Abstract and Introduction
Ulcers of the distal toe are common in patients with toe deformities and many times are complicated by osteomyelitis of the phalanx. Amputation of the toe is the standard treatment in many institutions; however, this can lead to abnormal biomechanics of the foot predisposing the patient to recurrent ulceration and further amputations, especially in patients with diabetes and those with neuropathy. It has been found that conservative, local operative procedures to remove the infected bone can avoid these complications and even avoid long-term antibiotic therapy. Many of these procedures can be performed in the wound clinic. To show its utility, a case report of this procedure and a small series of these patients treated in the wound clinic are presented.
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]
Ulcer of toe with osteomyelitis in a patient with diabetes and peripheral neuropathy.
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. 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.