the right foot and ankle, new plantar ulcers on both feet and ulcerated devitalized right 5th toe.

The right 5th toe was flaccid and partially transected by the infection

He was treated with intravenous antibiotics and again our usual local measures. His ulcers were infiltrated with gentamicin. His foot was initially soaked with dilute Betadine in Sea Soaks to clean the skin. It was then pumped in the Mini-Boot in a bath of Sea Soaks, gentamicin and vancomycin. Care was taken to avoid shear force on the 5th toe. He responded nicely as all of his lesions healed. And he did well for 18 months.

He returned November 17th, 1988 with cellulitis and draining ulcers on the dorsum of his right foot. His right 5th toe was healed but curved inward.

The 2nd MP joint was partially destroyed by osteomyelitis. The 5th toe is seen to be dislocated and curving inward.

He had been hospitalized in his community hospital 75 miles distant and had been responding poorly to treatment. He was transferred to Bryn Mawr and again promptly did well with local injections and boot therapy. He was largely treated as an outpatient until he healed. And was dismissed from our care. Subsequently, he became a boot technician for a physician living close to home where he received treatments as needed "on the job". When last telephoned in December of 1994, he reported that he still had lost no parts and was ambulatory.

Comments: This man was afflicted by repeated episodes of cellulitis and osteomyelitis, each commonly resulting in incision and drainage procedures, toe amputations, ray amputations and/or leg amputations in other centers. These procedures were not denied him because he was too sick for the operating room. Some claim a diabetic with such infections is never too sick for the operating room. They were not done simply because they were not necessary.