Chapters Transcript Complex Pedal Salvage Procedures Back to Symposium thank you dr cash it um Glad I don't have to compete between endovascular and open. So um I will my talk actually will be a little bit quicker because as dr Ambani and dr lee had mentioned, there's a lot of statistical data out there to uh to go over in terms of diabetic patients and alterations and the morbidity and mortality rates. So um you know from my standpoint I want to start off with you know, basic basic picture of of an open foot ulceration. Um and this is uh actually a lot to impact when we look at this officer. If I were to survey the audience right now, I'm sure. And I were to ask what would you be your approach to treating this? Of course the first response would be assessing the vascular status from both an arterial and a venous standpoint. And while I agree with that um we also would have responses of you know, appropriate glycemic control hypertension, hyper lipid e mia. However, when I look at this ulceration, one of the first things that I look into is what is this patient's overall functionality and oftentimes what's missed in these patients is iniquitous related deformity or an elongated metatarsal or a plantar flex metatarsal that would be dealing with. And you know, when it comes to your standard of care, which I would argue is not always the standard of care and a lot of these patients it would be offloading um treatment for this simple, we can place these places patients in total contact cast non weight bearing for a period of time and often times we are successful with treating it as long as we handle the metabolic deficiencies that these patients might present with as well as addressing their underlying vascular status and improving overall profusion to their foot when needed. However, a lot of our primary end goal points uh if you look through the literature do focus on time to healing of alterations and albeit that this is a great approach and something that we need to take into account. We fail to address the underlying secondary endpoint which is often associated with recurrence of ulceration. Um I will tell you in a lot of these patients that we place them in a total contact cast and we can argue with the literature based off whatever advanced therapy we may use, whether it be stem cell grafting or any type of soft tissue related plasticky or graph that we would utilize. The recurrence rate is going to be extremely high if we don't address the underlying functionality. So along with treating them and getting this wound healed via total contact cast off loading so and so forth. The next step is to get them into an appropriate diabetic shoe or offloading device. However, we also know that one of the major pitfalls when it comes to diabetes and diabetic ulceration. XyZ, the component of the neuropathy that exists within these patients which is associated also with myopathy. And there's enough literature to support that the chronic subtle changes occur by week. Um to even months with these patients. And we end up with changes within the stabilization and uh substitution within their foot. So they are approved for a diabetic shoe and insert annually. However their foot is changing throughout the entire course of the year. So one diabetic shoe, an insert is not going to be sufficient for these patients long term. So again as I look at this patient's foot uh without ignoring the underlying pathology that we need to address. I look at an acquaintance deformity usually associated with a tight achilles tendon and again an elongated metatarsal. And if these are treated and not all patients do require surgical intervention. But by treating the underlying pathology we can look to prevent recurrence of this ulceration after we do get it healed. And one of the most major important parts is to restore some of that native tissue that exists within the foot so that we can also again prevent the recurrence. So going on to more of a complex pedal approach to to these patients will start off with case number one. This is a 65 year old male history of hypertension, Hyperloop anemia triple a proper arterial disease. He underwent a prior and I and D. With underlying osteomyelitis to the right medial foot status, post bypass craft of the right lower extremity at an outside hospital. Uh He was then followed up with our vascular colleagues here at U. H. And angiogram was done which did show three vessel run run off and Patton C. Of the bypass graft. Our colleagues then referred over to Pattaya Tree. And the plan was to respect the non viable bone as well as an abductor paralysis, muscle flap inside too as well as the split thickness graft and evac. This patient was treated routinely for multiple months with wet to dry saline as well as deacons solution but it wasn't enough to clear the underlying infection. No long term I. V. Antibiotics. This patient did receive a picc line post agreement with long term I. V. Antibiotics as well as hyperbaric oxygen therapy. Um Not all patients that necessarily need hyperbaric oxygen