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Case Study
Treating Iatrogenic Calcaneal Osteomyelitis Following A Plantar Heel Injection
July 2014
Addressing questions of how to proceed when a calcanectomy is inappropriate, these authors detail how to treat a 24-year-old who experienced the rare complication of calcaneal osteomyelitis after an injection for plantar fasciitis.
Calcaneal osteomyelitis is a rare complication following injection treatment of plantar fasciitis. To date, there are two published reports documenting osteomyelitis following corticosteroid and local anesthetic injection for plantar fasciitis.1,2 With this in mind, we would like to discuss treatment options to consider when the physician deems calcanectomy inappropriate or the patient refuses it.
Injection of local anesthetic in combination with corticosteroid is an accepted choice in the treatment of recalcitrant heel pain diagnosed as plantar fasciitis.3 When one performs the injection properly, post-injection infection is exceedingly rare.4
This is a case of calcaneal osteomyelitis following injection in a patient with a calcaneal stress fracture misdiagnosed as plantar fasciitis. Authors have noted that subtotal and partial calcanectomy are effective treatment strategies for calcaneal osteomyelitis.5,6
When this treatment did not resolve her symptoms, the patient got a referral to a podiatrist. The podiatrist added physiotherapy and cryotherapy to the treatment plan. These additional modalities did not alleviate her pain and the podiatrist obtained a magnetic resonance imaging (MRI) study. The MRI revealed a linear decrease in T1 signal intensity, suggestive of a stress fracture of the calcaneus (see figure 1). The patient received a subsequent referral to the senior author’s practice for further evaluation and treatment options.
The examination revealed an edematous right rearfoot (see figure 2). No open lesions were present. The senior author applied a two-layer Jones compression bandage with a fiberglass shell in an attempt to reduce edema. The patient had instructions to be non-weightbearing on the right foot.
Upon removal of the cast, a hemorrhagic bulla was encompassing the entire heel (see figure 3). Compression of the lesion resulted in the expression of purulent drainage. No crepitus was present within the soft tissue. The patient complained of chills and was tachycardic, but she was afebrile and normotensive. The patient was admitted to the hospital for empiric antibiotic therapy.
We performed the first of four excisional debridements in the operating room setting (see figure 4). We also obtained a biopsy and culture of the calcaneus. Following the first operation, a repeat MRI revealed a mottled T1 signal intensity suggestive of osteomyelitis of the calcaneus (see figure 5). Bone cultures of the calcaneus revealed infection with methicillin-resistant Staphylococcus aureus (MRSA) and a bone biopsy showed fibrotic and chronic inflammation consistent with osteomyelitis.
The young patient was not amenable to total or subtotal calcanectomy. We formulated a course of long-term antibiotic therapy in conjunction with the infectious disease service. We employed weekly sharp debridements, negative pressure wound dressing and hyperbaric oxygen therapy (HBOT).
Three months after the first admission, the patient was hospitalized for a Clostridium difficile infection secondary to chronic antibiosis. Ten months after her initial presentation, the patient was admitted for a third time with a diagnosis of cellulitis, which emanated from an open wound at the plantar heel that was 1 cm in circumference (see figure 6). One year after her initial presentation, the patient was admitted a fourth time due to cellulitis and abscess formation.
The patient went to the operating room where we excised the wound and sinus tract, and performed a calcaneal debridement. We took multiple cores from the calcaneus via trephination and packed the deficits with OsteoSet (Wright Medical) calcium sulfate beads impregnated with vancomycin (see figure 7). The original bone culture organisms were sensitive to vancomycin and the use of calcium sulfate beads obviated the need for removal. Upon discharge, we followed the patient closely as an outpatient and placed her on eight weeks of intravenous cefazolin (Ancef, Sagent Pharmaceuticals) therapy.
