Osteomyelitis and Gangrene

Foot infections are the most common problem in people with diabetes. Sometimes, these infections are brought on by a decubitus ulcer-known as a bedsore. These are hard to treat because of impaired circulation in the small blood vessels. This, many times, keeps antibiotics from getting to the site of the infection. Infection from surrounding soft tissue takes weeks or months to enter the bone. Sometimes, chronic osteomyelitis is difficult to detect for many months. I have to wonder how long did Mom suffer from this infection, before it was diagnosed?

Acute osteomyelitis is the clinical term for a new infection in the bone. It's usually a chronic infection than develops because of an open wound or injury to the bone and surrounding soft tissue. Antibiotic therapy needs to be started early, and last for at least four weeks, up to six weeks. This is usually I.V. antibiotics, combined with topical wound care.

When a bone becomes infected, the marrow swells. The swollen tissue presses against the rigid outer wall. The blood vessels become compressed, which reduces the blood supply to the bone. Parts of the bone can die. The areas are hard to clear of infection, because antibodies and antibiotics have trouble getting there.

Debridement is sometimes necessary, as well as dead-space management and stabilization of the bone. For those who don't know, debridement is the term used, when the nurse or doctor must cut away the dead tissue, to make way for the new tissue to help in healing. Without debridement, chronic osteomyelitis doesn't respond to most antibiotic treatments, no matter how long it lasts. After debridement, it is necessary to obliterate the dead spaces created by the removal of tissue. Diabetes is a significant contributing factor in osteomyelitis. Severe cases can involve amputation.

Mom had gone home from the hospital on November 16, with the assurance that she was keeping that left foot. The one that had caused so much trouble, over the past year and a half. The doctors and nurses had worked hard to rid her of the osteomyelitis-the infection that was in the bone of her left foot.

Over that two-and-a-half weeks, we saw her go downhill, again. Very quickly. The nursing home informed us that her foot had begun to develop "that smell" again, and they had called her doctor. He had her sent on, bypassing the ER, and going in as a direct-admit. That was Thursday, December 6.

That night, we received grave news. The osteomyelitis had worsened, the decubitus ulcer was worse, and she now had gangrene. Something would have to be done. The nursing staff told us they recommended a consult with the orthopedic surgeon again. The one who had told her before that it was unnecessary, never came to look at her foot, this time. He simply said it was unnecessary, and that the family was pushing for an amputation the patient didn't want. I was there, the next morning, when the wound-care nurse treated her foot. I saw how bad it had gotten. I called my aunt and talked to her. She demanded a second opinion.

Chronic osteomyelitis in patients with diabetes is the most difficult infection to cure. Patients with diabetes can have a combined infection involving bone and soft tissue called "fetid foot." This extensive chronic soft tissue and bone infections causes a foul-smelling drainage, usually requiring extensive debridement and/or amputation.

Mortality risk is highest in patients with chronic osteomyelitis AND acute necrotizing soft-tissue foot infection. This was Mom. How many times had they already had to go in and debride that wound? I'd lost count.

It so happened that the specialist who came in to check her foot, on Friday evening was Dr. Hilborn. The one who'd worked on my knee, several months ago. I trusted him, and respected his opinion. I knew he would not recommend an unnecessary surgery. He'd spent time studying all of Mom's charts, and studying the MRI that had been done on her foot. THEN he came in to look at the foot, itself. He said it wasn't life threatening YET, but with the gangrene, it would become so. He wanted to catch it before it reached that point, before Mom got any weaker. He said that, the sooner the amputation was done, the better her chances of surviving the surgery. If this continued too much longer, she'd have a slim chance of making it through. He told us-and Mom-that removing that source of infection would greatly increase her quality of life.

My aunts and I held each other and cried. We knew Mom had wanted to keep the foot, if she could. SHE was the one who couldn't understand US being upset. She let us know, that when she heard gangrene had set up, there would be no saving the foot. By the next morning, we had reconciled the fact within ourselves. She'd come out of the hospital, this time, minus her foot. But SHE would live, and would get better. The infection would not be dragging her down.

My only concern was "What are her chances of surviving the surgery?"

Dr. Hilborn's response: "Much better, if we do this now. If we let this infection keep dragging her down, she won't have much of one." I trust his judgment. And I know he's a good doctor.

We met, as a family, at Mom's bedside, before they took her in for the pre-op, and prayed together. The surgery was supposed to take 1 ½ hours. The recovery, another 1 ½ hours. So, we waited in the surgery waiting room. The surgery ended up lasting only an hour. Then the recovery time, only 45 minutes. We were told she was doing better than expected.

Mom completely shocked those nurses, on the fifth floor of Wadley, when she was brought back in. She came in, smiling at everyone. Her RN told us that was the only time she'd ever seen ANYONE come back from surgery with a smile.

All day, we watched her condition begin to improve. Except for the expected pain, of course. But her color was better, her complexion was better. She had a better attitude, and her mind was clearer than it had been in weeks-even under the effects of the pain meds.

We've been told that most of her problems with the confusion and inability to feed herself came from that chronic infection. After amputating that foot, Dr. Hilborn told us that the infection was confined to that area. Blood cultures showed it's not in her blood. It's been compared to extraction of an infected tooth. Once the tooth is removed, the infection goes away. The source is gone, and the body can finally heal. So now we wait for that healing, and see how much better she's going to get.