therapy just because they have osteomyelitis. How what if it is a good adjunctive therapy? So here's a picture of the post revascularization angio that did show three vessel runoff significant or appropriate enough for healing of the current ulceration. So our problem really dealt with the osteomyelitis bone that needed to be respected. And one of the more important things was not just respecting the bone but getting coverage over that bone as soon as we possibly could. So a different approach. Um dr lee. I know you were concerned about some of your pictures but um some of mine maybe even more graphic. Um This is uh an approach where in the upper left slide you can see uh the necrotic bone that we did go down. We dissected. We got rid of as much of that necrotic bone as possible while maintaining functionality of that foot. Um You can see in the bottom right picture a small incision that was made over the origin of the abductor paralysis muscle. Uh This is where it does receive a lot of its perfusion as well. So we only resected half of that muscle off of the bone. Um And then superficial and subcutaneous lee. We transected that muscle and moved it distantly to cover over top of the necrotic bone and following doing so you can see the uh the flap that we occur. We were able to perform with that abductor muscle belly and covering it with a split thickness graft and covered that with a wound back and on top of it we use bone marrow aspirate, concentrate to help with the adherence of the graft as well as eradication of that underlying osteomyelitis which there is a lot of literature out there now to support the use of bone marrow aspirate, concentrate in the face of osteomyelitis here is him seven months later, we're still dealing with a tiny small wound. Um Most of this is really related to offloading appropriately. Um The patient is doing well. His pain is significantly better and you can see back where the uh the muscle was taken that has healed up uneventfully without any concerns. Um patients biggest problem which you can notice we've adjust as well was the Alex due to the significant osteomyelitis. Uh He did end up with a Alex expenses where the Alex was dorsal flex pretty significantly where we had to respect the extensive analysis previous tendon and lengthen the E. H. B. Um really not necessarily from a functional standpoint, but more so being able to fit into shoes. So we did this during the healing process as well. Here's another case of a 51 year old male insulin dependent diabetic a one C of 6.7, which I don't get to see too often. Um but that was a nice hypertension. Hyperloop infamously sleep apnea presented with shark. Oh, the right foot and ankle. He was unable to ambulance for the past couple of years due to his shark. Oh um he's basically been placed on and off. Total contact has for an extended period of time, but really with no goal for functionality moving forward. Um the plan was to offload him initially and this was mainly to take him out of his uh initial stages of charcoal charcoal presents in four different stages. Oftentimes you'll read three. The initial stage is more of a subclinical stage where we start to notice uh some clinical changes, but we don't really notice radio graphical changes and still stage one and that's usually when they present with an extremely swollen red warm foot. That is mistaken for infection. Um And especially in the face of no wound. This needs to be looked at a little bit closer the average number of times the patient with shark oh presents to the office that's been mistreated as an infection is around 2.8 times with trips to the emergency department. So with no open wound, no systemic infection that has occurred in a patient with diabetes or peripheral neuropathy which is really the only precursor to shark Oh neuropathy. Uh They should be referred to a specialist in this area to ensure that uh further damage is not occurring sub clinically. Um After offloading as he did present with a small wound. The plan was for reconstruction with the tibia tibia. Table Falconio fusion. Vienna I am nail in the mid foot fusion to follow. This is his presentation as you can see significant destruction of the talon. Navicular joint. Um As well as a various deformity of the uh taylor's at the ankle. Um As well as essentially no taylor's that's remaining. Uh It was essentially pulverized both anterior and posterior lee. So the game plan was to respect the the taylors at that point we were able to utilize and salvage a small portion of that tailors to use as bone graft. The post here aspect was left in place actually for stability purposes. It does not affect him functionality. It's anterior to the achilles tendon. Uh and we were able to fuse the tibia otello Falconio joint. He went on to a pseudo fusion which is perfectly appropriate in these patients. As long as you maintain stability. Um He does have a bit of a floating uh tiene related area that we did bring back at a later date and we threw two crossing screws from lateral to proximal to stabilize that