Addressing A Gangrenous Fifth Digit

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Author(s): 
Valerie L. Schade, DPM, AACFAS

In a case study involving a gangrenous fifth digit in an 88-year-old patient, this author discusses the use of a minimum incision ray resection and fillet of toe flap after appropriate revascularization to facilitate more expeditious healing and limb salvage.

An 88-year-old male presented to the emergency room with dry gangrene of the fifth digit of the right foot, which occurred approximately three weeks after the patient sustained trauma to this area.

   The patient and his family reported a similar presentation 18 months prior on the left foot. The patient presented to a different facility for treatment of his left foot. Surgeons performed a common femoral artery endarterectomy, superficial femoral artery angioplasty and open amputation of the fifth digit. Healing of the fifth digit amputation site was complicated by delayed wound healing and subsequent osteomyelitis necessitating partial resection of the fifth metatarsal, which the surgeons left open to heal. Physicians employed negative pressure wound therapy and used advanced wound care products for approximately six months until final healing occurred. Healing in this manner resulted in a hypertrophic scar, which had the tendency for callus formation.

   Upon presenting to the emergency room for the right foot, the patient was afebrile, had normal vital signs and was metabolically stable. The patient reported no known drug allergies. His past medical history consisted of hypertension, hyperlipidemia and neuralgia. The past surgical history consisted of the aforementioned left lower extremity procedures, back surgery and eye surgery. The patient’s current medications were simvastatin (Zocor, Merck) 20 mg at night, amlodipine (Norvasc, Pfizer) 30 mg daily, gabapentin (Neurontin, Pfizer) 800 mg three times daily, lisinopril 20 mg daily, hydrochlorothiazide (Dyazide) 10 mg daily and tramadol (Ultram, Janssen Pharmaceuticals) 50 mg daily. The patient denied use of tobacco or alcohol and lived in a single story home.

   Examination of the patient’s right foot revealed dry gangrene of the entire fifth digit. The peroneal artery had a monophasic signal and the dorsalis pedis and posterior tibial arteries were non-audible with Doppler exam.

   The patient was admitted. After an arteriogram of the right lower extremity, the patient underwent a femoral to popliteal bypass with a polytetrafluoroethylene synthetic graft. The day after the vascular procedure, surgeons performed a disarticulation amputation of the fifth digit at the level of the metatarsophalangeal joint, a minimum incision fifth ray resection and a fillet flap of the fourth toe to allow for closure of the amputation site.

   The patient remained non-weightbearing for four weeks and transitioned to full weightbearing for short distances only in a postoperative shoe for an additional two weeks. The patient was fully healed and returned to his preoperative ambulatory status at six weeks postoperatively in extra depth shoes with custom insoles. Physicians modified the left insole to limit callus formation along the hypertrophic scar on the left foot. The patient has remained fully healed 12 months postoperatively.

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