Nine weeks after the debridement of the calcaneus and implantation of the antibiotic-laden beads, a small hyperkeratotic lesion arose on the plantar foot, which we debrided (see figure 8). No local signs of infection were present. The patient did complain of pain to the lateral calcaneus, which we attributed to the alteration of her gait due to the presence of the wound. The infectious disease service discontinued intravenous antibiotics and prescribed oral cephalexin as suppressive therapy for a duration of five years. Refer to the table “Insights On The Treatment Of The Patient” at left for a concise summary of the patient’s course of treatment.
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).
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.
Researchers have reported that varying cleansing agents are effective at lowering the chance of infection if one uses them correctly. The most ubiquitous cleanser is isopropyl alcohol, which is reportedly effective for disinfecting the skin surface.17
Cawley and Morris compared skin preparation solely with ethyl alcohol versus a combination of chlorhexidine and ethyl alcohol.18 After culturing the injection needles, the study authors found that the combination of chlorhexidine and ethyl alcohol resulted in contamination in 14 percent of needles and ethyl alcohol alone resulted in 28 percent contamination. Both agents resulted in lower contamination rates than the uncleansed control group, but the results did not meet statistical significance.
Povidone-iodine solution should dry for at least three minutes after application. Studies have shown that povidone-iodine topical solution reaches its peak antiseptic potential when one allows it to air dry for 20 minutes.18 Some may view this as a less than ideal cleansing agent from a practical standpoint in a busy clinical practice setting.
Both WHO and the Centers for Disease Control and Prevention (CDC) offer recommendations for safe injection practices and protocols that may limit contamination to medications and equipment.15,19 Proper hand hygiene remains the most important tool in the fight against healthcare-related infections. Wear gloves whenever the possibility of coming in contact with the patient’s blood exists. Use single-use vials whenever possible. If using multiple-dose vials, do not reuse needles or syringes. The WHO guidelines for skin preparation state that one should utilize single-use applicators. One should cleanse the skin with alcohol, beginning at the proposed injection site and cleansing outward without going over the same area twice. Cleanse the skin for a full 30-second interval and allow the alcohol to dry completely.
Dr. Canales is in private practice at St. Vincent Medical Group in Independence, Ohio. He is the Associate Director of the PMR + RRA Residency Training Program at St. Vincent Charity Medical Center in the Department of Orthopedic Surgery, Podiatry Section in Cleveland. Dr. Canales is a Professor of Surgery at Kent State University College of Podiatric Medicine.
Dr. Bowen is a third-year resident in the PMR + RRA Residency Training Program at St. Vincent Charity Medical Center in Cleveland.
Dr. Gerhard is a third-year resident in the PMR + RRA Residency Training Program at St. Vincent Charity Medical Center in Cleveland.
References
1. Gidumal R, Evanski P. Calcaneal osteomyelitis following steroid injection: a case report. Foot Ankle. 1985;6(1):44-6.
2. Wronka KS, Sinha A. Calcaneal osteomyelitis following steroid injection for plantar faciitis: a case report. Foot Ankle Spec. 2012;5(4):253-5.
3. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline – revision 2010. Foot Ankle Surg. 2010; 49(3Suppl):S1-S19.
4. Baima J, Isaac Z. Clean versus sterile technique for common joint injections: a review from the physiatry perspective. Curr Rev Musculoskelet Med. 2008;1(2):88-91.
5. Cook J, Cook E, Landsman AS, et al. A retrospective assessment of partial calcanectomies and factors influencing postoperative course. Foot Ankle Surg. 2007; 47(4):248-255.
6. Baravarian B, Menendez MM, Weinheimer DJ, et al. Subtotal calcanectomy for the treatment of large heel ulceration and calcaneal osteomyelitis in the diabetic patient. Foot Ankle Surg. 1999; 38(3):194-202.
7. Gaenslen FJ. Split-heel approach in osteomyelitis of os calcis. J Bone Joint Surg. 1931;17:759–72.
8. Oguachuba HN. Use of instillation-suction technique in treatment of chronic osteomyelitis. Acta Orthop Scand. 1983;54(3):452-458.
9. Walenkamp GH, Kleijn LL, de Leeuw M, et al. Osteomyelitis treated with gentamicin-PMMA beads. Acta Orthop Scand. 1998;69(5):518-522.
