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Forum: OWL Lists: OTA:
[ORT-L] charcot foot ????

 
 


jeffrichmondmd at hotmail
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Dec 6, 2007, 9:49 AM

Post #1 of 7 (3048 views)
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[ORT-L] charcot foot ???? Can't Post
 


I know this is not the ideal forum for this, but I'd appreciate any help.....


52 year old obese female in "perfect health" (ie hasn't been to a doctor in 15 years for anything) slipped in the bathroom a few weeks back, and came to an ER 9 days later because of bleeding from her foot. No pain. Finger sticks in excess of 400. Transferred to my institution.

She had an approximately quarter size wound over her midfoot with her medial cuneiform extruded. I washed her out, reduced, perc pinned the cuneiform back in place and placed a limited ex-fix and a VAC to temporize. The wound has become very soupy in the few days since I first washed her out, and the skin has necrosed to about a half-dolalr size. The cuneiform is soft and clearly has to go..... Then what?

Is it worth a plastic procedure to try to cover this defect over beads while the foot is so acutely inflamed, with an attempt at a midfoot fusion down the road or amputation now, and at what level?

Any guidance would be appreciated. Unfortunately, she has fallen into the hands of a trauma surgeon as I can't get a foot surgeon interested.

Thanks

Jeff Richmond
Attachments: KELLER,ELIZABETH_LT FOOT Foot_11-28-07_#1.jpg (125 KB)
  KELLER,ELIZABETH_LT FOOT Foot_11-28-07_#2.jpg (133 KB)
  Picture 003.jpg (830 KB)
  Picture 008.jpg (909 KB)


jjbrooksmd at hotmail
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Dec 6, 2007, 2:36 PM

Post #2 of 7 (3047 views)
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RE: [ORT-L] charcot foot ???? [In reply to] Can't Post
 
Jeff,

What is this lady's vascular status? Have there been any lower extremity vascular studies done? Any evidence of PVD by history or on exam?

Sounds to me like ongoing infection deep in the foot that maybe wasn't reached with your I&D that's exacerbated by lack of blood flow so whatever ABx she's on aren't getting to the site of infection. What do cultures show?

My bet is this lady's heading for a transtibial amputation. I appreciate your sharing this case. Tough one indeed.

Jeff Brooks
Stamford, CT

________________________________
> From: jeffrichmondmd@hotmail.com
> To: ort-l@www2.aaos.org
> Subject: [ORT-L] charcot foot ????
> Date: Thu, 6 Dec 2007 12:49:59 -0500
>
>
> I know this is not the ideal forum for this, but I'd appreciate any help.....
>
>
> 52 year old obese female in "perfect health" (ie hasn't been to a doctor in 15 years for anything) slipped in the bathroom a few weeks back, and came to an ER 9 days later because of bleeding from her foot. No pain. Finger sticks in excess of 400. Transferred to my institution.
>
> She had an approximately quarter size wound over her midfoot with her medial cuneiform extruded. I washed her out, reduced, perc pinned the cuneiform back in place and placed a limited ex-fix and a VAC to temporize. The wound has become very soupy in the few days since I first washed her out, and the skin has necrosed to about a half-dolalr size. The cuneiform is soft and clearly has to go..... Then what?
>
> Is it worth a plastic procedure to try to cover this defect over beads while the foot is so acutely inflamed, with an attempt at a midfoot fusion down the road or amputation now, and at what level?
>
>
> Any guidance would be appreciated. Unfortunately, she has fallen into the hands of a trauma surgeon as I can't get a foot surgeon interested.
>
> Thanks
>
> Jeff Richmond

_________________________________________________________________
Put your friends on the big screen with Windows Vista® + Windows Live™.
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jeffrichmondmd at hotmail
New User

Dec 6, 2007, 3:08 PM

Post #3 of 7 (3047 views)
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RE: [ORT-L] charcot foot ???? [In reply to] Can't Post
ACtually she has palpable pulses and an angiogram shows reasonable flow into the foot. Cultures at the initial I&D are positive only for skin flora, but from the odor and look I am sure there is more growing now.

