case presentation: chronic plantar foot...
TRANSCRIPT
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Case Presentation: Chronic Plantar Foot Ulcer
Joseph L Fiorito DPM University of Washington
Dept. of Orthopaedics and Sports Medicine
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DISCLOSUREJoseph Fiorito
• No relevant financial relationship reported
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Chronic Diabetic Foot Ulcer • Neuropathic Diabetic Male
– No history of Peripheral Vascular Disease • New Ulcer Sub 1st met head
– Caused by ill fitted cast• Duration 1 year
• Treatment:– Not taking abx– Dry dressing– Offloading removable boot ( does not use ) – MRI last visit ( concern for osteomyelitis )
• Initial Presentation to my clinic– Second opinion regarding surgery and the need for a TMA
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Physical Exam
Dermatological Plantar L Foot Ulcer • Full thickness ulcer sub 1st
metatarsal head – 2 x 1.6cm – Depth 1cm – to bone
• No signs of skin infection
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Physical Exam
Plantar Flexed Met Head Gastroc EquinusDorsiflexion Contracture of MPJ
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MRI
Probe
To
Bone
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What Can We Do?
• Treatment Options??• Surgical vs Non Surgical– Does The Patient Need a TMA?– Does The Patient Need Antibiotics?
• Plan:– Combined Conservative and Surgical• Total Contact Cast x 2 weeks
– Prior to surgery
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Total Contact Cast
Initial Exam 1 week later- 50% reduction in size
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Surgical Plan• Osteomyelitis– Remove the tibial sesamoid bone• Also is an offloading technique
• Deformity– Equinus• Gastroc Recession
– Plantar Flexed 1st Ray• Tenotomy of the Peroneal longus tendon • Extensor Tendon lengthening.
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Gastrocnemius Equinus
Incision Placement Gastroc Recession • Cut the gastrocnemius
aponeurosis to allow for the foot to dorsiflex– Limit Forefoot Pressure.
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Gastroc Recession
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Gastrocnemius RecessionFoot Plantar flexed with Knee Extended
Foot Dorsiflexed with the kneed Extended
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Osteomylitis
Excision of Tibial Sesamoid• Remove infected bone as
well as reduce plantar pressure underlying the ulceration.
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Release of MPJ Contracture
Extensor Tendon Lenghtening• To reduce the dorsiflexion
of the hallux which is causing retrograde pressure to the metatarsal.
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Final Shot
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Post-Op Protocol• Weight bearing as tolerated in a diabetic
offloading boot – Until suture removal
• TCC weekly until healed – Transition into molded inserts and shoes
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One Week Post-OPNo plantar flexion of the metatarsal head Digit not dorsally contracted
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Post Op
2 weeks 2 years
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Thank You