Nonsurgical Treatment of Osteomyelitis of the Hallux Sesamoids: A Case Series and Literature Review.

The aim of the present study was to determine the effectiveness of nonsurgical treatment for osteomyelitis of the hallucal sesamoids. Osteomyelitis of the hallucal sesamoids in young and healthy patients is rare and might originate from hematogenous spread or after a puncture wound. In diabetic patients with peripheral neuropathy, it often results from direct contiguous seeding from adjacent ulceration. The superiority of surgical versus nonsurgical therapy is still debated. In our institution, all patients presenting with osteomyelitis of the hallucal sesamoids are first treated nonsurgically but eventually usually require a surgical procedure. We reviewed 18 patients with a clinical and radiologic diagnosis of osteomyelitis of the hallucal sesamoids treated in our institution during a 13-year period (from January 2000 to December 2012). The inclusion criteria were a signal alteration on magnetic resonance imaging or bone lesions on computed tomography or conventional radiographs, combined with a deep ulcer with a positive probe-to-bone test. Nonsurgical therapy consisted of frequent wound treatment, immobilization, offloading in a cast or other orthotic device, and oral antibiotics. Of the 18 patients, 11 had diabetes, 16 had peripheral neuropathy, 11 had peripheral arterial disease, and 5 had immunosuppression. After a period of nonsurgical therapy ranging from 4 weeks to 9 months, 15 of 18 patients required surgical excision, internal resection, or amputation. In this patient population, we no longer consider nonsurgical therapy a viable option. Patients should be advised, before starting nonsurgical treatment, that the therapy will be long and demanding and very often results in a surgical procedure.

One stage resection and pin stabilization of first metatarsophalangeal joint for chronic plantar ulcer with osteomyelitis.

BACKGROUND: Standard treatment of plantar first metatarsal head neuropathic ulceration with underlying osteomyelitis consists of extensive debridement of infected soft tissues and bone and often first ray amputation. The purpose of this study was to present a previously unreported, one stage, alternative to first ray amputation in patients with chronic first metatarsal head ulceration and associated chronic osteomyelitis. MATERIALS AND METHODS: A retrospective review was conducted of all patients that underwent one stage resection of the first metatarsophalangeal joint with pin stabilization for treatment of chronic plantar first metatarsal head ulceration with associated chronic osteomyelitis. The study included 15 patients (18 feet) who underwent 18 resections and stabilizations. All patients had a diagnosis of diabetic peripheral neuropathy, chronic plantar first metatarsal head ulceration of at least 3 months duration with exposed bone, and no gross purulence or acute cellulitis. Nine patients (60%) (11 feet) were available for followup telephone interviews. Four of the 15 (27%) (four feet) were deceased so they had medical record review only. The average followup was 48.8 months. RESULTS: All ulcers healed with the exception of one foot (5%) who required a transmetatarsal amputation for worsening infection and wound complications. Three feet (17%) developed recurrent ulcerations. No foot had amputation of only the hallux or first ray. CONCLUSION: This study presents a previously unreported, relatively simple, one stage treatment option for chronic first metatarsal head ulceration with underlying chronic osteomyelitis. This procedure allowed for successful healing of the ulcer while retaining the first ray.

Fungal osteomyelitis of the axial border of the proximal sesamoid bones in a horse.

CASE DESCRIPTION: A 12-year-old Standardbred gelding was referred for swelling of the right metacarpophalangeal joint. CLINICAL FINDINGS: Ultrasonography of the right metacarpal area revealed hypoechoic areas in the right digital sheath and metacarpophalangeal joint consistent with synovial effusion. Radiography of the right metacarpophalangeal joint revealed lysis of the axial border of the proximal sesamoid bones. Aspergillus fumigatus was detected on fungal culture of synovial fluid. TREATMENT AND OUTCOME: Regional limb perfusion (150 mg of amikacin in 60 mL of saline [0.9% NaCl] solution perfused for 30 minutes) was performed 2 and 4 days after admission. Itraconazole (5 mg/kg [2.27 mg/lb], PO, q 24 h) was administered for approximately 9 weeks. Joint lavage with amikacin (500 mg) in 1 L of saline solution was performed 4 times. Three months after discharge, the owner reported that the horse was mildly lame during trotting but was moving freely and comfortably during all gaits and had gained a considerable amount of weight. Because the osteoarthritis was not expected to improve and because it was recommended that the horse not return to purposeful exercise, the owner decided to retire the horse from racing. CLINICAL RELEVANCE: Various diagnostic imaging methods and fungal cultures are useful for diagnosing fungal osteomyelitis of the axial borders of the proximal sesamoid bones in horses. Fungal osteomyelitis of the sesamoid bones and erosive arthritis should be considered as a differential diagnosis for horses in which corticosteroids have been administered intra-articularly.