10. Perry AC, Rouse MS, Khalig Y, et al. Antimicrobial release kinetics from polymethylmethacrylate in a novel continuous flow chamber. Clin Orthop Rel Res. 2002;403:49-53.
11. Chang W, Colangeli M, Colangeli S, et al. Adult osteomyelitis: debridement versus debridement plus osteoset T pellets. Acta Orthop Belg. 2007; 73(2):238-43.
12. Crandall RC, Wagner FW Jr. Partial and total calcanectomy: a review of thirty-one consecutive cases over a ten year period. J Bone Joint Surg Am. 1981;63(1):152-155.
13. Martini M, Martini-Benkeddache Y, Bekkechi T, et al. Treatment of chronic osteomyelitis of the calcaneus by resection of the calcaneus. A report of twenty cases. J Bone Joint Surg Am. 1974;56(3):542-548.
14. Dann TC. Routine skin preparation before injection: an unnecessary procedure. Lancet 1969;2(7611):96-7.
15. WHO best practices for injections and related procedures toolkit. 2011. Available at https://www.who.int/injection_safety/sign/advocacy_booklet/en/index.html . Accessed April 14, 2014.
16. Khawaja RA. Routine skin preparation with 70% isopropyl alcohol swab: is it necessary before an injection? JLUMHS. 2013;12(2):109-114.
17. Workman ML. Comparison of blot drying versus air-drying of povidone-iodine cleansed skin. Appl Nurs Res. 1995;8(1):15-7.
18. Cawley PJ, Morris IM. A study to compare the efficacy of two methods of skin preparation prior to joint injection. Br J Rheumatol. 1992; 31(12):847-848.
19. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 68-69. https://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf . Accessed April 14, 2014.
Calcaneal osteomyelitis is a rare complication following injection treatment of plantar fasciitis. To date, there are two published reports documenting osteomyelitis following corticosteroid and local anesthetic injection for plantar fasciitis.1,2 With this in mind, we would like to discuss treatment options to consider when the physician deems calcanectomy inappropriate or the patient refuses it.
Injection of local anesthetic in combination with corticosteroid is an accepted choice in the treatment of recalcitrant heel pain diagnosed as plantar fasciitis.3 When one performs the injection properly, post-injection infection is exceedingly rare.4
This is a case of calcaneal osteomyelitis following injection in a patient with a calcaneal stress fracture misdiagnosed as plantar fasciitis. Authors have noted that subtotal and partial calcanectomy are effective treatment strategies for calcaneal osteomyelitis.5,6
A Closer Look At The Patient Presentation
A healthy 24-year-old female, employed as a pharmacy technician, visited her primary care physician with a complaint of unilateral heel pain. The patient reported a recent increase in activity in an effort to lose weight following the birth of her first child. The patient stated that her heel pain began after initiating a running program on a treadmill. Her primary care provider (PCP) diagnosed the etiology of the pain as plantar fasciitis and offered a treatment plan consisting of two injections of local anesthetic and corticosteroid within a six-day period.
When this treatment did not resolve her symptoms, the patient got a referral to a podiatrist. The podiatrist added physiotherapy and cryotherapy to the treatment plan. These additional modalities did not alleviate her pain and the podiatrist obtained a magnetic resonance imaging (MRI) study. The MRI revealed a linear decrease in T1 signal intensity, suggestive of a stress fracture of the calcaneus (see figure 1). The patient received a subsequent referral to the senior author’s practice for further evaluation and treatment options.
The examination revealed an edematous right rearfoot (see figure 2). No open lesions were present. The senior author applied a two-layer Jones compression bandage with a fiberglass shell in an attempt to reduce edema. The patient had instructions to be non-weightbearing on the right foot.
Treating The Repeated Complications
Five days later, the patient contacted the senior author with a complaint of numbness to her digits and 10/10 pain in the ankle. The patient reported bloody drainage seeping through the fiberglass shell of her compression cast. The patient immediately reported to the emergency department, where the senior author and residents met her.
