Bone biopsy of toe

[Creflo]

The podiatry service at my program has been requested by infectious disease to obtain a bone biopsy of toe(s) in order to direct antibiotic therapy for osteomyelitis. Is this possible, or are the bones to small? We have not done this, but I'm curious if others have. Thanks for any replies.

---

Members don't see this ad.

 

[PADPM]

The podiatry service at my program has been requested by infectious disease to obtain a bone biopsy of toe(s) in order to direct antibiotic therapy for osteomyelitis. Is this possible, or are the bones to small? We have not done this, but I'm curious if others have. Thanks for any replies.

Yes, a biopsy is possible and as you know is really the definitive way to obtain a diagnosis. Depending upon the site, size of the bone, etc., a small bone roungers can be used to get a bite, trephines to get a small plug of bone, etc.

It is generally recommended to not obtain the bone specimen through an infected ulcer, since that can impact the accuracy of the bone biopsy (it is being extracted through a dirty/contaminated wound).

As always, if you have procedural questions, you should ask your director. At this point you are in the learning process and your question should be answered by an attending with experience. Discussing this with ID may also be beneficial. In our main hospital, we have a great relationship with ID and vascular and work together.

 

[prettypod]

What program are you involved with? A resident? Student? This seems a pretty basic question, I'm sad to say, if you guys are having a problem with a bone biopsy, I would love to be able to tell trainees to stay away from your program.

 

[jonwill]

While it is definitely possible to take a bone biopsy of a toe, in MOST cases (meaning the diabetic/neuropathic/PVD patient), the vascularity of the patient is not such that it can effectively deliver enough antibiotic to the toe to eradicate the osteomyelitis. I usually will give the patient the option but let them know that the odds of success are very poor. I usually recommend toe amputation. Nothing is worse than dealing with a picc line and the side effects of 6 weeks of IV antibiotics and then still having to have a toe amp anyway!

 

[TheWookie]

What program are you involved with? A resident? Student? This seems a pretty basic question, I'm sad to say, if you guys are having a problem with a bone biopsy, I would love to be able to tell trainees to stay away from your program.

The Wookie says:

Ahhhh, Young Padawan, to base your opinion on an Academy of Training based on one anonymous Padawan here shows your immaturity, as well as your potential insecurity, in the Ways of the Force.

Also, to claim yourself as a Savior shows potential misuse of your training and is the path to the Dark Side.

Tread carefully, Young one.

 

[PADPM]

The Wookie says:

Ahhhh, Young Padawan, to base your opinion on an Academy of Training based on one anonymous Padawan here shows your immaturity, as well as your potential insecurity, in the Ways of the Force.

Also, to claim yourself as a Savior shows potential misuse of your training and is the path to the Dark Side.

Tread carefully, Young one.

 

[Feli]

As was mentioned above, just do a toe amp or a phalangectomy and wound edge excision to get closure. The ID doc probably knows the abx are more to prevent systemic or local infection spread... not to cure the osteo. If they are misinformed and want to medically treat the osteo (ie 6-8wks PICC abx), politely tell them the perfusion is too scant and abx side effects not really worth it in your opinion. If you make sure they know that you think you've excised all the bad bone after the surg, then they will likely just give 7-10d of PO abx on discharge, but they want to make sure their therapy is the correct one based on the bone gram stain or cx. That's good medicine and everyone is satisfied.

In general, when another refer/consult physician or a patient requests you provide a Rx or a treatment that's reasonable based on the condition (not necessarily optimal or your top choice, but not harmful, not unecessary, and not unreasonable), you just want to go with the flow. That's a good way to network and keep everyone happy... let them think they're running the show, and make some $ for yourself in the process.

 

[TheWookie]

In general, when another refer/consult physician or a patient requests you provide a Rx or a treatment that's reasonable based on the condition (not necessarily optimal or your top choice, but not harmful, not unecessary, and not unreasonable), you just want to go with the flow. That's a good way to network and keep everyone happy... let them think they're running the show, and make some $ for yourself in the process.

The Wookie says:

Extremely well said, Master.

Impressive...very impressive.