A 42-year-old Mexican-American man with diabetes presented to the emergency room with a 3-day history of left foot swelling, redness, and pain associated with nausea, fever, and chills. He reported having stepped on a nail 1 month prior. The patient was initially managed with oral analgesics and antibiotics and referral to a wound care center for debridement and dressing changes. His condition failed to improve. The patient was a non-smoker with history of hypertension, and myasthenia gravis. He denied any history of previous ulceration in either foot.\nPhysical examination revealed that his foot was exquisitely tender, with copious, fetid purulent discharge. The popliteal pulse and the digital capillary refill time were normal. Pedal pulses were not readily palpable due to edema and exquisite tenderness, which transcended his neuropathy. Nonetheless, he had normal Doppler signals on the dorsum of his foot. He had loss of protective sensation to his feet based on the Ipswich Touch Test (). An open ulceration of the plantar lateral fifth metatarsal probing to the capsular tissue with a tunneling track toward the proximal porta pedis was noticed. A malodorous purulent draining and deep tunneling lesion at the level of the distal medial arch with fluctuance encompassed the surrounding area. The entire forefoot was erythematous to the level of the midfoot. There were no palpable regional lymph nodes or lymphangitic streaking. The overall musculoskeletal appearance of the foot did not demonstrate any significant abnormalities or structural deformities (A).\nPertinent admission laboratory tests demonstrated a profound leukocytosis, with a white blood cell count greater than 36,000/µl and elevated segmented neutrophils. C-reactive protein (CRP) levels were greater than 25 mg/dl and the erythrocyte sedimentation rate (ESR) was 129 mm/h. The patient's comprehensive metabolic panel was remarkable for severe hyponatremia (122 mMol/l), elevated serum creatinine (2.0 mg/dl) and blood urea nitrogen (43 mg/dl), and serum glucose of 225 mg/dl. Radiographic imaging of the foot revealed peri-articular osteopenia about the fifth metatarsophalangeal joint, with subtle periosteal reaction, adjacent soft tissue swelling, and soft tissue gas, compatible with severe infection (B).\nAfter hospital admission and intravenous (IV) rehydration, the patient was taken to the operating room for urgent incision and drainage of deep space abscess in order to control the infection. Immediately upon making the incision, over 20 ml of frank pus was expressed from the wound. An extensive open debridement of the foot was performed extending proximally to the deep plantar tissues and superficial compartments with complete removal of necrotic debris involving cutaneous and subcutaneous tissue as well as muscle and tendon. The incision also required extension to the lateral aspect of the forefoot to the level of the fifth metatarsal head. Sharp debridement of all non-viable and grossly infected tissue was carried out utilizing hydro-surgical instrumentation. Once adequate debridement of all compartments of the foot was complete, the underlying bone was investigated for possible infectious involvement. It did not appear intra-operatively that there was violation of the capsular tissue of the fifth metatarsal phalangeal joint necessitating resection. The surgical field was irrigated with pulse lavage of 6 l of antibiotic-laden sterile saline. Perfusion to the soft tissue appeared more than adequate with hemostasis achieved utilizing cauterization and ligation. A soft tissue sample was sent to microbiology for Gram stain as well as culture and sensitivity in order to guide proper antibiotic therapy. The wound was dressed with a moist to dry dressing using 0.25% Dakin's solution. The patient was placed on IV ertapenem 1 g daily. Tissue culture ultimately yielded Prevotella bivia.\nIn the inpatient setting the wound was assessed daily and repeat surgical debridement was performed in the operating room twice more over the following week to remove nonviable tissue and evacuate any remaining abscess formation. The overall debridement involved much of the plantar medial and plantar forefoot area tissue but did not involve removal of bone (C). Once signs of infection abated and the wound ceased to exhibit tissue necrosis, negative pressure wound therapy (NPWT) was begun in preparation for split-thickness skin grafting (STSG). The patient was discharged from the hospital to a rehabilitation center with a peripherally inserted central catheter for continued antibiotic therapy and routine wound care in the form of NPWT dressing changes every 48 h. He was instructed to remain totally non-weight bearing during this time. The patient was evaluated in the outpatient clinic on a weekly basis to monitor the progression of the granulation tissue. Overall, the time from commencement of the NPWT to adequate depth reduction allowing for STSG was 26 days. After surgical application of a STSG taken from the ipsilateral thigh, NPWT was applied over the graft at a reduced pressure setting of 75 mm Hg for 5 days as a bolster to promote graft adherence. NPWT was removed on the fifth day in the outpatient clinic and nonadherent petroleum gauze and dry gauze dressing was placed over the graft site. The patient was able to return home and receive dressing changes every other day as well as weekly clinic visits with the surgical team. This continued until complete healing was observed at 8 weeks (D). The patient was then cleared to return to weight bearing status in a diabetic boot. The total time from initial debridement of the foot to complete healing and return to weight bearing activities was approximately 3 months. The patient was employed as a tile specialist at new home construction which required walking up and down stairs and kneeling on a daily basis.
