Osteomyelitis: Considering a Simple Toe-Sparing Procedure

My name is Dr. Tammer Elmarsafi. I'm a fellowship-trained podiatric surgeon. I did my fellowship in diabetic limb salvage, and I currently practice in a vascular group at Vascular Surgery Associates in Maryland.

When we see patients with diabetes complicated with peripheral neuropathy, if you see the same patient with hammertoes, bunions, a flatfoot deformity, a patient without neuropathy you wouldn't think so much about not counseling them, about the deformity, what it means, and you would certainly start thinking about the pathway to surgery.

In the diabetic population, unfortunately a lot of surgeons will see the same type of foot with the same type of pathology and deformities, and they'll continue to debride calluses and talk about preventative measures with diabetic shoes and inserts and such. Unfortunately that will eventually bite the patient and the surgeon. You'll wind up with some kind of ulceration, and when they become complicated ulcers, when they become complicated with infection and osteomyelitis, you're left with the question of how to treat, and the algorithm for treating say osteomyelitis of a toe oftentimes will either take a conservative approach, or the easy answer for a surgeon will be a definitive cure, which is if there's underlying osteomyelitis, you remove it. You remove the osteomyelitis by doing an amputation; (which) could be a partial toe amputation, could be a complete toe amputation.

But the real question is, do we need to, and for digital contractures in which you have, for example, a PIPJ dorsal ulcer with exposed bone, I have not seen conservative care, once that bone is exposed, no matter what methodology that you plan to take, once that bone is exposed you're likely going to wind up with either an acute osteo, or if you take too long it's going to be chronic osteomyelitis. Once that osteo sets in, or if the deformity is not reducible, you're stuck in a hard place. It's a surgical case, and in most cases what I've found is that patients who come in with loss of digits, if you ask them, "What did that toe look like before it was amputated?" oftentimes they'll describe a toe that for the most part looked pretty normal with the exception, of course, PAD and fully necrose toes, but they'll describe a small part of that toe that has some pathology to it. In the case of a PIPJ dorsal ulcer, rather than a complete toe amputation, you can do a small procedure that allows for salvage of that toe.

It's a simple procedure for what I think is a complex problem, and if you look at the prevalence rates for deformities of the foot in the neuropathic patient, toe deformities are way up there and indeed for someone with that particular type of deformity, with that type of neuropathic ulcer with exposed bone, the procedure is simple and you don't need much of a workup.

The surgical procedure is very... I would call it... It's a resection of the joint, and it's a resection of the ulcer. The soft tissue, whatever it needs to be debrided, you can ellipse that ulcer. Generally I will remove the intermediate phalanx and I will remove at least half of the distal aspect of the proximal phalanx, and what that does is essentially you are removing the deforming forces of the toe. It allows you to reduce that in terms of dorsal pressures in a shoe, for example, but in addition to that it gives you the opportunity to primarily close.

Now, the caveat here is you want to make sure that there's going to be no recurrence, and I think most people who deal in the limb salvage space do what I do, and that is to make sure that you're sending off bone specimen and bone cultures, and whatever comes back positive you're going to treat with antibiotics.

The real elephant that's in the room is the fact that, like I said, we see neuropathic patients all the time with all kinds of digital deformities and sometimes complex deformities, and when to pull the trigger for a prophylactic surgery before these ulcerations occur, I think that's where the real magic will hopefully... We're not waiting until these problems happen, so that would be my number one tip, but I would also urge that should someone present to you with one of these... It seems like it's such a small ulcer in a small surface area, but the bone is exposed and it's such a rigid contracture, it's very difficult to think anything other than amputation, try it. Consent the patient for both. You have nothing to lose. I bet you once you take out that amount of bone and just approximate that soft tissue envelope as if you're closing, you'll find that the toe remains rectus and you'd be able to preserve the toe, and I think that's a win.