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.