Treating Iatrogenic Calcaneal Osteomyelitis Following A Plantar Heel Injection
Today, three years after the initial procedure, the patient’s osteomyelitis is in remission. The patient ambulates in regular shoe gear with a silicone heel pad without pain or additional bracing. The patient has returned to full-time employment as a pharmacy technician and has resumed an exercise program. In the face of a daunting infection, we preserved the patient’s limb. Although there is a residual large deficit of the plantar fat pad (see figure 9), the patient has a fully functional result. The patient walks barefoot occasionally and has an adequate amount of residual fat pad to accommodate this (see figure 10).
A Closer Look At The Literature
This case report presents the third documented case of iatrogenic calcaneal osteomyelitis following a heel injection.
Authors have previously presented various tactics for dealing with calcaneal osteomyelitis. In 1931, Gaenslen described curettage of the cancellous core of the calcaneus while maintaining the cortical shell.7 Gaenslen performed this procedure through a plantar incision and did not pack the defect with antibiotic beads.
In 1983, Oguachuba proposed treating chronic osteomyelitis with a closed instillation-suction technique.8 Only one of the 28 patients had calcaneal osteomyelitis but had no recurrence of calcaneal infection at the one year follow-up. The other patients had osteomyelitis of the long bones of the lower extremity. In fact, in this study, only two out of the 28 patients had recurrence of osteomyelitis after the use of the closed instillation-suction technique.
The use of antibiotic-laden beads for the treatment of acute and chronic osteomyelitis first took place in 1970 and researchers subsequently described it in 1976 with the advent of polymethylmethacrylate (PMMA).9 Studies report that minimum inhibitory concentration of antibiotics eludes from PMMA beads from the first two days after implantation up to multiple weeks.10 A study by Chang and colleagues showed promising outcomes with the use of OsteoSet pellets in conjunction with debridement versus debridement alone, even though the results were not statistically significant.11
Other studies describe successful outcomes with either a calcanectomy or partial calcanectomy for the treatment of calcaneal osteomyelitis in the diabetic cohort.12,13 Due to the significant morbidities associated with partial or total calcanectomies such as fat pad instability, loss of Achilles tendon insertion/action, and failure leading to proximal amputation, one should reserve these procedures as a last resort in the sensate patient without diabetes.
Current Insights On Reducing Infection Risk
Perhaps it is easier to prevent an infection than to treat one. There is currently no gold standard for the preparation of skin prior to injection. In Dann’s classic 1969 article, he recommended against performing routine skin preparation on clean skin.14 This was subsequently reinforced by findings from later studies and is the current guideline of the World Health Organization (WHO).15,16