Late post-surgical complication; please help

I underwent cheilectomy of the right great toe for hallux rigidus (osteoarthritis of the big toe).  Things were improving quickly until day 7 when I developed cellulitis (skin infection) at and around the suture site on dorsum (top) of foot.  Was treated with IV Ancef and Cipro, with good response.  I was sent home after one day (on oral antibiotics) with no weight bearing.

Within a day, developed NEW swelling of entire forefoot and extreme point tenderness on the plantar side (underneath) of the metatarsal head.  The pain is mild when there is no pressure but severe with even a light touch, and it feels as if it is radiating deep into the foot.  I have been getting sweats and chills, but I have not had any fever.  I was readmitted and treated with several more days of IV antibiotics, with no change in the pain or swelling.  MRI was reported as showing no abscess, only a large collection of "fluid" that is "probably impinging on a nerve".  I was sent home on oral antibiotics.

I am now two weeks post-op.  The swelling has not diminished at all; it involves the entire lateral half of the foot (including all the toes) but especially the right great toe.  It feels like my foot is clamped (gently) in a vise.  It does not seem to be getting worse, either.  The point tenderness is just as severe.  It does not seem to be changing at all, despite antibiotics and several days with no weight bearing.  The surgeons seem to be stymied.

I have mild diabetes well-treated with diet and low doses of Metformin.  Labs show only mild elevation of ESR, with normal CBC.

Does anyone have any idea what this could be?  Any thoughts would be appreciated.

[S. Kaul, MD]

Hi there!

Well, it would be difficult to comment on the situation without a clinical evaluation, though with your description, possibilities such as compartmental syndrome and sudek’s dystrophy are important possibilities that may need to be considered along with insensitivity to the current antibiotic regimen. Uncontrolled diabetes may further complicate the situation by decreased response to management. I would suggest discussing the situation and the possibilities in detail with your treating doctor, for appropriate management.
Hope this is helpful.

Take care!