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Surgical Approach to
Diabetic Foot Ulcers / Case Studies Page 2 of 2 Case Study # 7 PMH - IDDM, S/P Stroke, Peripherial Neuropathy, HTN, Headaches, Hypercholesterolemia, CAD. PSH - S/P eye sx, S/P laser sx, Angioplasty, S/P Heart attack. Medications - Insulin, Clonidine, Propulsid, Procardia, Normodyne, ASA. Allergies - NKDA. On Exam - patient has Grade 1 ulceration L plantar medial hallux. Hyperkeratotic tissue around the ulcer. No odor, no sinus tracking, No red streaking up foot or leg. X-rays show a large prominence plantar L medial hallux at the proximal phalanx and IPJ. Assessment - IDDM. Chronic Ulcer L Hallux. CAD. S/P Stroke affected left hand. Plan - Patient had a exostectomy L hallux under MAC anesthesia. Patient's ulcer healed within 4 weeks. Goal - surgically removing enough bone to reduce pressure over ulcer allowing it to heal. When performing this procedure you need to be careful to keep the flexor hallucius longus tendon intact. Keep sutures in 3- 4 weeks. Do not let the patient get his or her foot wet until 1 week after suture removal, this will prevent any wound dehiscence.
PMH - NIDDM, S/P HTN. PSH - S/P R 4th / 5th toes amputation, hernia repair, S/P L knee sx, S/P subdural hematoma. Medications - None. Allergies - NKDA. Objective - A large Grade 2 ulceration with hyperkeratotic Left plantar 3rd MPJ. No red streaking up foot or leg. Positive Odor. Prominent bone spur dorsal Left 1st metatarsal base and medial cunieform area. S/P R 4th & 5th amputation. No signs of dehiscence or ulceration. X-rays show dorsal dislocation L 1st metatarsal base and excessive bone callous L 2nd & 3rd metatarsals with plantarflexed L 3rd metatarsal. Lesion marker shows ulcer area L 3rd MPJ. Assessment - NIDDM. Ulcer L 3rd MPJ caused by excessive bone callous from previous charcot foot. Dorsal Exostosis L 1st metatarsal base caused from subluxation from previous charcot process. Patient would benefit from exostectomy L 1st / 2nd / 3rd metatarsals. Plan - L foot surgery performed under MAC anesthesia without tourniquet. Dorsal Exostectomy L 1st metatarsal base. Exostectomy L 2nd & 3rd metatarsals. Excessive bone callous removed especially over ulceration Left 3rd metatarsal. Surgery performed through two dorsal incisions. Goal - Remove excessive bone callous from the Left 3rd metatarsal causing pressure ulcer. Patients with diabetes can handle a 1 to 2 hour surgery under Mac anesthesia, a lot better than trying to heal a chronic ulcer which runs the risk of developing Osteomylitis and possible amputation.
PMH - IDDM, Hypothyroidism, Peripherial Neuropathy, Hypercholesterolemia. PSH- appendectomy, hernia repair, multiple foot surgeries B/L, Back sx, B/L eardrum repair, B/L shoulder sx, L wrist sx, hysterectomy, R thumb sx, Total knee replacement L, Cataract sx B/L. Medications - Insulin, Amitriptyline, L-thyroxin, Ogen, Lipitor, Clonazepam, Ditropan, Celebrex, Nasonex, Inhalers, Lasix, K dur,Guaifenesin. Allergies - PCN, Ceclor, Morphine, Lortab, Floxin,Teracycline. Objective - Grade 1 ulceration R 1st MPJ with hyperkeratotic tissue around ulcer. No signs of infection. No sinus tracking noted. Prominent tibial sesamoid noted on x-ray above ulceration R 1st MPJ. (patient did develop Cellulitis from this lesion that was controlled by oral antibiotics and injection of Rocephin, and debridement (I &D) of ulcer in the office. This episode help convince the patient that she needed to have the surgery.) Assessment - IDDM. Chronic ulcer secondary to prominent tibial sesamoid R 1st MPJ. Patient would benefit from a R tibial sesamoid removal to reduce pressure on ulceration. Plan - Surgical excision of R tibial sesamoid performed. (intra-operatively the patients tibial sesamoid was adhered to the 1st metatarsal causing ulceration.) Patient healed ulcer within 5 weeks. Goal - reduce pressure causing the chronic ulceration. I treated this patient conservatively for 6 months with minimal success, but when I reduced the pressure by removing the sesamoid she completely healed the ulceration within 5 weeks and has had no problems since.
