When delay costs a limb: Severe chronic osteomyelitis in a patient with intravenous drug use

Intravenous drug use (IVDU) is strongly associated with severe infections including abscesses, endocarditis, necrotizing fasciitis, and osteomyelitis. When untreated, acute osteomyelitis can progress to chronic disease with biofilm-mediated antimicrobial resistance, soft tissue necrosis, and eventual limb loss. Reports of extreme cases requiring major amputation remain uncommon in the literature. We report the case of a 32-year-old female with a history of substance use disorder who presented with a chronic right forearm wound after more than one year without definitive treatment. Despite prior medical recommendations for amputation, the patient declined intervention and was lost to follow-up. She re-presented with worsening pain, soft tissue necrosis, exposed bone, and a pathological fracture. Operative management included a transhumeral amputation with confirmation of acute osteomyelitis and osteonecrosis on pathology. This case highlights the clinical and social challenges of managing chronic osteomyelitis in patients with IVDU, including delayed care, limited adherence, and high rates of antimicrobial resistance. Optimal management requires a multifaceted approach combining aggressive surgical debridement or amputation with systemic and local antibiotic therapy. Emerging treatment frameworks, such as the Philadelphia Treatment Algorithm for Xylazine-Associated Wounds, provide evidence-based guidance for similarly complex infections. Patients with substance use disorder are at increased risk for devastating complications of chronic osteomyelitis, including limb loss. Early recognition, structured treatment algorithms, multidisciplinary management, and integration of addiction treatment are critical to improving outcomes in this vulnerable population. • Chronic osteomyelitis in IVDU can progress to severe limb-threatening infection. • Delayed treatment may necessitate major amputation for infection control. • Biofilm resistance reduces systemic antibiotic effectiveness. • Structured algorithms aid management of complex substance-related wounds. • Multidisciplinary care and addiction treatment improve patient outcomes.