mid foot amputations torbay 2009

Midfoot Surgery in Diabetic Osteomyelitis

Authors :Paisey RB,Davis J, McCarthy R, Gornall R, Fadl, A

Institution Torbay hospital, South Devon Healthcare foundation Trust, Torquay, TQ2 7AA

Introduction

Background: Diabetic peripheral neuropathy and neuroischaemia are often complicated by foot infection with osteomyelitis. Prolonged antibiotic therapy can be curative, but ray excision, or leg amputation are frequently necessary, leading to an unbalanced foot , abnormal gait and foot pressures or need for prosthesis respectively. Co morbidities including cardiovascular disease, nephropathy, psychiatric and social problems all present challenges to successful outcome in terms of prompt rehabilitation with good long term mobility. Mid foot surgery to eradicate osteomyelitis can result in a good functional limb with broad area for weight bearing and rapid rehabilitation potential. Eight patients from the Torbay Hospital multidisciplinary foot clinic were offered mid foot surgery between Jan 2005 and December 2007.

Patients

Ninety five subjects with diabetes were reviewed in the foot clinic over the 3 year period, 40 with osteomyelitis, of whom 8 had metatarsal infection not responsive to clindamycin, or rifampicin and minocycline. They consented to undergo foot surgery.

Patient Characteristics

-8 patients-7 males,1 female-5 type2 DM,3 type1 DM-Duration of DM range 8-26 years, mean of

20 years-Age range 45-80 years, mean of 62.5 years

Comorbidities

6 nephropathy one haemodialysis

6 retinopathy

4 hypertension

3 hypercholesterolemia despite statin

1 Previous stroke

1 morbid obesity

1 myocardial infarction 3 ischaemic heart disease

2 previous Charcot joints

Ulcer Features

• Texas wound score:-2 patients had 3B

-6 patients had 3D

• Ulcer nature:-2 neuropathic

-3 ischaemic

-3 neuroischaemic

Infection

• All patients had preoperative osteomyelitis

• 5 patients had postoperative osteomyelitis

• All treated with long term antibiotics

• 2 developed Charcot changes after surgery

• Surgery aimed to excise all infected bone and preserve insertion of anterior tibial muscle.

Pre operative • 3 patients had contralateral right below

knee amputation

• 1 patient had contralateral left above knee amputation

• 6 had ipsilateral Angioplasty

• 3 had previous toe amputation

• 2 had hyperbaric oxygen treatment

17 months preoperative Pt 1

16 months preoperative Pt 1

Preoperative Pt 1

Post-op weight bearing Pt 1

Postop-weight bearing Pt 2

Sitting Pt 3

1 y post amputation Pt 4

Follow up

• 6 had right MTA• 2 had left MTA• 3 have > 2yrs follow up• 5 have 10-12 months follow up• 2 had recurrent ulcers• 1 proceeded to BKA after one week,

another after 10 months.• 4 required bespoke footwear

Current Mobility

• 4 walk unaided

• 4 walk with the aid of sticks and/or support

• 1 drives a normal car

• 1 able to drive an adapted car and transfer only

Conclusion

Midfoot amputation even in complicated subjects with intractable diabetic foot infection has resulted in good mobility for up to 3years in 8 subjects.

MRI scan in all cases preoperatively may have identified the two with early recurrence and subsequent BKA.