PMH - IDDM x 20 years, HTN, CAD, Hypothyroid, Asthma, Arthritis, Low Back Pain, Peripherial Neuropathy, Allergies, Hayfever. PSH - Heart Bypass, S/P L shoulder sx, gallbladder removal. Medications - Prozac, Insulin, Levothyroxin. Allergies - NKDA. Objective - Swelling Right midfoot and ankle area. Slight erythema R foot. Pain upon palpation R midfoot Lis Franc's area. No red streaking up foot or leg. Slight tightness R achilles tendon on knee extension. X-rays show bone destruction Right Lis Franc's area. Assessment - IDDM. Charcot Foot. Patient would benefit from an achilles tendon lengthening procedure to reduce destructive charcot forces. Patient needs to find a job that does not require so much walking, standing, working on concrete. Plan - A Right percutaneous achilles tendon lengthening procedure performed using two small incisions. A partial weight bearing fiberglass cast applied. Patient to use crutches. Patient was given a bone stimulator x 2 months to help with the charcot foot. Goal - Limb Salvage. Retain Function. Reduce destructive forces on the midfoot by performing achilles tendon lengthening procedure. Patient can not be non weight bearing. Change employment to reduce standing, lifting, walking forces. ( patients with charcot foot needs to slowed down as much as possible.) If I suspect that a patient has charcot foot I will perform the achilles tendon lengthening procedure as soon as I can, this helps reduce the strong plantarflexory force from the achilles tendon. Allowing the patient to be just non weight bearing without performing the percutaneous achilles tendon lengthening procedure will still cause charcot destruction because you still have a strong plantarflexory force of the achilles tendon.
PMH - IDDM, CAD, GERD, Heart Disease, Arthritis, Charcot foot, Hypercholesterolemia, Peripherial Neuropathy. PSH - Angioplasty, 2 stents, D&C, Hysterectomy, Gallbladder removal, L foot sx, L adrenalectomy, carpal tunnel, R achilles tendon lengthening, tonsilectomy. Medications - Insulin, Ambien, Zocor, Reglan, Lortab, Monopril, Neurontin, Actose, Prandin, Premarin. Allergies - Codeine, Demerol, Glucophage. Objective - Positive erythema, Painful upon palpation. Increased temperature L posterior heel, no pus noted, Red streaks up left foot and leg. Patient is Febrile. X-rays show no signs of Osteomylitis. Assessment - IDDM. Cellulitis L leg. Patient needs an incision and drainage procedure with hospital admission and IV antibiotic therapy. ( Patient did not need a BK amputation. This case showed me the importance of being treated by a physician who specializes in diabetic foot care and knows how to treat diabetic infections. ) Plan - Incision and
Drainage with pulsevac flush 9000 cc with GU irrigation .Cultures
Obtained. Medical Consult. Hospital Admission. Labs to monitor Goal - Limb Salvage Procedure. Stabilize the patient medically. Eliminate Infection through Incision and Drainage procedure and IV antibiotic therapy. ( The best antibiotics in the world are no substitute for an incision and drainage procedure. )
PMH - NIDDM, HTN, Low Back Pain, Gout. PSH - Back surgery, gallbladder removal. Medications - Naproxen, HCTZ, Zestril, Glyburide, Glucophage. Allergies - Penicillin. Objective - Skin Fissure R plantar hallux. Grade 2 Ulcer L foot Sub 2nd / 3rd MPJ. No erythema, No pus noted, No increase warmth to the Left Leg. No sinus tracking noted. X-rays show no signs of Osteomylitis. Assessment - IDDM. Although there are no obvious signs of Cellulitis on exam, he has been on antibiotics x 2 weeks. S/P Cellulitis L foot. Grade 2 ulceration Left foot that will be difficult to heal without surgery. Patient will do well with a modified pan metatarsal head resection L foot. Plan - L Modified ( I leave the 1st MPJ intact ) Pan Metatarsal Head Resection performed under MAC anesthesia. Puslevac Flush with GU antibiotics 6000 cc's. No tourniquet was used. TLS Drain used. I change the dressing the day after surgery secondary bleeding from bone resection. ( The dressing will be soaked in blood following surgery this is normal, but if you do not change the dressing the foot will get all macerated and develop a wound dehiscence or infection.) Goal - By performing the modified pan metatarsal head resection we eliminate the force causing the ulceration. Limb Salvage Procedure. Eliminate Possible Infection. Treating this patient early and aggressively the ulcer heals and we prevent Osteomylitis and possible amputation.
PMH - NIDDM, Chronic Edema, Cataracts, HTN, Anemia, S/P Scarlet Fever, Kidney Disease. Medications - Avandia, Amaryl, Lasix, Levoxil, Avalide. Allergies - Stadol. On exam - Moderate bunion formation B/L. Chronic Grade 1 ulcer plantar medial bunion R foot. Keratoma noted around the ulcer R foot. No sinus tracking noted. Pitting edema 2+ B/L legs and feet. A large skin fissure with hyperkeratotic tissue noted L 1st MPJ. X-rays showed no signs of Osteomylitis. X-rays did show a prominent hallux abducto valgus R foot. Assessment - NIDDM. R Bunion with chronic plantar ulceration. Severe Edema B/L. Severe Skin fissure L 1st MPJ Plan - Surgical correction of the Bunion R foot under Mac anesthesia. The patient healed the ulceration 4 weeks after surgery. Patient developed decreased Plantarflexion Right 1st MPJ and limited range of motion post-operatively. Patient was content that the ulcer went away, but disappointed that she lost mobility after bunion correction. Post op x-rays show good correction of previous bunion Right foot. Consider MRI. Possible Flexor Hallucis Longus Tendon Rupture. Goal - by correcting the deformity, this should take pressure off the ulcer and allow it to heal. Reduce edema post operatively by using a Jones compression dressing x 4 days.