> From: jjbrooksmd@hotmail.com> To: ort-l@www2.aaos.org> Subject: RE: [ORT-L] charcot foot ????> Date: Thu, 6 Dec 2007 17:36:10 -0500> > > Jeff,> > What is this lady's vascular status? Have there been any lower extremity vascular studies done? Any evidence of PVD by history or on exam?> > Sounds to me like ongoing infection deep in the foot that maybe wasn't reached with your I&D that's exacerbated by lack of blood flow so whatever ABx she's on aren't getting to the site of infection. What do cultures show?> > My bet is this lady's heading for a transtibial amputation. I appreciate your sharing this case. Tough one indeed.> > Jeff Brooks> Stamford, CT> > ________________________________> > From: jeffrichmondmd@hotmail.com> > To: ort-l@www2.aaos.org> > Subject: [ORT-L] charcot foot ????> > Date: Thu, 6 Dec 2007 12:49:59 -0500> > > > > > I know this is not the ideal forum for this, but I'd appreciate any help.....> > > > > > 52 year old obese female in "perfect health" (ie hasn't been to a doctor in 15 years for anything) slipped in the bathroom a few weeks back, and came to an ER 9 days later because of bleeding from her foot. No pain. Finger sticks in excess of 400. Transferred to my institution.> > > > She had an approximately quarter size wound over her midfoot with her medial cuneiform extruded. I washed her out, reduced, perc pinned the cuneiform back in place and placed a limited ex-fix and a VAC to temporize. The wound has become very soupy in the few days since I first washed her out, and the skin has necrosed to about a half-dolalr size. The cuneiform is soft and clearly has to go..... Then what?> > > > Is it worth a plastic procedure to try to cover this defect over beads while the foot is so acutely inflamed, with an attempt at a midfoot fusion down the road or amputation now, and at what level?> > > > > > Any guidance would be appreciated. Unfortunately, she has fallen into the hands of a trauma surgeon as I can't get a foot surgeon interested.> > > > Thanks> > > > Jeff Richmond> > _________________________________________________________________> Put your friends on the big screen with Windows Vista® + Windows Live™.> http://www.microsoft.com/windows/shop/specialoffers.mspx?ocid=TXT_TAGLM_CPC_MediaCtr_bigscreen_102007---> [This E-mail scanned for viruses by Declude Virus]>


FCyran at mednet
New User

Dec 6, 2007, 3:14 PM

Post #4 of 7 (3047 views)
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RE: [ORT-L] charcot foot ???? [In reply to] Can't Post
She needs a MRI so see the extent of the osteomyelitis in her mid/hind foot. It is unlikely that a diabetic with neuropathy with resolve the infection. She will ultimately will wind up with either a Symes or BKA IF the infection isn't limited to that bone. A poorly done BKA will have less problems than an ok Symes.

Diabetes is more of a small vessel disease so we're not surprised at the palpable pulses. A palpable PT pulse is required for a Symes though. If you do a Symes, I'd recommend casting her for 6-8 weeks afterwards to allow the heel fat pad to really get anchored down to the distal tibia.

F. Cyran
Musculoskeletal Oncology, U.C.L.A

-----Original Message-----
From: ORT-L-owner@www2.aaos.org [mailto:ORT-L-owner@www2.aaos.org]On Behalf Of Jeff Richmond
Sent: Thursday, December 06, 2007 9:50 AM
To: ort-l@www2.aaos.org
Subject: [ORT-L] charcot foot ????




I know this is not the ideal forum for this, but I'd appreciate any help.....


52 year old obese female in "perfect health" (ie hasn't been to a doctor in 15 years for anything) slipped in the bathroom a few weeks back, and came to an ER 9 days later because of bleeding from her foot. No pain. Finger sticks in excess of 400. Transferred to my institution.

She had an approximately quarter size wound over her midfoot with her medial cuneiform extruded. I washed her out, reduced, perc pinned the cuneiform back in place and placed a limited ex-fix and a VAC to temporize. The wound has become very soupy in the few days since I first washed her out, and the skin has necrosed to about a half-dolalr size. The cuneiform is soft and clearly has to go..... Then what?

Is it worth a plastic procedure to try to cover this defect over beads while the foot is so acutely inflamed, with an attempt at a midfoot fusion down the road or amputation now, and at what level?


Any guidance would be appreciated. Unfortunately, she has fallen into the hands of a trauma surgeon as I can't get a foot surgeon interested.

Thanks

Jeff Richmond


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wdburman at frontiernet
New User

Dec 6, 2007, 7:10 PM

Post #5 of 7 (3046 views)
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Re: [ORT-L] charcot foot ???? [In reply to] Can't Post
>>>The cuneiform is soft and clearly has to go..... Then what?

Since you are ready to take your chances in a non ideal forum...
How about, after medial cuneiformectomy & wound debridement, another
try with the wound vac
http://www.thelancet.com/journals/lancet/article/PIIS0140673605676957/abstract

or

loosely packed resorbable antibiotic beads
http://www.podiatrytoday.com/article/2010

If that works - a total contact cast followed by a CROW (charcot
restraint orthotic walker) (Fig 7 & 8)
http://www.aafp.org/afp/20011101/1591.html
to see if the ulcer/wound can heal and if the midfoot can consolidate.

If the excised medial cuneiform is any good, I wonder if it could be
adequately disinfected and saved as autograft - in case a midfoot
fusion is needed.

