Recommendation

The patient stopped all antibiotics. He was advised to wear a pneumatic short leg boot to left foot at all times that was to be removed only for foot cleansing and assessment.

To maintain nonweight bearing on left lower extremity, the use of crutches or knee walker was recommended. Radiographs of the patient’s left foot and ankle were scheduled for three weeks later.

Mr. L underwent smoking cessation counseling, and was e-prescribed a nicotine transdermal patch (NicoDerm CQ). A follow-up was scheduled for three weeks later.


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Outcome

The patient returned in three weeks with persistent left foot edema, unchanged left foot temperature differential, and no radiographic sign of bone healing.

Mr. L was recommended to undergo left foot arthrodesis with internal fixation due to refractory CN. The patient was referred back to his internist for preoperative glycemic management prior to surgery given HbA1c above 7%.  

Two weeks later, Mr. L underwent ambulatory arthrodesis and was discharged home in a below-the-knee splint with instructions to observe three months of strict nonweight bearing.

Within the three months, the patient had repeat casting of the left lower extremity. Repeat radiograph indicated proper bone alignment maintained with joint union. The patient was transitioned to specialized foot wear (CROW Walker) and started weight bearing activities.