Treatment of Osteomyelitis of the Toes Without Amputation in the Wound Clinic Setting

Ulcers of the distal toe with osteomyelitis are common in patients with diabetes and peripheral neuropathy as well as those with toe deformities such as hammertoes (Figure 1). The deformed toes and/or neuropathic toes are not protected from pressure when walking, this pressure easily results in ulceration Because of the small amount of subcutaneous tissue between the skin and the end of the phalanx, bacteria can quickly spread to the tip of the phalanx with resulting osteomyelitis. Unfortunately, many physicians and surgeons consider the only treatment of this problem to be amputation of the toe, many times including the metatarsal head of the tarsometatarsal joint.^1,2 However, even the amputation of one toe can result in biomechanical changes of the foot, predisposing these patients to future recurrent ulcers and ambulation problems.^1,2

Some may consider administering long-term intravenous antibiotics if amputation is not performed, but the use of long-term antibiotics has not been shown to increase healing rates and has been shown to prolong ulcer healing times compared with conservative operative procedures removing the infected bone in the toe combined with oral antibiotics.³ In an attempt to confirm these results, the author’s wound clinic treated 45 patients with distal toe ulcers and osteomyelitis of the distal phalanx with excision of the ulcer and removal of the infected distal phalanx using local anesthesia; all procedures were performed in the wound center. The following is a case report discussing this treatment approach.

The patient is a 45-year-old female with type 1 diabetes and peripheral neuropathy. Three months before the patient presented to the wound clinic, an ulcer developed on the tip of the left great toe. The patient was unaware of how the ulcer developed due to the neuropathy. Her medical doctor prescribed topical and oral antibiotics. After 10 weeks of this treatment, the patient’s condition did not seem to be improving, so she was referred to the wound clinic. When the patient initially presented, an ulcer on the tip of her left great toe showing redness and swelling was noted (Figure 2). Probing the small defect in the toe revealed the bone, which was soft and felt to be infected. After obtaining written informed consent, conservative surgery was performed.

The toe then was prepared for the procedure. Due to the peripheral neuropathy, anesthesia was reinforced with a digital block of 1% xylocaine. Hemostasis was ensured with a sterile rubber band tourniquet at the base of the toe. An elliptical incision was used to excise the ulcer and expose the underlying infected bone. All of the infected bone can be removed through this incision, including the entire distal phalanx if necessary (Figure 3). The wound was irrigated with saline solution and packed with oxidized regenerated cellulose (ORC)/collagen/silver-ORC dressings to assure hemostasis. The incision was closed with a single layer of interrupted 3-0 nonabsorbable nylon sutures (Figure 4). After the dressing was applied and the patient was doing well (ie, no problems or complications with the wound or patient), she was released to go home. Oral antibiotics were administered for 7 days. The specimen was sent to pathology; acute and chronic osteomyelitis were confirmed. Bone cultures showed the presence of Staphylococcus aureus. The patient was seen in follow-up on the third postoperative day and was doing well. By 2 weeks postoperatively, the wound was healed, the stitches were removed, and the patient resumed normal activity. At the 3-month, 6-month, and 1-year follow-up visits, there was no evidence of recurrent ulcer or infection..

Conservative operative procedures on toes with ulcers and osteomyelitis are effective and safe approaches to these problems that could lead to significant morbidity for the patient. The ability to treat these patients with conservative operative procedures, especially if performed in the wound clinic or outpatient setting, allows the patient to receive appropriate therapy without the challenges associated with hospitalization and without significant foot deformities that result from more extensive procedures.

Ulcers of the distal toe with osteomyelitis are common in patients with diabetes and peripheral neuropathy, as well as in patients with toe deformities such as hammertoes (Figure 1). This case presentation and the work of others confirm that conservative surgery for removing the infected bone in the toe combined with oral antibiotics are very successful in the treatment of these conditions.³ The procedure generally involves disarticulation of the interphalangeal joint without disturbing the distal head of the middle phalanx. If any portion of the middle phalanx is involved in the infection, another approach would be indicated.

If controlling the bleeding is a concern, the procedure can be done with a sterile rubber band snugly placed around the toe during the procedure. Packing the defect, where the bone was removed, with a hemostatic agent will help ensure no postoperative bleeding will occur. In this procedural case report, the author administered oral antibiotics for 1 to 2 weeks. If there is more concern about local bacterial control, the wound can be packed with antibiotic beads usually containing an antibiotic agent useful against S aureus; however, this has rarely been necessary.^4,5

In the 45 patients treated in the outpatient setting at the author’s wound center, it has been shown that at 1-year postoperatively a recurrent infection requiring toe amputation developed in only 1 patient. No major amputations were required in the patients studied. These results show that 98% of these patients were healed with the conservative operative procedure and oral antibiotics. The work of others has confirmed the efficacy and safety of treating these patients with conservative operative procedures in the outpatient setting.^6,7

Patients with ulcers of the distal toe with osteomyelitis can be safely and effectively treated conservatively by removing the infected bone followed by a course of oral antibiotics. This avoids major foot amputations with the resulting deformities and increased risks of further ulceration and amputation. These procedures can be safely and effectively performed in the wound clinic or outpatient setting.