Bill Burman, MD
HWB Foundation
http://www.hwbf.org


>I know this is not the ideal forum for this, but I'd appreciate any help.....
>
>52 year old obese female in "perfect health" (ie hasn't been to a
>doctor in 15 years for anything) slipped in the bathroom a few weeks
>back, and came to an ER 9 days later because of bleeding from her
>foot. No pain. Finger sticks in excess of 400. Transferred to my
>institution.
>
>She had an approximately quarter size wound over her midfoot with
>her medial cuneiform extruded. I washed her out, reduced, perc
>pinned the cuneiform back in place and placed a limited ex-fix and a
>VAC to temporize. The wound has become very soupy in the few days
>since I first washed her out, and the skin has necrosed to about a
>half-dolalr size. The cuneiform is soft and clearly has to go.....
>Then what?
>
>Is it worth a plastic procedure to try to cover this defect over
>beads while the foot is so acutely inflamed, with an attempt at a
>midfoot fusion down the road or amputation now, and at what level?
>
>
>Any guidance would be appreciated. Unfortunately, she has fallen
>into the hands of a trauma surgeon as I can't get a foot surgeon
>interested.
>
>Thanks
>
>Jeff Richmond
>
---
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Gary.Jones at concordortho
New User

Dec 7, 2007, 6:10 AM

Post #6 of 7 (3038 views)
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Re: [ORT-L] charcot foot ???? [In reply to] Can't Post
Jeff, I do foot surgery and trauma. First comment: If you foot surgeons aren't interested in this your institution has a problem. This is their "acetabular fx".
There is the slow approach or the quick approach. You can save a foot like this sometimes. Take out the cuneiform, aggressively treat the infection (ID involved, surgical debridement, VAC dressing, leave the ext fix for a time). Once the infection is solved, she needs a total contact clamshell orthosis (short leg). I ususally keep her NWB for 3-6 months until the inflammation has clearly quieted down. Then another 6 months FWB in the orthosis. She is at risk for Charcot changes at another level in the foot.

The quick way (I would involve her in the decision making) is an open amputation. I think a Chopart's level amp is possible with a VAC dressing, and leaving enough flaps to close at 5-7 days. Symes amp would be the next level.

Richmond <jeffrichmondmd@hotmail.com> 12/6/2007 12:49 PM >>>

I know this is not the ideal forum for this, but I'd appreciate any help.....


52 year old obese female in "perfect health" (ie hasn't been to a doctor in 15 years for anything) slipped in the bathroom a few weeks back, and came to an ER 9 days later because of bleeding from her foot. No pain. Finger sticks in excess of 400. Transferred to my institution.

She had an approximately quarter size wound over her midfoot with her medial cuneiform extruded. I washed her out, reduced, perc pinned the cuneiform back in place and placed a limited ex-fix and a VAC to temporize. The wound has become very soupy in the few days since I first washed her out, and the skin has necrosed to about a half-dolalr size. The cuneiform is soft and clearly has to go..... Then what?

Is it worth a plastic procedure to try to cover this defect over beads while the foot is so acutely inflamed, with an attempt at a midfoot fusion down the road or amputation now, and at what level?


Any guidance would be appreciated. Unfortunately, she has fallen into the hands of a trauma surgeon as I can't get a foot surgeon interested.

Thanks

Jeff Richmond

Gary S. Jones, M.D.
Concord Orthopaedics, P.A.
gary.jones@concordortho.com
Physician Coordinator: Nancy Shurtleff
Direct dial (603) 724-2337
FAX: 603 228-7268
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aobonedoc at comcast
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Dec 8, 2007, 5:37 PM

Post #7 of 7 (2968 views)
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Re: [ORT-L] charcot foot ???? [In reply to] Can't Post
Hello,

The plain xrays show abnormality in both the navicular and the medial aspect of the proximal portion of the first metatarsal: infection vs neuropathic change.

One could widely resect the infected bone which probably will allow the soft tissue to close. Maybe with a few months on nonweigh bearing the Charcot would collapse down stable. Overall a longshot and even if successful would require custom shoe use with double upright bracing along the tibia.

In the long term I think she most likely to have an amputation.

--
Sincerely and respectfully,



M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
1100 W. Central Road, Suite 304
Arlington Heights, Illinois 60005
(phone) 847-394-5650
(fax) 847-394-5699
(email) AOBoneDoc@comcast.net
www.AOBoneDoc.com

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-------------- Original message --------------
From: Jeff Richmond <jeffrichmondmd@hotmail.com>


I know this is not the ideal forum for this, but I'd appreciate any help.....


52 year old obese female in "perfect health" (ie hasn't been to a doctor in 15 years for anything) slipped in the bathroom a few weeks back, and came to an ER 9 days later because of bleeding from her foot. No pain. Finger sticks in excess of 400. Transferred to my institution.

She had an approximately quarter size wound over her midfoot with her medial cuneiform extruded. I washed her out, reduced, perc pinned the cuneiform back in place and placed a limited ex-fix and a VAC to temporize. The wound has become very soupy in the few days since I first washed her out, and the skin has necrosed to about a half-dolalr size. The cuneiform is soft and clearly has to go..... Then what?

Is it worth a plastic procedure to try to cover this defect over beads while the foot is so acutely inflamed, with an attempt at a midfoot fusion down the road or amputation now, and at what level?


Any guidance would be appreciated. Unfortunately, she has fallen into the hands of a trauma surgeon as I can't get a foot surgeon interested.

Thanks

Jeff Richmond
Attachments: KELLER,ELIZABETH_LT FOOT Foot_11-28-07_#1.jpg (125 KB)
  KELLER,ELIZABETH_LT FOOT Foot_11-28-07_#2.jpg (133 KB)
  Picture 003.jpg (830 KB)
  Picture 008.jpg (909 KB)

 
 
 


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