Presenting a case of a 64-year-old male with diabetes who developed a limb-threatening infection after dropping boiling tea on his left foot, this author shares insights on the aggressive treatment regimen and multidisciplinary care that enabled the patient to return to normal activities in four months.
It is a commonly perception that many necrotizing deep infections lead to limb loss and can even lead to death if one does not address these infections quickly. In this day and age, when there are multiple surgical specialties involved and rapid intervention along with antibiotic therapy, it is very possible to save not only the life but the limb as well. The next challenge is focusing on making that limb as functional as possible to allow the patient to get back to a more normal way of life.
A 64-year-old male dropped boiling tea on top of the left foot on June 11, 2019. He developed a large blister the next day and then experienced fever and chills over the next two days. The patient and his wife decided to go to urgent care on June 14 due to the fever and chills as well as substantial redness and pus with the left foot.
The patient had a medical history of insulin-controlled type 2 diabetes with neuropathy along with controlled hypertension and hyperlipidemia. The patient was using an insulin pump and taking a diuretic as well as a statin drug. He was not used to pain in the foot so he considered this pain very concerning. After evaluation, the urgent care physician recommended transfer to a traditional emergency department.
When the patient got to the ER, his blood glucose was 184 mg/dL with a white blood cell count of 25,000 cells/mm3. His C-reactive protein (CRP) was greater than 9 mg/dL, the erythrocyte sedimentation rate was (ESR) 24 mm/h and creatinine was 2.4 mg/dL. The patient had no previous history of kidney issues. Emergency room physicians initiated broad-spectrum antibiotics after blood and wound cultures, and immediately admitted the patient to the hospital. A small bedside incision and drainage showed purulence with malodor and necrotizing soft tissue. Same-day operative incision and drainage showed substantial necrotic tissue and further liquefactive necrosis.
Wound cultures revealed Streptococcus pyogenes and methicillin-sensitive Staphyloccus aureus (MSSA). Blood cultures also showed Streptococcus. A postoperative white blood cell count came back at 28,000 cells/mm3 and we took the patient back to the OR on June 16 for further debridement and amputation of the fifth toe by disarticulation to remove further demarcated necrotic and infected tissue. A third operative debridement took place on June 17.
On June 18, while still on intravenous antibiotics, the patient had a white blood cell count of 22,700 cells/mm3 along with further necrosis of the dorsal and plantar foot as well as the medial ankle and leg. I subsequently performed further debridement as well as amputation of the third and fourth toes, and a partial resection of the fifth metatarsal. At this point, the medial leg wound area spanned 13 cm up the medial leg.
Pertinent Insights Into The Limb Salvage Efforts
On June 20, the white blood cell count trended down to 18,200 cells/mm3 and the patient was feeling better. Further evaluation by vascular surgery determined the patient had adequate blood flow to the extremity so it was up to the patient to decide between advanced limb salvage efforts or //a more proximal amputation. The vascular surgery team advised waiting until the removal of all non-viable tissue before making a decision. The patient continued to improve over the next few days and decided to attempt limb salvage.
He went back to the OR on June 24 for more extensive ultrasonic debridement of all additional non-viable tissue with partial resection of the third and fourth metatarsals. There was no evidence of further infection and the patient remained stable. This led to the decision to suture multiple amniotic grafts onto the foot and leg, and employ negative pressure wound therapy (NPWT) over the grafts at 100 mmHg with medium intensity continuous settings. After being discharged from the hospital, the patient followed up in the office as an outpatient.
I took the patient to the OR on July 18 to address the very large soft tissue defect on the medial ankle and leg, which connected to a substantial plantar foot wound. There was also a large dorsal foot wound due to the resection of both bone and tissue from the toes and metatarsals. There was no further infection at this time and the antibiotic course was complete. The large defects necessitated substantial tissue closure with flaps in addition to further grafting to provide the best chance of healing and a functional limb.
