Diabetic Foot Care

Surgical Approach to Diabetic Foot Ulcers / Case Studies

By Dr. Brian Richman

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Approximately two years ago I started looking and treating diabetic foot ulcers in a whole new perspective. In addition to treating the ulcer through local wound care, glucose control, pressure off loading, good nutrition, good vascular flow, etc. (which I still try to maximize) I treat the etiology of the ulcer by surgically correcting the problem.

I had an insulin dependent diabetic patient with charcot foot, who twisted my arm to do something before the destructive forces of the active charcot foot progressed. I was very reluctant and worried about doing anything surgical on this patient. I had always been taught to try all the conservative therapies for active diabetic charcot foot. The patient was 68 years old IDDM female and could not be non weight bearing. She talked me into doing a percutaneous achilles tendon lengthening procedure, a midfoot stabilization procedure, and a plantar exostectomy. (see my future article on achilles tendon lengthening in the diabetic charcot foot). Anyway to make a long story short, I preformed the surgery and put her in a weight bearing fiberglass cast. She healed with no problems, no further deforming destructive forces causing ulceration, no difficulty with the fiberglass cast, no difficulty walking, and no problems post operatively from being weight bearing. I started to consider diabetic prophalatic surgery as a treatment option in treating pressure ulcers.

Here are some of my case studies from some of my diabetic patients. They have given me permission to use there history, physical exam, assessment, x-rays, photographs, and treatment on this web site. They have given me permission to use their story with hope that it may benefit physicians and / or patients with diabetes with further knowledge in the treatment of diabetic charcot foot, ulcers, and infections.

I have tried to present a wide variety of examples, so you could get a feel for how these prophalatic diabetic surgeries work. These 15 case studies are condensed into a couple of small paragraphs to give the pertinent facts. Most of these cases have had multiple office visits with a lot of conservative therapy before surgical intervention. It is very important to evaluate blood flow and potential of healing before considering surgical correction for a diabetic foot ulcer. Non invasive vascular studies, Segmental pressures, ankle brachial index, Doppler studies, the 5 minute hyperemia test, photoplethysmography, TcO2 pressures, albumin levels, and nutritional status can be effective tests to evaluate blood flow and healing potential. I would recommend that you never use a tourniquet on a diabetic patient. (Every patient is different and this should not be seen as the standard of care, or as a need for surgical treatment in every diabetic foot ulcer.)

*** Here are some rules follow when performing
surgery on patients with diabetes. ***

I perform diabetic foot surgery in a hospital or surgery center environment.
I try to get the patient's physicians (medical team) involved pre-op and post-
operatively.
I try to do surgery first thing in the morning. (the patient is able to get back on
schedule with insulin, medications, and food quicker and with less complications.)
I use MAC anesthesia. (patients are not nauseated after, quicker recovery, and less complications following general anesthesia.)
I do not use a tourniquet (most diabetic patients do not have great blood flow to start with, prevents blood clots, trauma to the vascular structures, and allows better healing.)
I use a mixture of 9 cc 0.5 % Marcaine plain + 1 cc of decadron as local anesthesia. This potentates the Marcaine and usually allows 36 hours of local anesthesia post operatively. (Most diabetic patients have some neuropathy and won't need a lot of local anesthesia.)
I use 3.0 nylon sutures and I leave them in for 3-4 weeks. (to prevent wound dehiscence)
I do not let patients get their foot wet. (prevents infection, dehiscence, and maceration)
On diabetic infections, I perform and incision and drainage procedure and flush the wound
with G.U. Antibiotics and a pulse a vac flush (usually 2-3 bags of 3000 cc's per bag)
I use a TLS Drain (to prevent hematoma, swelling, helps prevents infection, and drainage.)
I change the dressings frequently 1 - 2 times per day, the first 1- 2 days after surgery. (they will bleed a lot and soak the bandages causing maceration and delayed healing.)
I use a Modified Jones compression dressing with crutches on most of my post op patients x 4 days. (This reduces swelling which reduces pain.) I sometimes use this dressing in my diabetic patients.

(There are 15 diabetic case studies in the following pages.)

Case Study # 1

Subjective - Patient is a 54 year old male who complains of a ulcer underneath his L big toe x 3 years. States that he is a truck driver. States that he had 2 previous surgeries from another physician.