Upon removal of the cast, a hemorrhagic bulla was encompassing the entire heel (see figure 3). Compression of the lesion resulted in the expression of purulent drainage. No crepitus was present within the soft tissue. The patient complained of chills and was tachycardic, but she was afebrile and normotensive. The patient was admitted to the hospital for empiric antibiotic therapy.
We performed the first of four excisional debridements in the operating room setting (see figure 4). We also obtained a biopsy and culture of the calcaneus. Following the first operation, a repeat MRI revealed a mottled T1 signal intensity suggestive of osteomyelitis of the calcaneus (see figure 5). Bone cultures of the calcaneus revealed infection with methicillin-resistant Staphylococcus aureus (MRSA) and a bone biopsy showed fibrotic and chronic inflammation consistent with osteomyelitis.
The young patient was not amenable to total or subtotal calcanectomy. We formulated a course of long-term antibiotic therapy in conjunction with the infectious disease service. We employed weekly sharp debridements, negative pressure wound dressing and hyperbaric oxygen therapy (HBOT).
Three months after the first admission, the patient was hospitalized for a Clostridium difficile infection secondary to chronic antibiosis. Ten months after her initial presentation, the patient was admitted for a third time with a diagnosis of cellulitis, which emanated from an open wound at the plantar heel that was 1 cm in circumference (see figure 6). One year after her initial presentation, the patient was admitted a fourth time due to cellulitis and abscess formation.
The patient went to the operating room where we excised the wound and sinus tract, and performed a calcaneal debridement. We took multiple cores from the calcaneus via trephination and packed the deficits with OsteoSet (Wright Medical) calcium sulfate beads impregnated with vancomycin (see figure 7). The original bone culture organisms were sensitive to vancomycin and the use of calcium sulfate beads obviated the need for removal. Upon discharge, we followed the patient closely as an outpatient and placed her on eight weeks of intravenous cefazolin (Ancef, Sagent Pharmaceuticals) therapy.
Nine weeks after the debridement of the calcaneus and implantation of the antibiotic-laden beads, a small hyperkeratotic lesion arose on the plantar foot, which we debrided (see figure 8). No local signs of infection were present. The patient did complain of pain to the lateral calcaneus, which we attributed to the alteration of her gait due to the presence of the wound. The infectious disease service discontinued intravenous antibiotics and prescribed oral cephalexin as suppressive therapy for a duration of five years. Refer to the table “Insights On The Treatment Of The Patient” at left for a concise summary of the patient’s course of treatment.
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
Researchers have reported that varying cleansing agents are effective at lowering the chance of infection if one uses them correctly. The most ubiquitous cleanser is isopropyl alcohol, which is reportedly effective for disinfecting the skin surface.17
Cawley and Morris compared skin preparation solely with ethyl alcohol versus a combination of chlorhexidine and ethyl alcohol.18 After culturing the injection needles, the study authors found that the combination of chlorhexidine and ethyl alcohol resulted in contamination in 14 percent of needles and ethyl alcohol alone resulted in 28 percent contamination. Both agents resulted in lower contamination rates than the uncleansed control group, but the results did not meet statistical significance.
Povidone-iodine solution should dry for at least three minutes after application. Studies have shown that povidone-iodine topical solution reaches its peak antiseptic potential when one allows it to air dry for 20 minutes.18 Some may view this as a less than ideal cleansing agent from a practical standpoint in a busy clinical practice setting.
Both WHO and the Centers for Disease Control and Prevention (CDC) offer recommendations for safe injection practices and protocols that may limit contamination to medications and equipment.15,19 Proper hand hygiene remains the most important tool in the fight against healthcare-related infections. Wear gloves whenever the possibility of coming in contact with the patient’s blood exists. Use single-use vials whenever possible. If using multiple-dose vials, do not reuse needles or syringes. The WHO guidelines for skin preparation state that one should utilize single-use applicators. One should cleanse the skin with alcohol, beginning at the proposed injection site and cleansing outward without going over the same area twice. Cleanse the skin for a full 30-second interval and allow the alcohol to dry completely.
