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Poster session 7: Surgery
P7.01
Major amputation in a diabetic foot clinic: An assessment of outcomes
Dane Wukich, UPMC Mercy, Pittsburgh, PA, United States
Aim: To evaluate the outcomes of diabetic patients who underwent transtibial amputation
(TTA). Methods: Self-reported outcome was assessed using the SF 36 and the Foot and
Ankle Ability Measurement (FAAM). The study group included 31 diabetic patients who
underwent a TTA (minimum follow up of 52 weeks) and completed both the SF-36 and
FAAM preoperatively and postoperatively.
Results: At a mean follow up of 141 weeks, significant improvement occurred in all eight
subscales of the SF 36, SF-36 Physical Component Summary Score, SF-36 Mental
Component Score, FAAM ADL and FAAM Sports scores. 26 of 31 patients (84%) were
ambulatory with a prosthesis at the most recent follow up and none of the patients required
an unplanned contralateral TTA. One patient underwent staged bilateral TTA for bilateral
diabetic foot disease. Of the 30 patients with unilateral TTA, nine (30%) developed foot
wounds on the contralateral foot. Six of the 31 patients (19.3%) developed a wound on their
residual limb during the follow up period. 30 of 31 patients (97%) were alive at the most
recent follow up. One patient with end stage renal disease died 3 years after TTA.
Conclusion: Diabetic patients who underwent TTA reported improvement in physical and
mental quality of life (QOL) using a generic measure of overall health and region specific
measure of lower extremity function (FAAM). Although major amputation is a devastating
complication, this study demonstrates that in selected cases, TTA may offer the opportunity
for improved QOL in diabetic patients with non-reconstructable deformities. No patient
required a contralateral TTA, however 30% developed a wound on the contralateral foot.
Patient survival was high (97%). Properly performed TTA is a useful procedure for diabetic
limb salvage surgeons.
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Page 1 of 8
P7.02
The role of Modified Pirogoff’s Amputation in treating diabetic foot infections
Nather Aziz, National University Hospital, Singapore, Singapore
Keng Lin Wong, National University Hospital, Singapore, Singapore
Shumin Amaris Lim, National University Hospital, Singapore, Singapore
Zhaowen Dennis Ng, National University Hospital, Singapore, Singapore
Hwee Weng Dennis Hey, National University Hospital, Singapore, Singapore
Aim: To evaluate the results of Modified Pirogoff Amputation in the treatment of diabetic foot
infections.
Methods: Six patients with diabetic foot infections were operated on by the National
University Hospital (NUH) diabetic foot team in Singapore between November 2011 and
January 2012. All patients underwent a Modified Pirogoff ’s Amputation for diabetic foot
infections. All the operations were performed by the senior author (A Nather)
Inclusion criteria included the presence of a palpable posterior tibial pulse, ankle brachial
index (ABI) of more than 0.7, and distal infections not extending proximally beyond the
midfoot level. Clinical parameters such as presence of pulses and ABI were recorded.
Preoperative blood tests performed included a glycated hemoglobin level, hemoglobin, total
white blood cell count, C-reactive protein, erythrocyte sedimentation rate, albumin, and
creatinine levels. All patients were subjected to 14 sessions of hyperbaric oxygen therapy
postoperatively and were followed up for a minimum of 10 months. The surgical technique
adopted by the senior author was described and illustrated
Results: All six patients had good wound healing. Tibio-calcaneal arthrodesis of the stump
was achieved in all cases by 6 months postoperatively. All patients were able to walk with
the prosthesis.
Conclusions: The Modified Pirogoff ’s Amputation has been found to show good results in
carefully selected patients with diabetic foot infections. The selection criteria included a
palpable posterior tibial pulse, distal infections not extending proximally beyond the midfoot
level, ABI of more than 0.7, hemoglobin level of more than 10 g/dL, and serum albumin level
of more than 30 g/L.