PMH - IDDM x 14 years. PSH - Tonsilectomy. Medications - Insulin. Allergies - NKDA. Objective - painful swollen Left forefoot especially over the Left 4th MPJ area. Slight erythema noted. A small healed entrance wound noted L th MPJ area. No signs of pus. X-rays show no signs of Osteomylitis. Assessment - IDDM. S/P Puncture Wound Left foot x 1 month. Patient needs to have an incision and drainage procedure with IV antibiotic therapy. Plan - Incision and
Drainage procedure performed under MAC anesthesia. Pulse Vac flush with GU
antibiotics. Patient had some retained foreign body ( rubber from tennis
shoe ) in the wound. Patient had a mid line placed in left arm. Patient
was put on 6 weeks of IV antibiotic therapy. Patient got better
immediately after performing the incision and drainage procedure. The
patient recovered with no signs of Osteomylitis and no partial amputation.
Diabetic patients can handle an incision and drainage procedure they can
not tolerate infection and pus. Diabetic puncture wounds need to be
treated quickly, aggressively, and appropriately or the patient can
develop a severe infection, osteomylitis, tissue damage, ulceration and /
or amputation. Do not wait on a diabetic puncture wound, hoping that it
will get better with antibiotics. By performing the incision and drainage
procedure, this will Goal - Limb Salvage.
Prevent Osteomylitis, Tissue Damage, and Possible Amputation. Eliminate
Infection. Patient and physician education on the treatment of diabetic
puncture wounds. PMH - IDDM, Charcot Foot, Peripherial Neuropathy, CAD, HTN, Hypercholesterolemia, Hypothyroid, S/P Cellulitis R foot, Chronic Ulcer R midfoot. PSH - Appendectomy, S/P Achilles tendon lengthening R, S/P R midfoot stabilization, S/P exostectomy R midfoot, S/P I & D, S/P Thyroid sx, S/P Tubal Pregnancy. Medications - Insulin, Norvasc, Glucophage, Diovan, Tricolor, Amitriptyline, Klonopin, Synthroid, Glucotrol. Allergies - Demerol, Talwin. Objective - Ulcer present plantar medial cunieform area. Positive edema and erythema R medial cunieform area. Pus noted. Foul Odor present. Palpable screw noted plantar medial R midfoot. Abducted R forefoot Deformity and R midfoot secondary from previous charcot. No red streaking up foot or leg. R lateral x-ray shows signs of Osteomylitis present with bone destruction R 1st metatarsal mid shaft, 1st MPJ has no signs of Osteomylitis. X-rays also show previous charcot deformities R midfoot and forefoot. Assessment - IDDM. Charcot Foot. Severe R foot Infection with Osteomylitis. Patient is a high risk for a BK amputation. Painful hardware. Plan - Hospital Admission. Medicine Consult. Pre-Op Labs. R foot surgery under MAC anesthesia. Incision and Drainage Procedure with removal of infected bone and painful hardware R. I gave her Vancomycin IV Antibiotics post operatively. ( I removed all the infected bone of the mid shaft of the 1st metatarsal, Incision and Drainage Procedure performed with 9000 cc' s of GU irrigation with the Pluse Vac flush. I made a dorsal and plantar incision to allow drainage of all pus. I removed all the hardware. Used a TLS Drain with new gauze packing. Then I prayed and hoped for the best. ) The patient did great even with removal of most of her 1st metatarsal. The anesthesiologist stated " I didn't think you could get that foot to look so good." She was on 8 weeks on IV antibiotic therapy with Collagenase ointment and daily dressing changes for her ulcer. Goal - Limb Salvage.
Removal of Osteomylitic bone while keeping foot function intact. Patient
is always going to have a deformity from previous charcot changes.
Stabilize the patient medically. The importance of performing
an Incision and Drainage procedure early for diabetic infections can not
be underestimated. The procedure will help stabilize the patient, decrease
the patient's pain, temperature, white blood count, infection, and sed
rate. The incision and drainage will also help reduce hyperglycemia, and
decrease the pathogen microbe count thus allowing the IV antibiotic
therapy to be more effective.
go to Page 1 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
If you have any questions or would like to know more about these surgical techniques please call me at 1-801-825-4709 . |
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