mid foot again. All the goal is for a stable plant a grade foot if you can achieve union at the same time. Fantastic. Uh If not it's not necessarily the end of the world as long as infection has been controlled and eradicated and the last case is a 72 year old male past metal history of coronary heart disease. A fib hypertension, Hyperloop anemia, P. V. D. And a chronic wound and osteomyelitis to his ankle to the right ankle. He fell off a ladder in 1979 broke his ankle and he said problems ever since he had an ankle fusion that was done developed a wound infected hardware. This was removed has had residual pain and ulceration now for the past 4 to 5 years and it's basically been on and off I. V. Antibiotics with subsequent agreements. Yet no real bone biopsies no further exploration of the underlying osteomyelitis. So the goal is a vascular work up which turn out um To be satisfactory as well as aggressive debridement of infected bone I. V. Antibiotics, implantation of an antibiotic cement spacer and the eventual dynamic fusion via an external fixate er to counter the bone loss and deformity correction to allow this patient to walk again. This was done via taylor spatial frame for anyone familiar with this. This allows us to get dynamic compression as well as correction deformity. It's typically done around the ankle or for limb length deformities. However, we're able to utilize this device and software and essentially flip it 180° to utilize the hind-foot outside of the ankle. Um to achieve what we needed to do. Here's a picture of his ankle. You can see the fusion that occurred, you can see on the lateral view the taylors with a lot of punched out lesions, Radio loosen. See this was all osteomyelitis bone. Um Of course this patient's gonna end up with chronic ulceration for an extended period of time and unless you remove that bone they're not going to hell. However, if you were to remove this bone we don't have much real estate per se to work with from a functionality standpoint. So he was also offered a blown amputation on multiple occasions. The patient was not willing to proceed with that process and we had maybe another option that we could proceed with. So this patient underwent a significant reception of the osteomyelitis bone, essentially the entire taylor head portion of the navicular portion of the balconies and portion of the cue Boyd on the right hand side. That's the antibiotic spacer cement that we utilized. You can see how large of a void that was that we had to fill. Here's an X ray with the removal of the necrotic bone. Again, we've got a large void that we would need to fill in this area. That's not a functional foot. Um You can see it's compressing it inter operatively where we can get this back down into an appropriate position but we are going to be left with a little bit of a void to fill in the right side is the antibiotic cement. So again, a large void that we did need to fill in this patient. However, we took the patient back in after six weeks of antibiotics as well as the antibiotic spacer with appropriate bone cultures. We filled this in with a synthetic biologic graft that was utilized that will convert into bone over the course of the next year to year and a half. This was also mixed with other biological grass as well as cancel this bone chips. Um and bone marrow aspirate to aid in the healing process on the upper right. You can see those are pins from the external fixture that was utilized which will show on the next slide, which is going to allow us to get compression across the site. And here is a picture of the foot laterally. You can see the foot is definitely about 2 to 3 inches smaller. He'll be buying two different size shoes moving forward. Um But we do have excellent opposition of that site uh utilizing the the external fixture. You can see in that middle slide. There's struts as well as on the left side that allows us to get dynamic compression over a period of time. So this patient, what we did is inter operatively we took a picture of the foot, the tibia as well as the foot on a lateral view and the balcony and were able to determine what his current position is and what position would like this patient to get into. And it runs through a software program. And those struts that are on the outside are set up per millimeter. And this patient goes home with his prescription. And he makes these changes on his own every day where he adjusts this. It does not hurt him. It doesn't cause any problems, but he can make this correction over a period of time. And here's a look at the foot now um approximately 10 weeks after we performed the procedure. You can see excellent opposition of the bone at this point. Um he will be in this fix later now for the next, you know, 4-6 months. Uh and but he'll be able to ambulance here in the next couple of months and hopefully move forward to be able to save his life. Thank you Created by Related Presenters Craig Frey, DPM System Director, Podiatric Medical and Surgical Services University Hospitals View full profile