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Page 2 of 8
P7.03
Surgical diabetic foot debridement: Improving training and practice using traffic light
principle
Raju Ahluwalia, Kings College Hospital, London, United Kingdom
Sinthujah Francis, Kings College Hospital, London, United Kingdom
Jennifer Tremlett, Kings Colllege Hospital, London, United Kingdom
Victoria Morris, Kings College Hospital, London, United Kingdom
Prashant Vas, Kings College Hospital, London, United Kingdom
Micheal Edmonds, Kings College Hospital, London, United Kingdom
Surgical debridement is an integral part of the management of diabetic foot infections. Acute
debridement is perceived as a straightforward yet challenging task usually undertaken by
'oncall' trainee surgical staff., Importantly, we observed a high number of patients require a
second surgical-debridement to complete eradication of infection. This study aims to assess
the adequacy of debridement and the effectiveness of a common training program, using a
novel yet simple tool - the traffic light, model in diabetic foot debridement.
We reviewed all non-ischaemic diabetic foot debridements, undertaken by, our orthopaedic
team i from October 2013 until September 2014.From October 2013 to June 2014,
conventional debridement, was carried out but from July 2014, we used the, Red Amber
Green, traffic light, model of debridement. This involves novel assessment, to aid the extent,
of debridement by, the marking of necrotic tissue (red zone), followed by the area of
granulation (amber) and then healthy tissue (green), All infected feet were reviewed by the
senior surgeon and marked Red Amber Green, and debridements, were undertaken by
orthopaedic trainees. We compared surgical outcome measures - length of stay, wound
closure and need for repeat debridement at 14 days before and after introduction of this
model.
In the first period (Oct 2013 to June 2014) 48 debridements were undertaken. Within this
group 16 (33%) repeat debridements were required; 10 required a further procedure
conducted within 14 days followed by definitive surgery at 23.4 days (17-31 days). Two
cases required further ray amputation.. In the second period (July to September 2014), 17
patients underwent debridement using the Red Amber Green, tool. Only 1 patient (6%, )
returned to theatre for further debridement due to infection within 14 days (at day 5). As a
consequence the length of stay was 8.2 days less than in, the first group.
We demonstrate that adopting the Red Amber Green tool, the challenge of acute foot
debridement can be simplified for the inexperienced trainee, in managing the acute footattack requiring surgical debridement. It has the additional benefit of better infection
clearance and reducing the need for further debridements and length of stay.
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Page 3 of 8
P7.05
First experience of the foot stump lengthening in diabetic patients
Roberto De Giglio, Azienda Ospedaliera Legnano, Abbiategrasso, Italy
Alexander Kirienko, Humanitas Clinic Institute, Rozzano, Italy
Aim: In Chopart-level amputations the heel often deviates into equinus and varus, anterior
and lateral wound dehiscence and ulceration may occur requiring higher-level amputation.
The aim was demonstrate that distraction lengthening of the stump rebalancing leverage
arms of the hind and forefoot, correct equinus and prevent ulceration ( Fig.1).
Fig. 1 Principle of foot stump lengthening.
Method: Three patient with short foot stump were treated with percutaneous osteotomy of
the anterior part of the calcaneus and neck of the talus, application of circular external
fixation and progressive, distraction 1 mm per day started in the third day. Percutaneous
Achilles tendon lengthening were added as needed in two cases. In the beginning,
longitudinal distraction for anterior lengthening was done, than the correction of equinus with
the same frame and patients start partial weight bearing. After bony consolidation a total
contact cast for 4 weeks.
Results: The It was achieved lengthening in mean 25 mm. Mean time of consolidation
period was 65 days. The average age of the 1 women and 2 men was 51.9 years (range, 4362). Postoperative complications included minor wound healing problems in 3 patients, wires
breakage in one, wound breakdown requiring revision in 1. All three patient had successful
soft tissue healing and new bone formation. The mean AmpuPro score was 108 points (of
120), and the mean Prosthesis Evaluation Questionnaire scale was 144 points (of 200).
Conclusions: This technique with the use of the Circular external fixator could be a salvage
solution to the problems that often exist with postoperative Chopart stump.