PMH - Gout, Chronic Ulcer L, HTN, Low Back pain.

Medications - Zestril, Allopurinol.

Allergies - NKDA

On Exam - Chronic Grade 2 ulcer with keratoma L plantar hallux
and 1st MPJ area. Sinus tracking present. Positive odor. Positive swelling L hallux. No signs of Osteomylitis on x-ray. X-rays show a prominent exostosis L plantar hallux.

Assessment - Non healing Ulcer L plantar hallux and 1st MPJ area caused by prominent exostosis and prominent tibial sesamoid. Gout. Plan - Exostectomy L hallux and surgical excision of L tibial sesamoid. Following the planned surgery, the patient's ulcer was completely healed within 5 weeks.

Goal - by removing prominent bone and tibial sesamoid this will reduce
pressure off the chronic ulcer an allow healing. ( I used a medial incision L hallux above the ulcer, and left the ulcer alone. Keep sutures in 3 to 4 weeks to prevent a wound dehiscence.)


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Case Study # 2

Subjective - Patient is 65 IDDM male who has had diabetes x 53 years comes in to the office complaining of a painful Right foot x 3 weeks. States that he has had a previous R 1st ray resection States that he has an ulcer R foot. States that there is a foul odor present. States that he is seeing another physician who thinks he needs a BK amputation. States that he is IV antibiotics Kefazolin 3 times per day. States that he has Peripherial neuropathy.

PMH - IDDM, CAD, PVD, BPH.

PSH - S/P R foot sx, open heart sx x 2.

Medications - Insulin, Maxzide, Lanoxin, Flomax, Kefazolin.

Allergies - NKDA.

Objective - Ulcer sub R 3rd MPJ with pus noted. Painful upon palpation. Positive odor. No red streaks up foot or leg. S/P R 1st ray resection with callous medial 1st metatarsal. Pus noted after debridement of this callous also. Barely palpable pulses B/L. X-rays show acute Osteomylitis R 2nd and 3rd metatarsal heads. X-rays also show S/P R 1st ray resection.

Assessment - Acute Osteomylitis R forefoot. Acute infection R foot. Patient needs IV antibiotics, an incision and drainage procedure along with more definitive surgery. I debated to do a pan metatarsal head resection vs. transmetatarsal amputation vs. a BK amputation. I thought his foot could be saved. I opted to do a pan metatarsal head resection realizing that he may need a BK amputation if this did not work.

Plan - Expressed the pus from wound in office. Admission to hospital. Medicine Consult. Right Modified Pan Metatarsal Head Resection surgery performed under MAC anesthesia in hospital OR. Flushed the wound with 3 bags (3000 cc each ) of GU irrigation. Change IV antibiotics to Vancomycin. Check Vancomycin levels and kidney function. In doing the Pan metatarsal head resection I did not use a tourniquet, and I used a two incision dorsal approach removing non infected bone first, flushing, closing, then I removed infected bone last with copious amounts of flushing, TLS drain, closing. (I know this goes against many surgical principles taught, but I had very few options.) Patient healed the ulcer within 5 weeks, is still ambulating with both legs, and had no other signs of Osteomylitis. Patient was on IV antibiotics x 7 weeks.

Goal - Limb Salvage Procedure. Eliminate Infection. Retain foot function. Medically stabilize the patient. (if you perform a transmetatarsal amputation you should also consider a achilles tendon lengthening or release to prevent an Equinovarus deformity post operatively.)


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Case Study # 3

Subjective - A 67 year old IDDM male complains that his left foot and ankle have bothered him for over a week. States that he put on an old cast boot that he had and it feels alittle better. Denies any history of trauma.

PMH - IDDM, Charcot foot, Peripherial Neuropathy. S/P R Hallux ulcer with Osteomylitis. S/P R 3rd MPJ ulcer with Osteomylitis.

PSH - S/P R pan metatarsal head resection. S/P R achilles tendon lengthening, S/P R distal R hallux amputation. S/P R foot sx, tonsilectomy, L ankle sx,

Medications - Insulin.

Allergies - NKDA.

Objective - Pain upon palpation Left midfoot Lis Franc's area and sinus tarsi area. Pain upon palpation Left 1st - 2nd metatarsal base. Patient has a tight achilles tendon L. No signs of ulceration or infection. X-rays Left foot show a Lis Franc's dislocation, and a plantar subluxation of the Navicular bone, and a medial cunieform fracture. No problems with ankle joint.

