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Managing Complications From An Unexpected Source In Charcot Surgery

These authors discuss complications including infection and non-union that resulted from a foreign body left in the foot during long-term outpatient wound care.

Podiatric surgeons rely on all aspects of the health system for the treatment and care of their patients, especially in the perioperative setting. The collaboration of physicians, surgeons, skilled nursing and physical therapists contributes to the overall success of each individual patient. However, with each additional medical provider incorporated into the patient’s care, physicians need to apply more diligence to avoid miscommunication and error.

As a surgeon’s practice continues to grow, it is inevitable that one encounters difficult cases and complications. In this article, we present a unique case involving a complication because of long-term outpatient wound care.

When A Patient Presents With Acute Ankle And Recurrent Midfoot Charcot Deformity

Well known to the podiatric surgery team, a 52-year-old woman with diabetes presented for follow-up with a chronic left plantar foot wound. At presentation, the wound was non-infected and did not probe to bone (Figure 1a,1b,1c). In previous years, the patient had extended wound care for various plantar and digital wounds as well as surgical intervention for her left midfoot Charcot deformity. Previous surgeries included a Charcot reconstruction and plantar planing.

The patient developed the recent wound due to her equinus deformity and osseous breakdown due to an ankle Charcot deformity. Given her hindfoot and ankle instability, the surgical plan consisted of an arthrodesis to obtain hindfoot and ankle stability with arthrodesis and subsequent offloading of the chronic plantar central wound. 

We employed circular external fixation to compress the hindfoot and ankle after formal joint preparation. We also corrected the soft tissue equinus with a tenotomy of the Achilles tendon. The senior surgeon avoided the use of internal fixation due to the presence of an open wound.

Arthrodesis assisted by multiplanar external fixation is better suited for patients with previous open wounds and for patients who are unable to tolerate prolonged weightbearing restrictions after surgery (see Figure 2a/2b).1 The patient’s initial post-op course was uneventful with plantar wound healing. However, due to soft tissue impingement and concerns of recurrent half pin site infections, we removed the frame at eight weeks and placed an antibiotic-coated medullary nail for stability until bony fusion could be visible on radiographs.

When Complications Necessitate Another Visit To The OR

Two months following the placement of the antibiotic-coated medullary nail for tibiotalar-calcaneal fusion, the patient presented to the emergency room with complaints of fever and malaise. Radiographic evaluation revealed evidence of an infected non-union at the level of the left ankle joint (see Figure 3a/3b). The patient was admitted for IV antibiotics and scheduled for operative debridement, intraoperative cultures, and removal of the hardware.

Once in the operative suite, upon removal of the internal fixation, we found Iodoform packing at the proximal end of the medullary nail (see Figure 4a/4b). We performed tibial debridement at this point using a medullary reamer system and subsequently placed a cement spacer impregnated with vancomycin and tobramycin. The patient utilized IV antibiotics and had close infectious disease monitoring for six weeks until normalization of the erythrocyte sedimentation rate and C-reactive protein lab values.

To date, the patient is doing well with the current antibiotic medullary spacer intact and all plantar wounds and incisions have healed without further complications. The patient has recently transitioned to protected weightbearing as tolerated in a custom Charcot restraint orthotic walker (CROW) and has not returned to the operating room for further debridement or revision (see Figure 5).

What You Should Know About Gossypiboma

Gossypiboma by definition is a mass of cotton material, usually gauze, sponges and/or towels, inadvertently left in a body cavity. Arora and Johal published a single case report in the Journal of Orthopedic Case Reports in 2014, documenting one of the few reported gossypibomas in the lower extremity.2 Their particular case resulted in complications involving infection, non-union at the open reduction internal fixation (ORIF) site and need for further operative intervention. Aside from Arora and Johal’s case report, literature on lower extremity complications involving retained packing is scant.

In our current case, we believe the previous surgeons inadvertently left the foreign body from wound packing and is the likely cause of the hardware infection that occurred in this patient. A review of the patient’s medical records revealed that the last time the patient had packing placed into the wound was two years prior to the most recent surgical ankle reconstruction. While it is impossible to predict when surgeons left this foreign body behind, in future practice, we will be evaluating patients who fit this type of clinical profile for the potential of retained foreign body in both the clinical and surgical setting.

Wukich and colleagues have noted that complications are common in patients undergoing Charcot reconstruction of the ankle and hindfoot.3 Approximately 30 percent of patients in their study experienced a superficial or deep infection while another 25 percent experienced a non-infectious complication. Given the high complication rates involved in Charcot reconstruction, surgeons should expect obstacles in the post-surgical setting and be ready to manage these complications if they occur. However, in some instances, there are external factors beyond the control of the surgeon that can induce a complication, which can only be described as “unexpected.” Our case report incorporates an unconventional complication that occurred in the wound care setting with unfortunate consequences affecting the postoperative course.

In Conclusion

Foot and ankle surgeons are commonly managing patients in the setting of Charcot neuroarthropathy with the presentation of chronic wounds that require long-term wound care. The surgeon needs to be aware of the patient’s wound care course and apply vigilance in the OR setting to prevent a potential of foreign body-related infection when performing complex reconstruction. However, being able to manage complications such as these can still result in a successful surgical outcome, specifically when the goal is limb preservation.

Dr. Mayer is the Co-Chief Podiatric Surgery Resident with the Department of Veterans Affairs Maryland Health Care System and the Rubin Institute for Advanced Orthopedics at Sinai Hospital of Baltimore.

Dr. Siddiqui is the Director of the Podiatric Surgery Service at the Rubin Institute for Advanced Orthopedics at Sinai Hospital of Baltimore. He is the Director of the Foot and Ankle Deformity Correction and Orthoplastics Fellowship at the Rubin Institute for Advanced Orthopedics. He is the Assistant Residency Director with the Baltimore VA/Sinai Hospital Surgical Residency Program.

Tarina Ayazi is an undergraduate clinical neuroscience major at the Virginia Tech University with an anticipated Bachelor of Science degree in 2019.

References

1. Siddiqui NA, Amanda P. Midfoot and hindfoot Charcot joint deformity correction with hexapod-assisted circular external fixation. Clin Surg. 2017; 2:1430.

2. Arora RK, Johal KS. Gossypiboma in thigh- a case report. J Orthop Case Rep. 2014; 4(3):22–4.

3. Wukich DK, Raspovic KM, Hobizal KB, Sadoskas D. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev. 2016; 32(Suppl 1):292–296.

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Brittany E. Mayer, DPM, Noman A. Siddiqui, DPM, MHA, and Tarina Ayazi
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