A 46-year-old Mexican-American man with diabetes, hypertension and hyperlipidemia presented to the emergency department with a 2-week history of acute progressive constitutional symptoms. These symptoms were the result of an infected plantar left foot ulcer that had been noted to have increased swelling, drainage, and foul odor along with the more recent development of an area of black, skin blistering. The underlying ulceration had been present for approximately 1 year and resulted from a skeletal malformation of the foot secondary to longstanding Charcot arthropathy of 9 years duration that left him with a collapsed arch and bony prominence on the bottom of the midfoot. Despite surgical reconstruction of the foot at the time of initial arch collapse and ulceration, the patient had suffered from chronic, intermittent wound breakdown, and repetitive infections requiring hospitalization and IV antibiotics. He did not have a weight bearing offloading device. For the last year, the patient had been unemployed and without health insurance and was therefore self-managing his wounds with a poultice recommended by a family doctor in Mexico. He had, however, just started a new job as a clerk in a deputy sheriff's office, but this position was probationary and he was not yet eligible for health benefits.\nUpon evaluation in the emergency room, the patient was febrile with an oral temperature of 39.1°C and otherwise normal vital signs. Laboratory studies were remarkable for a leukocytosis of 24,900/µl and markedly elevated inflammatory markers, with a CRP level of 31.1 mg/dl and ESR of 143 mm/h. The patient's comprehensive metabolic panel was significant for hyponatremia (128 mMol/l), elevated serum creatinine (3.2 mg/dl), blood urea nitrogen (60 mg/dl), and a serum glucose level of 228 mg/dl.\nPhysical evaluation of the affected lower extremity revealed palpable pedal pulses, severe foot and ankle edema, and a lack of protective sensation from the toes to the mid-calf. Dermatologic examination revealed a full thickness, 15 cm2 ulceration of the plantar central midfoot, extending to the bone. Frankly malodorous discharge and sinus tracking to well-circumscribed necrotic gas-filled bulla of the medial foot were also evident (A). Radiographic findings demonstrated gas in the dorsal and medial foot, significant soft tissue edema, and osseous breakdown of the midtarsal bones with osteolytic erosions at the level of the ulceration suggestive of osteomyelitis (B).\nFollowing fluid resuscitation and administration of broad spectrum antibiotics, the patient was promptly transferred to the operating room for surgical incision and drainage. The debridement extended from the area of ulceration down to the underlying bone including a portion of central cuneiform that was sent for culture and sensitivity to rule out osteomyelitis. From the area of plantar ulceration the incision was extended through the sinus track to the medial arch and area of necrotic tissue. All areas of obvious diseased tissue were removed with the assistance of high pressure water debridement. All compartments of the foot were explored for any residual abscess or gas formation. Once adequate debridement was achieved, the foot was irrigated with copious amounts of antibiotic treated saline solution (C). Necrotic soft issue was sent for Gram stain and culture and sensitivity in order to identify bacterial pathogens for proper antibiotic therapy. The wound was dressed with Dakin's 0.25% solution wet to dry dressing to be changed twice daily. The patient was placed on a broad spectrum course of antibiotics (vancomycin and ertapenem) pending results of tissue and bone cultures. Results of initial blood culture demonstrated Streptococcus anginosis-constellatus and the culture results of the bone and soft tissue infection were positive for mixed gram positive and gram negative flora including anaerobic bacteria; at this time antibiotic therapy of piperacillin/tazobactam was continued and other antibiotics discontinued. The patient was followed closely by the surgical team and did not undergo further soft tissue debridement because the open wound did not exhibit ongoing necrosis, the leukocytosis was improving with antibiotic therapy and subsequent blood cultures were negative.\nThe surgical team had extensive discussions with the patient. Mutually agreed goals of subsequent therapy were to enable the patient to ambulate; to prevent recurrence of this wound and infection that had been plaguing him for nearly a decade; and, to allow him to return to his current probationary position as a deputy sheriff so that he would have a means of support and health benefits. After weighing the limb salvage options including significant bone debridement to remove residual bone infection, external fixation, delayed soft tissue coverage, prolonged recovery phase and even if successful, the lifetime risk of re-ulceration, he elected to proceed with primary below the knee amputation in order to facilitate timely discharge and progression to a weight bearing status in a prosthesis that would permit him to return to his job. He also was concerned that prolonged treatment and convalescence that prevented early return to work could result in loss of his new-found employment.\nOne week after the initial surgical incision and drainage, the patient underwent a below the knee amputation. The patient was discharged on oral amoxicillin 4 days following surgery having been in the hospital a total of 10 days. He was sent home after working with physical therapy and able to ambulate with a walker and having been instructed on transferring abilities. Two weeks after the amputation, healing was unremarkable, and the skin sutures were removed (D). He returned to work within 4 weeks and was ambulatory with a prosthesis at 6 weeks postoperatively.