Assessment - IDDM. S/P Charcot foot R. S/P R foot surgery. Lis Franc's Dislocation Left foot. Subluxation L Navicular bone. Fracture L medial cunieform in good position. Problems with Left foot are probably related to Charcot foot. Tight achilles tendon causing strong plantarflexory destructive force on the left foot. Peripherial Neuropathy. ( It is not normal for a patient to have non burning pain with Peripherial Neuropathy. Look for the cause of the pain including fractures, charcot foot, infection, or in this case Charcot foot with Lis Franc's joint Dislocation. )

Plan - Patient needs a percutaneous achilles tendon lengthening L with a Lis Franc's Dislocation repair with internal screw fixation. ( I used a large Accumed screw in between the 1st - 2nd metatarsal base that helped bring the Lis Franc's Joint in better alignment. ) By correcting the Lis Franc's dislocation this should help with the Navicular subluxation. The patient is going to be in a fiberglass cast and have a bone stimulator after surgery, the medial cunieform fracture is in good alignment and does not need internal fixation.

Goal - Realignment of the Lis Franc's Dislocation will decrease the pain in the midfoot and subtalar joint. If you suspect Charcot foot you should do a achilles tendon lengthening procedure to reduces the destructive forces on the midfoot and ankle. ( I have found that these patients can be weight bearing with crutches in a fiberglass cast even though they have just had a percutaneous achilles tendon lengthening and active charcot foot. This goes against every surgical principal and medical management of charcot foot that I was ever taught. ) Most patients are elderly or physically unable to be completely non weight bearing even with crutches, walker or a wheelchair. This is a big factor post operatively if the patient can still partially or completely weight bear in a fiberglass cast without causing further damage.


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Case Study # 4 Part A

Subjective - Patient is a 68 year old insulin dependent diabetic who complains of a painful L heel and ankle. States that she picked a callous on left heel 2 weeks before coming to the office, and developed an infection.

PMH - IDDM, heart bypass, S/P leg ulcer graft, Venous Stasis Disease, Low back pain, CAD.

Medications - Lopressor, Prozac, Premarin, ASA, Monopril, K+, Lasix, Amaryl, Insulin.

Allergies - Myopan.

On Exam - Edema L ankle. Signs of Cellulitis left ankle and posterior heel. Painful Left plantar heel tender to palpation.. Positive odor, Pus noted. Palpable pulses 1 + Left DP and PT. X-rays showed no signs of Osteomylitis. Sed Rate = 83, WBC = 19.6 Hemoglobin A1-C = 6.9

Assessment - IDDM. Cellulitis/Infection L heel.

Plan - Surgical Incision and Drainage Procedure with pulse vac flush preformed L posterior medial heel. Admission to hospital for IV antibiotic therapy. Medicine consult. Culture Reports showed 4+ Streptococcus, 4+ E. Coli. Patient was put on Zosyn and Flagyl antibiotics.

Goal - Stabilize the patient. By performing the incision and drainage procedure and IV antibiotics you decrease the bacteria count, decrease the pain , decrease the active infectious process, and will decrease the hyperglycemia.

Case Study # 4 Part B

Subjective - Same patient as in part A. Patient had a lot of necrotic and infected tissue she developed a large plantar ulcer Left heel about 2 -3 weeks after incision and drainage procedure.

On exam - patient has a large 7 cm ulceration with fibrotic tissue Left plantar posterior heel, approximately 3 cm depth of wound. Patient has a lot of skin necrosis from previous infection. No pus, No odor. Patient developed Osteomylitis of L plantar heel about 2 months after I & D. X-rays showed bone destruction Left posterior plantar heel

Assessment - IDDM with severe ulceration L plantar heel. Patient at risk for a below the knee amputation. A Partial calcanealectomy may save this patient's foot.

Plan - Patient had a L partial calcanealectomy under MAC anesthesia approximately 2 months after initial infection. She was readmitted to the hospital for medical management and IV antibiotics. After hospitalization patient went to nursing home for further rehab. Patient's wound continues improve and heal, S/P surgery x 3 months.

Goal - limb saving procedure, remove infected bone, decrease pressure on ulcer, heal wound with time, local wound care, and proper medical management.


