T-2 DM SEVERE BUNION/HT SX

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I have a long question:

I performed a bunion/hammertoe sx that was very severe problem on a T-2 DM with decreased but adequate circulation. This healed fine and at 3wks removed sutures and looked very good. Then at 3.5wks a small area of dehisence at the 2nd MPJ occured serious fluid but not really any drainage. I cleaned this up and put the patient on omnicef 300 BID. This did not close at 1cm opening and I did use non absorbable sutures at the MPJ capsule. The H.T. was so severe I had to do a mini keller on the base of the 2nd proximal phalanx. He went to a wound clinic and they had him apply betadine and tefa pad which scabbed over. I did debride this at 13 wks, opened it up , probed the area 1 cm and I tried to see the suture but could not. I sent him to a vascular specialist who did an angioplasty, bone-scan and MRI upon which the bone scan came back positive. I did use screw fixation for the bunion. The MRI was inconclusive or poor quality. The vascular doctor had a PICC line installed and patient was started on a 6wk I.V. antibiotics. About a week later he had a indium scan which I think came back positive for osteo. The patient finished his I.V. antibiotics and was started on oral metronidazole 500 BID and omnicef 300mg BID for another 3 months.

My questions are: wouldn't the wound look infected or the foot look infected for a diagnosis of osteo? There was never any purulent exudate, patient never had fever, etc. X-rays did not show signs of osteo. The patient has closed the small dehisence site but I feel he might of been having a reaction to the absorbable suture at 13wks. Would the bone scan be positive from surgery?

Dr Michael E McGowan

 

Dr. McGowan:

I suppose the real answer is that we may never know the real answer. However, it is entirely possible that the dehiscence at 3 weeks was a reaction to the suture and it became secondarily infected or, because of the patient's vascular disease never completely healed. Scintigraphy in general is not an ideal tool for identifying infection. If the MRI was inconclusive, I wouldn't hang my hat on osteo as a diagnosis. If it is ultimately osteo, though (and the wound opens up again), this is a complication of surgery, and should be dealt with as such-- either with further debridement or treatment to suppression.

I hope this helps a bit!

Cheers, -DGA