Extreme Limb Salvage Case #1

There are situations where I’m not sure if limb salvage is better than a below the knee amputation. These situations are very complex and patient specific, making it difficult to research, so I can’t offer advice based on research and evidence. In my opinion, as long as there is a possibility that we can save it, no matter how dysfunctional the limb will be, it should be up to the patient to decide on the fate of their limb. I can’t predict who can or cannot walk again. If the patient wants to push the limit of what’s possible with limb salvage and take that leap of faith, I’m happy to be their guide every step of the way.

This is a man with diabetes and arterial disease who recently underwent an angioplasty by vascular surgery to heal his chronic wounds. The wound in front of his ankle became infected, traveling deep into one of the tendons, and started to spread quickly throughout the tendon and into the rest of his foot.

Infection involving the EHL tendon

I took him to the OR and performed a debridement of the infection, removing a large portion of dead skin and tendon.

2 days after debridement

Unfortunately, after a couple days, more pus was found in the remaining tendon, with signs concerning for a slowly progressive necrotizing soft tissue infection. Now that we knew the type of infection we were dealing with, we needed to get much much more aggressive.

Second debridement, now with bones and joints of the first ray exposed.

The infection got into multiple bones and joints, making this an extremely difficult wound to heal. Additionally, the major tendons responsible for dorsiflexing his foot were infected and had to be removed. He would need to wear a brace for the rest of his life. At this point, I’m not sure if it is worth the long recovery and multiple surgeries to save the foot if the end result is a non-functional foot that will need a brace. I let the patient decide what he wants to do, and he wants to try to save the foot.

I put a wound vac on the wound, and he was discharged to a nursing home where the nurses gave him IV antibiotics and did the wound vac changes multiple times a week. I saw him in my office weekly, and took him to the operating room every 2 weeks for debridement. He was also followed closely by our vascular colleagues and needed additional balloons and stents of his arteries to help the wound heal.

After the 5th surgery, the wound was finally looking granular, however with bone still exposed. We needed something to cover the bone, and the wound vac alone might not work, so I used a graft made out of shark cartilage and bovine tendon called Integra (I have no affiliation or financial interest with the company).

On the image above and to the left, there is a silicone layer on top of the Integra graft that keeps the wound sealed and allows it to heal underneath in a sterile environment. A wound vac was placed on top of the graft to keep it in place. After 4 weeks of observation, the silicone layer was removed, and the result was the image to the right, where the graft allowed the granulation tissue to grow into the graft and bridge over the bone. I took him to the operating room the next week for a final surgery, a skin graft.

A month after the skin graft surgery, he was prescribed a brace which a prosthetist made for him. He has not walked in 6 months, but he can do short distances such as from bed to bathroom without crutches. With physical therapy, he will gradually be able to do more. He is grateful to still have a foot and for him it was worth all of the pain and all of the surgeries.

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