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Case Study # 5 Part A

Subjective - Patient is a 76 year old NIDDM female complains of an ulcer distal tip of R 3rd toe.

PMH - Peripherial Neuropathy, HTN, NIDDM, Hypercholesterolemia. Medications - Premarin, Accupril, Lopressor, Lozal, Clonidine, Lipitor, Amitriptyline. Allergies - NKDA

On exam - hammertoe R 3 digit with severe keratoma and Grade 1 ulceration distally, no sinus tracking, no signs of infection.

Assessment - NIDDM. Hammertoe causing ulceration R 3rd digit.

Plan - Patient had surgical correction for hammertoe, arthroplasty procedure. Ulcer healed with in 4 weeks. No signs of reoccurrence.

Goal - by correcting the hammertoe there is no pressure area
to cause the ulcer

Case Study # 5 Part B

Subjective - Same patient as in part A 3 years later, now she is an 79 year old IDDM female who complains of collapsing of her R midfoot x 3 weeks. Denies any history of Trauma.

Objective - collapsed midfoot R. Weakness R Posterior tibial tendon, patient unable to do a toe raise R foot. Pronated R foot compared to Left. Slight tightness of achilles tendon R. X-rays show slight destruction of the medial cunieform/midfoot area.

Assessment - IDDM. Possible Charcot Foot R. Possible rupture of the R Posterior Tibial Tendon causing pronation.

Plan - Patient had surgical correction R foot, consisting of a percutaneous achilles tendon lengthening procedure and a Young's Tenosuspension. Post op management consisted of crutches and a partial weight bearing fiberglass cast.

Goal - By lengthening the achilles tendon you reduce the charcot forces causing destruction on the midfoot. By performing the Young's Tenosuspension ( transfer the Tibialis anterior tendon underneath the Navicular tuberosity ) you help hold up the pronated foot. ( The posterior tibial tendon was not ruptured in this case, which makes charcot foot a lot more likely.) Patient is unable to be non weight bearing, therefore fiberglass cast with crutches is the next best option.


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Case Study # 6

Subjective - Patient is a 67 year old NIDDM male with pain in his Left big toe x 2 months. Patient had been to his family practitioner and had seen another podiatrist. Patient complained of a painful non-healing ulcers.

PMH - H/O seizures, NIDDM, S/P Brain Cancer, S/P Lung Cancer.

Medications - Dilantin, Paxil, Lortab. Allergies - NKDA.

On exam - patient had a 2 cm distal ulcer L plantar hallux with black eschar. Positive odor. Palpable pulses 1+ L DP and PT. Patient also has an ulceration distal tip of the L 5th toe. X-rays showed Osteomylitis distal phalanx L hallux and Osteomylitis of the L 5th distal phalanx.

Assessment - NIDDM. Non healing ulcer with Osteomylitis L Hallux and L 5th. Patient would benefit from a distal hallux amputation and distal L 5th toe amputation.

Plan - The patient had a distal hallux amputation at the IPJ L hallux and L 5th distal toe. Patient sutures were left in for 3-4 weeks. Patient had no pain and toes healed with no ulceration.

Goal - when you remove enough osteomylitic bone you no longer have a bone infection, and you want to try to close a previous wound. By performing this surgery you accomplish three things, # 1 get rid of the bone infection, # 2 you close the wound, and # 3 you now don't have an ulcer to heal )


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Dr. Brian Richman is a podiatric physician specializing in diabetic foot care, foot and ankle surgery, biomechanics, sports medicine, and general podiatry care. He practices at Davis Hospital and Medical Center in Layton, Utah.

For more information contact Dr. Richman at 1660 West Antelope Drive Suite # 110 Layton, Utah 84041 or visit his web site at www.DrBrianRichman.com

Acknowledgment. I would like to thank Marva Myler-Jensen, M.Ed., for her contributions to this manuscript. I would also like to thank all my patients for having faith, confidence, and trust in me to allow me to be there podiatric physician. I would especially like to thank these 15 diabetic patients for allowing me to put these case studies on the Internet to help further the treatment in diabetic foot care. I would like to thank my nurses Margaret and Heather for helping me retype many articles and information for this web site.

If you have any questions or would like to know more about these surgical techniques please call me at 1-801-825-4709