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Page 4 of 8
P7.06
The choice of organ-sparing surgical method in patients with surgical complications
of the neuropathic form of the diabetic foot syndrome
Vladimir Obolenskiy, City Hospital #13, RNRMU, Moscow, Russia
Victor Protsko, City Hospital #79, RUFP, Moscow, Russia
Elena Komelyagina, Endocrinology Clinic of the DHM, Moscow, Russia
Aim: to present a review and to estimate the prospects of using organ-sparing surgical
methods in the treatment of patients with surgical complications of the neuropathic form of
the diabetic foot syndrome (SC NF DFS).
Materials and methods: 1) For the purpose of stimulation of regeneration after wound
debridement in patients with stage 1 – 2 neuropathic trophic ulcers (according to Wagner's
classification), we use applications of flat clots of platelet-rich autologous conditioned
plasma. 2) In patients with stage 2 neuropathic ulcers caused by deformation of the anterior
foot bones, we employ corrective mini-osteotomy. 3) For stage 3 associated with destruction
of the metatarsal bones and the metatarsophalangeal joints, we perform resection of the
affected bones, subsequently filling the defects with a collagen sponge, impregnated with an
antibiotic*), and then closing the wound with primary suture.
For patients with Charcot foot syndrome following resection of the affected bones: 4) we fill
the defect with a collagen sponge, impregnated with an antibiotic, and then close the wound
with primary suture; 5) or stabilize the mid-foot using compressive screws; 6) or use
extrafocal corrective osteosynthesis using Ilizarov’s method. 7) If saving the foot is
unfeasible, we amputate using Pirogov’s technique and osteosynthesis using Ilizarov’s
method.
Results: No recurrence of trophic ulcers or osteomyelitis of the foot bones was observed
during a 1.5-year follow-up in any of the patients treated according to Options 1 – 4 and 7.
There was one case of septic instability of a compressive screw after more than one month
in the Option 5 group, the screw was then removed. In the Option 6 group, there was one
case of an unstable bone fragment; its removal, was necessary.
Conclusions: The described methods appear promising in the treatment of patients with SC
NF DFS; their effectiveness may be assessed after randomized trials are completed.
*) Collatamp EG, EUSA
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Page 5 of 8
P7.07
Chronic heel ulceration caused by penetrating trauma treated with staged surgical
approach and external fixator offloading: A case report
Tiffany Hoh, MedStar Washington Hospital Center, Arlington, VA, United States
John Steinberg, MedStar Georgetown University Hospital, Washington, DC, United States
Katherine Raspovic, MedStar Georgetown University Hospital, Washington, DC, United
States
Aim: Chronic diabetic heel ulcers are difficult to treat with the risk of higher-level amputation
and limb loss. This is a unique case study utilizing an Ilizarov external fixator for aggressive
offloading of a chronic heel ulcer caused by puncture wound and staged surgical approach.
Methods: A case report of a 54 year old male with history of uncontrolled diabetes
presented with a right heel ulcer as a result of stepping on a nail. Patient initially presented
to an outside hospital for removal of nail and local wound care. He later presented to our
emergency room with cellulitis and chronic heel ulceration. The patient was initially treated
by conservative therapy with no improvements. Upon our initial evaluation, patient was taken
to the operative room for several surgical debridements and application of negative pressure
wound therapy. Later he underwent aggressive offloading with an Ilizarov external fixator
and ultimately application of split thickness skin graft.,
Results: The patient healed at 8 weeks status post split thickness skin graft. At the last
follow up, the ulcer was epithelialized and the patient was ambulatory with a satisfactory
result.
Conclusions: This case study is an example of limb salvage of a patient with uncontrolled
diabetes presenting with chronic heel ulceration as a result of a traumatic injury with staged
surgical debridement, aggressive offloading with external fixator, and ultimately split
thickness skin graft application.
