Dilemma: Deciding Limb Preservation vs Amputation

This is an inside look of the internal conversation I have with myself. Yes, I talk to myself. A lot and out loud. 

It is my priority to give patients control in their treatment plan. There are many options in deciding how to proceed with a foot problem, whether it be nonsurgical or surgical or even considering a second/third/millionth opinion. I, myself, like options too so I always offer this to patients. Sometimes the decision is easy. For example, an ingrown toenail that waited too long to see the light of day that is now painful, red, swollen and the nail is piercing the skin in a really weird way. What options do I give? I present options and it's consequences:

1) Do nothing. But you have to live with the pain and it will get worse. 

2) Cut the nail out. It'll make you feel better but it might also grow back the same way. A non-commital level of care. A needle does enter your toe to inject a local anesthetic so you don't feel pain during the procedure. 

3) Cut the nail out and make sure it doesn't grow back. Using a chemical to burn the root of the nail has about 95% of success of never growing back. For the (un)lucky small percentage of people who experience recurrence, we can repeat the procedure. It will drain while your body is reacting to the chemical for 2-4 weeks. People are able to return to normal activity with little to no pain right away. 

These are relatively easy solutions, you either want it gone permanently or not. But I was struck with another type of problem with a patient who has a bone infection. These are more tricky. I'll present you a case that I see often but am always disappointed with the options.  

A 70+ year old male presents with a callus to the left foot at the head of the 1st metatarsal. It has been red, swollen, painful for many months and recently got worse. He delayed care because he continues to work in order to support his family. He has a history of rheumatoid arthritis and smokes cigarettes heavily with no intention of quitting. His joints have gradually moved over time and now he has to cut a hole in his shoe to fit his foot in it. His xrays from the emergency room were suspicious for bone lesions but the patient was sent home with follow-up in my clinic. 

When I saw the patient, he looked sick and had difficulty walking. He was given antibiotics but it didn't seem to do much for him. I shaved down the callus and found an ulcer underneath it. I then ordered an MRI and the results were unfortunately positive for osteomyelitis (bone infection). So what's next?

At the follow-up appointment, the family admits the patient continued working despite my recommendations to stay off of it. But of course, life goes on and bills need to be paid whether our body understands it or not. So naturally the infection looks worse and now these are our options:

 A rheumatoid foot with a severe bunion deformity and associated ulcer at the bony prominence. The brown color is betadine paint on the ulcer (not seen here).

A rheumatoid foot with a severe bunion deformity and associated ulcer at the bony prominence. The brown color is betadine paint on the ulcer (not seen here).

1) Do nothing. The infection will get worse, it will spread, and he will lose more parts of his body than desirable. 

2) The most conservative approach in treating bone infection in the foot is 6 weeks of IV antibiotics. Although no evidence exists that 6 weeks is the magical number, that has been common practice for a very long time so we'll just leave it at that. What this really means to the patient is that they'll have to get a PICC line (peripherally inserted central catheter) placed in their arm, keep it clean, and go to a facility or have home health do the antibiotic injections several times a week. This does not guarantee complete resolution of the bone infection, it sometimes keeps it at bay but is a viable option in many instances. This is limb-preserving.

3) However, if there is an associated bone deformity, like a bunion as seen in the picture, then treating it conservatively will not take away the mechanical problem. The bony bump rubs against the ground or shoe abnormally so an ulcer can re-develop and we'd be at the same place again. Leaving us this option: amputation of the infected bone, which would be the big toe and the bone behind it (1st ray amputation). This is also limb-preserving but at a higher level. 

Some may say, yea just cut it off and move on. Unfortunately, it is not that simple. The technical part of "cutting it off" is indeed straightforward but I don't take this lightly. When it comes to cutting off the big toe and the bone behind it, yes we are definitively removing the infection and it will not come back. But what patients need to know is the aftercare and biomechanical consequences of taking away the part we place the most pressure on while walking for propulsion. 

The aftercare, ideally, is to stay off of the foot and be in a protect boot until it heals. In immunocompromised people (diabetics for example) it will take longer than normal to heal, maybe 4-6 weeks. In healthy compliant individuals, it'll be more like 2-3 weeks. 

The biomechanical consequence of removing the primary propulsive part of your foot is that even when the amputation site heals, the adjacent toes will start to contract and new sores can occur. (Think of having 5 people pulling a heavy box, then one person decides to quit so the remaining 4 has to put more energy into pulling the box.) When the remaining tendons pull harder on the remaining toes, the toes hammers. It is common to see the tip of the remaining toes develop a callus and hide an underlying ulcer if left ignored. 

The patient must discuss his choices with family and I strongly encouraged them to be present at their next office visit. It is a lot of information for anyone but something, rather than nothing, must be done.

What would I recommend? Based on his desire to return to normal activities of daily living quickly (he wants to continue working as a laborer), amputation would be the best option as it is the most definitive solution for the current problem. He will need to see a podiatrist regularly for maintenance thereafter. 

What else would you recommend?