RI Clinical Case of the Month
Outcome and Your Thoughts

Thanks to all of you for the great responses to last week’s case. Below is a brief summary of the patient outcome along with radiographs. I have also included several of your replies and suggestions.

PATIENT OUTCOME

Essentially the patient was taken to the OR for debridement and hardware removal followed by ID consult for IV antibiotic management. Deep soft tissue cultures confirmed staphylococcus aureus and enterobacter cloacae but no evident osteomyelitis. The local care was acetic acid packing initially followed by VAC dressing on POD #1. At POD #6 the wound was granular and showing excellent progress, so a return trip was made to the OR for re-fixation of the 1st and 2nd metatarsals. You can see that internal as well as supplemental external fixation was used for the 1st ray due to the instability of that fragment. The original dorsal abscess site of the 2nd ray was left open with Integra bioengineered alternative tissue and VAC dressing upon d/c home at POD #8. A repeat outpatient debridement, revision of fixation, and repeat Integra was performed at POD #21 with continuation of the VAC. At POD#38, a repeat wound debridement of the 2nd ray and application of Apligraf bioengineered alternative tissue was performed and VAC continued. The site was completely closed and healed at approximately 2.5 months post op. It should also be noted on the final x-rays that 2 of the proximal external fixation pins broke off in the bone due to patient ambulation.

Here are the radiographs:

Here are some reader comments:

What a train wreck! I would admit for IV abx, get an ID consult to evaluate the patient, culture any drainage that presents itself, make the patient NWB, and schedule her for an I&D with removal of hardware (both the screws, the cerclage, and the remaining k-wire). Following that, Imaging such as MRI might be helpful to evaluate for possible osteo (considering the possibility of several week duration soft tissue infection). Assuming no OM, and once you got the infection under control, i would try to re-fixate the 1st met, possibly with a mini-rail fixator or with more traditional AO ORIF. If there is adequate remaining bone stock at the akin and the 2nd met osteotomies, both would benefit from fixation, and i would use screws to stabilize these locations. For the second toe, i would remove more of the proximal phalanx and transition the arthrodesis to an PIPJ arthroplasty. Following this definite correction, i would make the patient NWB for 6-8 weeks until the first met osteotomy site was healed.

Ryan Fitzgerald, PGY-I
Podiatric Surgery
Washington Hospital Center

First, you need to determine if there is truly an infectious process going on in the 2nd MTPJ. If so, the hardware needs to be removed and the wound opened, flushed and allowed to drain for 2-3 days with the patient on IV antibiotics.

Once the wound has been cleaned and there is no evidence of further infection, I would reduce the second metatarsal osteotomy and fixate it with a 2-0 cannulated screw. Another option is to throw a k-wire (I would use a 0.062 guage) through the digit, across the MPJ and across the osteotomy to fixate it. Close the wound in layers.

Focusing on the 1st metatarsal, my guess is that the screws were not long enough when they were first thrown. If I had to guess, I would say that the screws used were 3-0 screws. After cleaning up the edges of the osteotomy and establishing some good bone bleeding, I would focus on re-fixation of the osteotomy. Your choices here are to try to replace these with adequate-length 4-0 cannulated screws (assuming the bone stock is adequate). The other option is to put compression staples across the osteotomy. Again, close in layers. The akin actually looks like it is in good apposition. I would leave this alone.

Once the procedure is complete, BK cast (you can bi-valve it for swelling purposes) and, if the patient is not steady enough on crutches, then a walker would be a better choice. I would also try to get an external bone stimulator. There was little evidence of bony healing occurring after 3 weeks and I think a bone stimulator would be a reasonable modality to try to move along the healing process. I would also continue the patient on 10 days to 2 weeks of oral antibiotic post-operatively. If no allergy to quinolones, Cipro should be included in the regimen.

Heather Kaufman, DPM
kaufmandoc@yahoo.com

I would remove all hardware, realign and re-fixate with plates and screws for the 1st met and hallux. pull pin from 2nd toe, revise arthroplasty and retrograde k wire into 2nd met to serve as splintage. cast for 2 weeks, remove, dressing change, and if all ok, cast on for another 4-6 week. 2 week course of antibiotics also.

Fernando L. Quirindongo, DPM
footdoc755@gmail.com

My thought about the treatment plan would be

Removal of all the hardwares,
Aggressive I&D,
Ceretec Scan to rule out any bone infection involvement,
IV Antibiosis
=> The goal is to clear the infection in this foot before any fixation planning.
Complete off weight bearing
If no bone infection, then surgical fixation can be proceed in 2 months
This 2 months is to give time for the wound to heal, decrease edema, resolve cellulitis and wound stable. However, if patient has medical hx that suggestive to compromised wound healing process, the wait period could be longer than 2 months.
If there is bone infection, then TMA or proximal amputations should be in consideration.
Just a thought, for the osteotomy on proximal phalanx, which procedure was performed and which deformity was tried to correct? shorten the great toe perhaps? because from the xray on AP view, the midshaft portion of proximal phalanx seem to be resected.

Helene Nguyen, DPM
helenedpm@yahoo.com