Foot osteo does not heal. Amp it (and the joint adjacent to it) early and often.
Distal phalanx osteo = amp at mid-prox phalanx.
Sesamoid osteo = first ray resect or TMA as appropriate
Met head osteo = ray resect or TMA as appropriate.
Tarsal osteo = BKA
Etc.
Do that
asap, before it spreads to next joint/bone, causes gas, or the cellulitis damages the skin you need for closure. Get source control.
The key to amputations is them being
functional. They are not to have more wounds/amp in a year. Nonsense.
Learn early that Lisfranc, Chopart, ankle Symes, etc don't work... leave that nonsense to "teaching centers" wasting ppl's time. Those contract, fail quickly, and are hard to make filler/AFO for. Skip them. Once you lose the tib anterior or pero brevis inserts, the foot is done... it's not balanced. The tendon transfers into bones or fusions adjacent to the osteo bones are for inept podiatry surgeons who don't have enough work or just want to cut. So, yeah, basically, many podiatrists dink around and dink around and do topical stuff and wound care or nibble amps or multiple debrides just to keep the cash register on. It's sad. You'll see it at meetings, on clerkships, probably in residency or in practice. That failure to get source control and amp in timely fashion will literally kill some ppl from the cardio and pulm and obesity problems from being in chair/boot... or the osteo will eventually flare to gas or sepsis. Do what's right for the pt instead.
...Do all of the IV and PO abx you like... you're just protecting the proximal tissues and bloodstream (for awhile). That should only be done for short amounts of time to let ppl come to grips with amp, to medically optimize or revasc the pt, or to try to stabilize/improve the cellulitic flap you need for TMA or whatever. The medical abx tx for osteomyelitis does not work in the foot (or most other areas). Any decent ID will tell you to get source control... then mop up with a week or two of abx, get them to filler+shoe store and on with their life.
If pt is
not a surgical candidate (frail, PAD, etc), they can do lifelong abx (under med doc, not you).
If they are a surgical candidate, discharge them from your practice in short order if they refuse amp after MRI or bone biopsy confirms osteomyelitis dx. Don't ever give them the illusion it's fine with abx just because the wound "heals" or the swelling subsides. There will, unfortunately, be plenty of TFPs around you who will put a frame or wound graft or abx pellets on their calc osteomyelitis or osteomyelitis cunieforms Charcot and tell them everything will be fine. Happy day... makes ya proud to be a podiatrist sometimes.
academic.oup.com