The first and second toes became the source of the flaps. I removed the nails in an excisional manner and performed linear incisions, avoiding the neurovascular structures on the sides of the toes. I subsequently resected part of the distal first and second metatarsals to allow for further mobility of the flaps. I rotated the flaps to cover the entire void on the dorsal aspect of the foot as well as distally and laterally over the third through fifth toe amputations. I held off on suturing the flaps down at this time in order to evaluate the remaining wound coverage needs.
Subsequent use of doppler guidance allowed the team to follow the medial plantar artery and dorsalis pedis artery where it reconstructs the vascular pedal arch in order to map out the circulation for the remaining distal plantar medial soft tissue. After mapping, I created a fasciocutaneous flap down to the intrinsic musculature deep to the plantar fascia, lifting and mobilizing it to be able to close most of the plantar foot defect. With all three flaps laid into position, they covered nearly the entire pedal defect, except for a small plantar distal lateral area. At this point, I employed deep sutures to tack down the flaps and utilized an atraumatic technique to preserve circulation and skin closure with nylon to minimal tension, just letting the skin edges abut. Capillary refill time to all areas of the flaps were within normal limits.
Finally, I performed ultrasonic debridement of the medial ankle and foot to healthy bleeding tissue. The area was still very deep so I applied amniotic grafts to the tissue and sutured the grafts into place with 3-0 chromic gut suture. I used NPWT over the area at 100 mmHg medium intensity continuously to help add volume to the area with the hope of skin grafting later.
Reviewing The Graft Take And Other Elements Of The Patient’s Progression To Wound Healing
The patient followed up in the office one week later and the grafts were integrating well with only some small superficial flap necrosis, which one might expect in flaps of this size. The deep tissue of the flaps took well with no complications. We ensured close outpatient follow-up to keep the patient out of the hospital.
After the patient’s medial ankle/leg wound achieved good granulation along with better volume, I took him back to the OR on August 15. The flap sites were fully healed at this point as was the superficial flap necrosis. I thoroughly prepared the wound bed on the left ankle and leg with an ultrasonic debrider. After the injection of lidocaine with epinephrine under the skin and thorough scrubbing of the harvest sites, I used a dermatome to harvest two areas of skin from the right posterior medial and posterior lateral legs. I meshed the split-thickness skin grafts at a 1.5:1 ratio and applied them to the left medial ankle and leg. I secured the grafts with 4-0 chromic sutures and subsequently applied bolster dressings to the area. I then applied a small, thin placental-based graft to the split-thickness skin graft harvest sites to help decrease inflammation, pain and scarring.
The patient came to the office two weeks after this last procedure for the first dressing change. There was good take of the skin grafts to the left side. The right leg harvest sites had no pain as per the patient. I anecdotally attribute this to the use of the placental graft. In my experience with other split-thickness skin graft harvest sites, patients relate substantially more pain at the harvest sites than at the operative sites. The swelling of the flap areas started to reduce and he followed up again two weeks later with even further improvement.
The patient started to walk on the foot in the beginning of October with a surgical shoe while waiting for a filler for a sneaker. The large flap sites compressed in size as expected to level with the other skin of the plantar foot, allowing ambulation with no issues. This was a significant benefit of using a plantar tissue-based fasciocutaneous flap. When the patient was able to execute full activity in sneakers, it did cause a small area of distal medial foot skin breakdown, which healed after debridement in the OR at the end of October with a subsequent application of a small amniotic graft.
This extreme limb salvage effort to address necrotizing fasciitis of the left foot and leg was successful due to a multi-team approach with intravenous antibiotics by infectious disease colleagues, confirmation of adequate circulation by the vascular surgery team and a variety of combined bone and soft tissue procedures in a staged manner. The patient was able to return to normal activity in only a four-month period and is enjoying his active life. He wears a diabetic shoe with a toe filler and his wife now checks his feet daily
Dr. Wohlgemuth is in private practice in Galloway, Hammonton and Brigantine, N.J. He is a surgical teaching attending physician for the Podiatric Residency Program at Inspira Medical Center in Vineland, N.J.