Chronic Neuropathic Ulcer With Osteomyelitis

A 46-year-old male patient with type 1 diabetes diagnosed at the age of 27 years was referred to the outpatient diabetes foot clinic because of a chronic ulcer under his right fifth metatarsal head. He had acceptable diabetes control (HBA1c: 7.7%), pro-liferative diabetic retinopathy treated with laser in both eyes, but no nephropathy. He complained of muscle cramps during the night and chronic constipation interrupted by episodes of nocturnal diarrhea. The patient had a history of painless diabetic foot ulceration for 3 years under his right foot after a burn injury. He had attended the surgery department of a country hospital,

Neuropathic Ulcer
Figure 8.31 MRI image showing osteomyelitis. A magnetic resonance imaging-Tl-weighted sagittal image of the foot illustrated in Figure 8.30 showing a phlegmonous mass (arrow) extending from the skin into the deeper tissues and causing erosion of the fourth metatarsal head
Osteomyelitis Foot
Figure 8.32 Chronic neuropathic ulcer over a bunion deformity
Periosteal Reaction Osteomyelitis
Figure 8.33 Plain radiograph of the foot illustrated in Figure 8.32 showing bone resorption, periosteal reaction and destruction of metatarsophalangeal joint of the hallux due to osteomyelitis

where he had his foot dressed and several courses of antibiotics were prescribed. The patient continued to keep himself active, without any special footwear since he felt no discomfort or pain.

On examination, severe diabetic neuropathy was found. The peripheral pulses were palpable and a full-thickness neuropathic ulcer with gross callus formation was observed under his right fifth metatarsal head (Figure 8.34). Sharp debridement was carried out and the underlying bone was probed with a sterile probe. A plain radiograph revealed pseudoarthrosis of a stress fracture of the upper third of his fifth metatarsal, bone resorption in the metatar-sophalangeal joint, and osteolytic lesions in the fifth metatarsal epiphysis (Figures 8.35 and 8.36). Post-debridement cultures from the base of the ulcer revealed Staphylococcus aureus, Proteus vulgaris and Entero-coccus spp. The patient was treated with amoxicillin-clavulanic acid 625 mg three times daily for 2 weeks. He was advised to rest and appropriate footwear and insoles were prescribed. A fifth ray amputation was undertaken and antibiotics continued for two more weeks. A bone culture revealed

Staphylococcus aureus. The wound healed completely in 2 weeks.

A ray amputation consists of removal of a toe together with its metatarsal. The unin-volved half of the fifth metatarsal shaft was preserved, so that it retained the insertion of the short peroneal muscle. Ray amputation results in narrowing of the forefoot, but the cosmetic and functional result is excellent. However, the biomechanics of the foot are disturbed after such an operation and this leads to the exertion of high pressure under the metatarsal heads of the adjacent rays.

Keywords: Neuropathic ulcer; osteomyelitis; ray amputation

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