Addressing the treatment of a patient with multiple comorbidities, this author emphasizes how advanced vascular surgery techniques in combination with serial debridements and advanced wound care prevented a below-knee amputation.
A 56-year-old female presented to an emergency room with a cold and painful right leg. She had a long-standing history of type 2 diabetes, coronary artery disease (CAD), renal disease, severe peripheral vasculopathy and recent revascularization with an attempt at a right transmetatarsal amputation (TMA) from another facility. Re-occlusion of right leg popliteal flow in combination of microvascular disease led to poor healing of transmetatarsal amputation site. The previous treatment team recommended the patient undergo a below-knee amputation and she presented requesting additional opinion from our vascular department.
On initial exam the patient presented with a cold limb and necrosis of the amputation site with dehiscence. She also presented with large necrotic heel wounds exhibiting ischemic necrosis of the wound base. We noted non-palpable dorsalis pedis (DP) and posterior tibial (PT) pulses to the right lower extremity. She related extensive rest pain and was only able to keep her leg in a dependent position.
Non-invasive arterial studies including arterial Doppler and arterial duplex revealed significant vascular disease including stenosis of previous femoral-popliteal bypass graft. The patient’s clinical presentation including the cold limb, multiple ischemic ulceration, tissue necrosis and rest pain correlated with the vascular findings (see first two photos above). The patient had stage 6 peripheral arterial disease (PAD) as per the Rutherford classification and stage IV PAD as per the Fontaine classification.1 Higher staging often relates to advanced tissue loss and the assumption that wound healing will require greater perfusion.
The timing of vascular intervention is critical in preventing further tissue loss and earlier intervention dramatically improves patient outcomes and prevention of amputation. In my experience, endovascular revascularization is favorable over open surgery due to lower morbidity and mortality rates. After vascular surgery evaluation, the patient had right lower extremity angiography with percutaneous revascularization including balloon angioplasty of the popliteal artery and limb trifurcation and stenting of the right common iliac artery.
Postoperative examination demonstrated increased vascular flow with a strong palpable dorsalis pedis pulse and audible posterior tibial doppler signal. Lower extremity exam at this time revealed extensive necrosis with a large soft tissue deficit of the heel as well as dehiscence with fibrotic tissue at the attempted TMA site. Understanding that timing of podiatric intervention after revascularization is critical, our team recognized a limited window in which this patient with multilevel arterial disease might heal. Accordingly, we closely coordinated with vascular surgery on the timing of the podiatric plan.
Pertinent Aspects Of The Podiatric Intervention
After adequate restoration of blood flow to the right lower extremity, surgical intervention took place the following day including revisional transmetatarsal amputation with plantar foot and heel debridements and application of a multilayer graft a bilayer-meshed Integra® wound matrix serving as a dermal regeneration template (see third and fourth photos above). Sharp wound debridement with additional ultrasound debridement with integrated aspiration provided selective debridement of necrotic tissue.
Postoperatively, the patient remained in the hospital for further monitoring and infectious disease consultation. The patient received intravenous antibiotic therapy tailored to intraoperative cultures. The pathology specimen margin and osseous clearance specimen did not show any evidence of osteomyelitis. Upon discharge, the patient received oral antibiotics per infectious disease recommendations.
The patient presented to our outpatient wound healing center for follow-up one week after hospital discharge. In addition to serial debridements and amniotic tissue graft applications, we added hyperbaric oxygen therapy (HBOT) to help facilitate wound healing. The HBOT sessions were five days a week at three atm oxygen for approximately two hours per treatment session. The patient underwent a total of 12 weeks of HBOT along with weekly wound care visits. The patient tolerated outpatient wound care and HBOT very well with minimal complications. Her wounds progressed toward healing weekly (See fifth through seventh photos above). The patient kept appointments for scheduled follow-ups and ultrasounds of the right lower extremity with vascular surgery. She showed excellent progress and at about 12 weeks post-op, she was discharged from HBOT and the wound healing center (see eighth photo above).
A multidisciplinary team approach is often necessary to achieve limb salvage, especially for patients with an extensive medical history. I find that healing rates and limb salvage rates greatly increase in these difficult cases when providers utilize multiple modalities for these patients. Adjunctive therapy, including HBOT, advanced wound healing biologics and serial wound debridement, may enhance healing capabilities. In my experience, a team approach provides the most optimal results in preventing amputation in high-risk patients.
Dr. Palmieri is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Medicine. He is in private practice in Elk Grove Village, Ill.
1. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease. Int Angiol. 2007;26(2):81-157.