Dr. Canales is in private practice at St. Vincent Medical Group in Independence, Ohio. He is the Associate Director of the PMR + RRA Residency Training Program at St. Vincent Charity Medical Center in the Department of Orthopedic Surgery, Podiatry Section in Cleveland. Dr. Canales is a Professor of Surgery at Kent State University College of Podiatric Medicine.
Dr. Bowen is a third-year resident in the PMR + RRA Residency Training Program at St. Vincent Charity Medical Center in Cleveland.
Dr. Gerhard is a third-year resident in the PMR + RRA Residency Training Program at St. Vincent Charity Medical Center in Cleveland.
References
1. Gidumal R, Evanski P. Calcaneal osteomyelitis following steroid injection: a case report. Foot Ankle. 1985;6(1):44-6.
2. Wronka KS, Sinha A. Calcaneal osteomyelitis following steroid injection for plantar faciitis: a case report. Foot Ankle Spec. 2012;5(4):253-5.
3. Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline – revision 2010. Foot Ankle Surg. 2010; 49(3Suppl):S1-S19.
4. Baima J, Isaac Z. Clean versus sterile technique for common joint injections: a review from the physiatry perspective. Curr Rev Musculoskelet Med. 2008;1(2):88-91.
5. Cook J, Cook E, Landsman AS, et al. A retrospective assessment of partial calcanectomies and factors influencing postoperative course. Foot Ankle Surg. 2007; 47(4):248-255.
6. Baravarian B, Menendez MM, Weinheimer DJ, et al. Subtotal calcanectomy for the treatment of large heel ulceration and calcaneal osteomyelitis in the diabetic patient. Foot Ankle Surg. 1999; 38(3):194-202.
7. Gaenslen FJ. Split-heel approach in osteomyelitis of os calcis. J Bone Joint Surg. 1931;17:759–72.
8. Oguachuba HN. Use of instillation-suction technique in treatment of chronic osteomyelitis. Acta Orthop Scand. 1983;54(3):452-458.
9. Walenkamp GH, Kleijn LL, de Leeuw M, et al. Osteomyelitis treated with gentamicin-PMMA beads. Acta Orthop Scand. 1998;69(5):518-522.
10. Perry AC, Rouse MS, Khalig Y, et al. Antimicrobial release kinetics from polymethylmethacrylate in a novel continuous flow chamber. Clin Orthop Rel Res. 2002;403:49-53.
11. Chang W, Colangeli M, Colangeli S, et al. Adult osteomyelitis: debridement versus debridement plus osteoset T pellets. Acta Orthop Belg. 2007; 73(2):238-43.
12. Crandall RC, Wagner FW Jr. Partial and total calcanectomy: a review of thirty-one consecutive cases over a ten year period. J Bone Joint Surg Am. 1981;63(1):152-155.
13. Martini M, Martini-Benkeddache Y, Bekkechi T, et al. Treatment of chronic osteomyelitis of the calcaneus by resection of the calcaneus. A report of twenty cases. J Bone Joint Surg Am. 1974;56(3):542-548.
14. Dann TC. Routine skin preparation before injection: an unnecessary procedure. Lancet 1969;2(7611):96-7.
15. WHO best practices for injections and related procedures toolkit. 2011. Available at https://www.who.int/injection_safety/sign/advocacy_booklet/en/index.html . Accessed April 14, 2014.
16. Khawaja RA. Routine skin preparation with 70% isopropyl alcohol swab: is it necessary before an injection? JLUMHS. 2013;12(2):109-114.
17. Workman ML. Comparison of blot drying versus air-drying of povidone-iodine cleansed skin. Appl Nurs Res. 1995;8(1):15-7.
18. Cawley PJ, Morris IM. A study to compare the efficacy of two methods of skin preparation prior to joint injection. Br J Rheumatol. 1992; 31(12):847-848.
19. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. 68-69. https://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf . Accessed April 14, 2014.
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