Case 74: Effective and Economical Therapy of Osteomyelitis in Independent Patient

At age 64, this bachelor retired sailor had insulin-dependent diabetes 18 years. Until his right big toe was amputated in 1973, he had maintained a two-pack a day cigarette addiction. He began taking Aldomet for hypertension in 1977. He essentially regulated his diabetes himself and practiced a vigorous exercise program riding his bicycle many miles daily and doing calisthenics and pushups. For several years, he had been under the care of his general surgeon who trimmed his plantar callus and treated his plantar ulcers. He was referred November 24, 1982 with an infection in a plantar ulcer that had not responded to the antibiotics and outpatient treatments of his surgeon over nine weeks. His Doppler arterial waveform at the ankle was low and eleven millimeters wide pointing to the presence of arteriosclerosis obliterans in addition to obvious neuropathy. He refused admission to the hospital and when a baseline X-ray of his foot showed no osteomyelitis, he began a pattern of coming to the office requesting boot treatment when he noted his ulcer drainage to be foul or thick. A repeat x-ray on March 17th, 1983 did show osteomyelitis. He became a more regular patient. His foot was treated with local antibiotic injections followed by 40 minute Mini-Boot sessions as an outpatient. His ulcer healed and his osteomyelitic bone re-calcified.

Penetrating ulcer under 3rd Metatarsal Head, Nov. 24th, 1982

Dissolution of 3rd Metatarsal Head and Proximal Phalanx, March 17th, 1983.

Antibiotic injections into the plantar aspect of his foot were aimed at the metatarsal-phalangeal joint. This particular injection was aimed more proximally.

Antibiotic injections into the dorsum of the foot were directed likewise at various distances around the 3rd MP joint.

His foot ulcer healed. He continued to get the callus under the 1st metatarsal shaved on occasion.

Note here that the bone of the 1st MT joint has re-calcified and is as radio-opaque as adjacent bones. The proximal phalanx and metatarsal appeared to have fused.

He returned in February 1986 with a toe ulcer of four weeks duration and an ankle/arm index of 0.28 in the left leg. He responded to a few treatments and his ulcer healed. He was found dead in his apartment two months later.

Comments: We have been successfully treating osteomyelitis in the diabetic foot for many years. One wonders why the technique has not become a standard of care. It is safe. It is not associated with the complications of long term intravenous antibiotic therapy. It is relatively cheap. It is obviously easily done as an outpatient. What complications of intravenous therapy, are you asking? We have seen patients die from yeast infections developing on the tip of their central catheter. We have had several referred after suffering thrombosis of an axillary vein. We have had several referred after aminoglycoside-induced renal failure. Then, of course, there is the cost of hospitalization or the visiting nurse. Fortunately, for those still practicing intravenous therapies and inhospital surgical debridements, the nurses and physicians reviewing these cases for insurance companies are generally poorly informed regarding patient care?
The independence of this patient was a problem. He would have done better more quickly if he had come as directed for daily treatments. These techniques are effective but have the disadvantage when performed as an outpatient of requiring patient cooperation. Patients with lesions simultaneously on both feet have difficulty avoiding traumatizing the lesions especially when they live alone and have to care for themselves. Such patients are best hospitalized where, unfortunately, if they are covered by "managed care" insurance programs, they are likely to be prematurely discharged when they begin to show improvement.