Correcting Deformity in a Complex Wound Care Patient With Multi-Plane Ex Fix

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Hi, it's Dr. Rimi Statkus from Northern Illinois Foot and Ankle Specialists in the northwest area of Illinois. I have a history of diabetic limb salvage, musculoskeletal reconstruction of the foot, reconstructive rearfoot and ankle surgery, and I work across multiple wound clinics. I'm board certified by ABFAS. And today obviously we're focusing more on the surgical aspects and wound healing.
 
A brief description of the patient presentation
 
So this is a 54-year-old patient that came to me as a second opinion. She previously underwent a complete resection, an amputation of the fifth ray by another surgeon. Because of the extensive infection that was previously present that wound had healed, but there was a significant loss of function and inversion of the foot and ankle because of the peroneus brevis insertion was lost and was not able to be anchored into the cuboid prior to me seeing her. So she had a, like I said, a significant cavovarus deformity and a large wound because of the lateral loading presence.
 
How did the surgeons correct the deformity and heal the wound?
 
Given that there was significant inversion in varus deformity, the patient did not have a functional limb. She had recurring ulceration in the lateral midfoot area and without proper offloading, this was never going to heal properly. So what we did was we applied a multi-plane hexapod and we did deformity correction over 4 weeks. So every single day there was 3 times a day it was changed to bring the foot back into a rectus position. As I said we confirmed it with negative bone biopsies throughout to make sure that there was no bone infection.
 
As an adjunct to the frame application, we also used a fish skin graft because she initially had a very large deficit present with the wound. So the micronized version was able to fit anatomically deep into the area and then a sheeted graft on top for healing. We also used negative pressure wound therapy to get rapid wound healing. So by the time we got full deformity correction within 4 weeks, the wound was completely healed.  We were then able to stage it through to the next part of the procedure with a tibiotalar or calcaneal arthrodesis, so she'd have a functional limb to stand on and to ambulate with.
 
What are the most important tools for physicians when treating patients with multiple comorbidities?
 
So certainly a multi-disciplinary input. In this circumstance, the patient had diabetes and neuropathy. Arterial supply was good. She did have a history of coronary artery disease. Previously, her A1C was extremely elevated and uncontrolled diabetes. So obviously the input from the endocrinologist was significant to get that down into an acceptable range and get rid of it or reduce the risk of that immunocompromised state that we see with these patients. So a multidisciplinary input definitely goes a long way in this circumstance and then with my side in terms of surgical planning to create a functional limb.
 
How can considering the complete clinical picture help achieve long-term limb salvage?
 
So in these complex patients there are so many variables that we need to control. As I said, getting the work out from arterial perspective that was clear, so we didn't have to pursue interventional cardiology or procedures in that context. We also had our pedorthotists come involved with this, so in terms of offloading modalities, this was a multi-step process because if you don't address all avenues and aspects of it, then you're doomed to fail. We had infectious disease throughout when she had bone infection present previously. We had multiple bone biopsies to clear that part of it before we stage the next part of the procedure.