Charcot? Osteomyelitis? Both? A Case Review

Gradual bone destruction of the midfoot after standard treatment with IV antibiotics

Gradual bone destruction of the midfoot after standard treatment with IV antibiotics

I inherited this patient from a colleague from what I thought would be a simple case. It started out as a middle aged poorly controlled diabetic with a foot infection. After surgical debridement, we were not sure if the bone was also infected so took a bone sample. The results were also inconclusive so together with the infectious disease specialist, we agreed that we should treat it as if it was osteomyelitis (bone infection) since this patient had recurring foot infections in the past. After 7-8 weeks of IV antibiotics, the patient developed bony destruction at the midfoot. 

What to do next?

Cases like this keeps me up at night for days at a time. I worry about the patient's deteriorating health, possible loss of job, and mental decline. The patient is at a risk for a below knee amputation since the antibiotics did not help all that much and surgical resection of the midfoot would leave it very unstable. If the midfoot continues to collapse, a plantar ulceration could result and then more surgery. 

Could this have been prevented? Bone infection is difficult and there has been no easy answer to "curing" chronic bone infection. Antibiotics can quiet it down but the infection will linger and acute flare ups can always recur. There's no definite duration for therapy, it is based on the idea that bone takes at least 4 weeks to remodel so 4-6 weeks of antibiotics became the gold standard of treatment along with monitoring of bloodwork. This patient received longer duration of therapy and was still not cured of the bone infection. The risk of longer treatment is kidney damage, cost, and other adverse effects of the drug. 

The plan for this patient is another round of IV antibiotics but realistically, another surgery is likely, whether it be a radical midfoot wedge resection or a below knee amputation. This will be dependent on the patient and what they want to endure. 

Email me your thoughts and what you have had success with. Let's discuss. 

 

Nonhealing Diabetic Toe Ulcer

I received this patient as a second opinion for a nonhealing diabetic foot ulcer located at the bottom of the great toe and the patient had been treated for at least 4 months. Off-loading and local wound care was not sufficient and the wound would never completely heal. I had to consult a good friend who I trusted to have seen more of these then I had. There are many approaches to this problem and I wanted something very simple and we both agreed that an in-office flexor tenotomy was the way to go. This took no more than 5 minutes to perform, from sterile prepping to wound closure. After one week of the procedure, the wound healed. Although not pretty, both the patient and I are happy with the results. 

Things I learned from this case & hope residents (and aspiring medical students) take away from my posts:

- If the wound does not change or improve after a month of the same treatment, you must try a different approach. Don't be afraid to try something new. Of course, weigh the risk vs benefit to what you choose to do.

- Consult as many people as you need to, read as much as you can, and use all of your resources. Don't give up too soon!

- Be clear and honest with the patient. I often find myself saying "I am not sure if what I do will work perfectly, but we need to try something different because the current treatment is not working. I want you to get better and I'm sure you do too." If I sense the patient does not trust me (yes, it happens), I am more than happy to recommend other providers. I need the autonomy to do what is necessary but I also need the patient's cooperation and set the appropriate expectations. 

Naturally, when patients heal and they don't need me anymore, a piece of me is sad that I may never see them again. But  oftentimes, that is a good thing.