A 48-year-old village dweller with a 5-year history of type 2 diabetes mellitus was referred for glycemic control before planned disarticulation of the distal phalanx of the right great toe for suspected osteomyelitis.
He had initially presented to the department of orthopedics with pain and progressive swelling of his right great toe for the preceding 2 weeks; a working diagnosis of diabetic neuropathic foot ulcer with mild diabetic foot infection was considered and disarticulation was planned.
He did not perceive any form of trauma to the right great toe in the recent or remote past.
Clinical examination revealed a swollen right great toe with an elevated local temperature and desquamation of the overlying skin giving rise to a small and shallow ulcer over the dorsum.
The probe-to-bone test result was negative, and there was no underlying abscess or active discharge from the ulcer.
The ankle-brachial pressure index was 1.1 bilaterally, and the 10-g monofilament test was 4/6 on the right side and 5/6 on the left side.
The ulcer was reclassified as University of Texas grade 1 stage B.
Radiography of the right foot revealed near-complete resorption of the distal phalanx of the right great toe.
A negative probe-to-bone test and the absence of characteristic radiologic findings of osteomyelitis put the initial working diagnosis in question.
Although Charcot’s neuroarthropathy and osteomyelitis are well-known complications of diabetes, secondary osteolysis has largely been underappreciated and underreported.
What appears radiologically to be bone destruction consistent with osteomyelitis might instead represent secondary osteolysis due to increased peripheral blood flow, inflammatory hyperemia, granulation tissue, or soft-tissue infection.
To conclude, secondary osteolysis may closely mimic osteomyelitis on plain radiographs, and a correct and timely diagnosis of secondary osteolysis avoids unnecessary surgical intervention.
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