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Page 6 of 8
P7.09
Surgical off-loading for diabetic patients with ESRD and PAD in Japan
Mamoru Kikuchi, Saga University Hospital, Saga, saga, Japan
Tetsuji Uemura, Saga University Hospital, Saga, Japan
Aim: Japanese patients with diabetes mellitus (DM) tend to weigh less than their
counterparts in Western countries, and a higher proportion present with end-stage renal
disease (ESRD). Patients with DM and ESRD have severe calcification of the blood vessels,
resulting in a high incidence of peripheral artery disease (PAD). Basic off-loading and foot
care, in addition to the necessary revascularization is not sufficient for adequate protection of
their feet, and further aggressive prevention such as surgical off-loading to correct podiatric
deformation becomes necessary.
Methods: Study subjects included 30 patients of Saga University Hospital and associated
institutions whose foot deformities had developed to the ulceration. All patients had been
treated with surgical off-loading to address this issue.
Results: Satisfactory wound healing was achieved in all cases, with no recurrence.
Conclusion:
The following are general tips regarding this procedure.
1) TcPO2 or skin perfusion pressure (SPP) values >50 mmHg close to the affected area
were required to perform surgery.
2) When performing in combination with revascularization, the results of the latter should be
discussed thoroughly with the physician performing the revascularization. If sufficient dilation
has been achieved, SPP should be checked immediately to confirm that it has improved to ≥
50 mmHg prior to performing surgery. Considering the risk of reocclusion of the blood
vessels, the time between the revascularization and the surgery should be minimized.
3) The surgery should aim primarily to achieve as much simplicity as possible as well as
ensure that blood flow will not be disturbed.
In contrast to Westerners, Japanese do not wear their shoes inside the house, and thus
comprise an entirely different patient group that is more difficult to treat by footwear offloading. As such, the most promising approach would likely be the most aggressive and
invasive prevention method, which is surgical off-loading. Unfortunately, patients with
DM/ESRD/PAD have a high occurrence of complications during surgery, and treatment is
extremely challenging. For patients in Asian countries, a diabetes foot ulcer prevention
strategy that differs from that of Western countries needs to be established.
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Page 7 of 8
P7.10
How much can you guarantee the survival rate of free flap in diabetic foot ulcer
patients with end-stage renal disease?
Donghyeok Shin, Konkuk University Medical Center, Seoul, Korea, South
Wonchul Choi, Konkuk University Medical Center, Seoul, Korea, South
Aim: Advances of free tissue transfer have provided good results on limb salvage of
threatened diabetic foot ulcer (DFU). But patients with end-stage renal disease (ESRD) are a
challenging group of patients when considering microvascular free flap salvage of the
diabetic foot because uremia inhibit infection control and wound healing. Moreover,
anticoagulation used in dialysis can cause post operation bleeding and hematoma formation.
Reviewing the results of free flap surgery on diabetic foot patients with end-stage renal
disease, we tried to evaluate how ESRD affects the result of free tissue transfer.
Methods: From July 2009 to June 2014, a retrospective review of 15 free flap surgeries was
made in 14 DFU with ESRD patients in Konkuk University Medical Center, Korea. All
patients were on hemodialysis. Precise preoperative evaluations were performed, including
endocrinology, nephrology, and, cardiovascular system. Before free flap surgery, adequate
debridement was performed until viable tissue was attained. Strict infection control had been
done with antibiotics which could cover the serial culture results. The flap survival rate,
various post-operative complications were evaluated.
Results: Of the total 14 patients, 11 patients had undergone percutaneous angioplasty.
There were one case of total flap loss, and two cases of partial flap loss. In which cases split
thickness skin graft was required. The total flap survival rate was 93 percent. There was no
major limb amputation and the limb salvage rate has been 100 percent. One of the major
postoperative complications was wound dehiscence that needed to perform delayed primary
closure. There was one follow up loss and the average length of follow up was 15 months.
Conclusion: Combination of end-stage renal disease and diabetes mellitus have led
surgeon to avoid aggressive wound care like free flap surgery because of poor medical
condition of patients and impaired wound healing. Some authors recommend immediate
amputation when treating the threatened limb of diabetic foot patients with end-stage renal
disease. However, we could get the similar results comparing to healthy patients, so we
think we don’t need to hesitate doing free flap for patients with end-stage renal disease.
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