Rifampin and Maggot Debridement as Non-operative Treatment for Heel Ulcer Complicated by Chronic Calcaneal Osteomyelitis

Background: The current standard of care for heel ulcerations with calcaneal osteomyelitis is extensive resection of all affected bone and soft tissue. However, surgical debridement has a high rate of complication, including reoccurrence and deformity of the weightbearing surface of the foot. Additionally, this diagnosis has a poor prognosis: a recent study found that 52% of cases of calcaneal osteomyelitis lead to major amputation in contrast to 0.3% for forefoot and 18% for midfoot.

Purpose: This case report demonstrates a successful non-operative treatment for chronic calcaneal osteomyelitis through larval debridement, local wound care, and eight weeks of rifampin therapy. 

Materials and Methods: A 49-year-old female with spinal cord injury and paraplegia presented with extensive heel ulcer secondary to long leg cast. The full thickness eschar with local signs of infection and extensive slough was found. Radiographs were suspicious for chronic osteomyelitis, which was confirmed by bone biopsy. Bone culture confirmed Staphylococcus hominis. The patient was treated concurrently with eight weeks of rifampin and doxycycline. Local wound care included two applications of larval debridement and seven applications of amnion products. Serial radiographs were utilized to monitor osteomyelitis. 

Results: At completion of eight-week therapy, the patient achieved full epithelization of wound and radiographic suppression of calcaneal osteomyelitis. The patient has remained clinically and radiographically stable for 4 months. 

Conclusion: In this case, rifampin therapy was an appropriate alternative to surgical standard of care for osteomyelitis and heel ulcer. This treatment effectively avoided complications associated with surgical debridement and achieved limb salvage.