by Jay Lieberman DPM, FACFAS

LOWER EXTREMITY EXAMINATION:  Peripheral vascular status intact.  Pedal pulses graded +2/+4 bilateral.  Capillary refill <5 seconds bilateral.  Temperature gradient: increased.  Digital hair: present.  Skin: atrophic, but well hydrated.  Unable to discern a 10 gm Semmes-Weinstein filament.  Mycotic nails on second and third toes left foot.

SOCIAL HISTORY:  The patient has a 40 pack-year history of smoking.  He has virtually eliminated the habit.His hemoglobin A1c suggests that he is under relatively good control.  I recommended participation in a smoking cessation program.

An X-ray of the foot is negative for underlying osteomyelitis

Cultures revealed Staph aureus with sensitivity to Keflex, which was prescribed.

The wound was debrided full thickness with a scalpel.

Undermined tissue was removed as well. He was given an offloading Darco shoe and started on Bactroban bid.

Debridement with removal of undermining tissue.		Wedged Shoe

Over a four-month period, we would notice that the wound would repeatedly heal uneventfully, only to return a short time afterwards.  His return presentation was usually with extensive hyperkeratosis, subcutaneous dried hemorrhage, and undermining.  During one return visit, the plantar condyles and plantar plate of the fifth MPJ were visible.  At that point, the patient was sent for an MRI, which was negative for underlying osteomyelitis.

Subsequent tissue cultures revealed methicillin resistant staph aureus, which was sensitive to Linezolid.  The patient was started on 600mg q12.  The wound developed a viable granulating base and appeared to be virtually closed.  Unfortunately, some time later, he returned to the office again with hyperkeratosis and undermining.  Again, the wound probed to the glistening plantar surface of the metatarsal.

Pre Op

The patient was brought to the operating room and placed under IV sedation.  The surgical site was regionally anesthetized slightly proximal to the wound.  A Freer elevator was used to evaluate the extent of undermining tissue.

Periosteal elevator used to check for undermining tissue.

Surgical circumscription of undermined tissue down to plantar capsule and plantar plate, fifth MPJ.

Removal of chronic ulceration.

The wound was then surgically circumscribed through subcutaneous layer and into the fatty layer.  Care was taken not to disturb any neurovascular structures or the flexor tendon. The wound extended deeply to the plantar plate and the articular cartilage overlying the fifth MPJ.  Utilizing an osteotome and mallet, the plantar condyles were decorticated.

Removal of plantar condyles.		Decorticated plantar condyles, fifth MPJ.

This was done to eliminate the prominence at the level of the fifth MPJ and to remove the plantar articular cartilage with a goal of better neovascularization and formation of granulating tissue. This afforded us the ability to biopsy and culture the bone. A jet lavage was then performed.  The GraftJacket was put into place and sutured with 3-0 prolene.  A double layer of Adaptic was applied.

Pulsed Lavage		Immediate post op GRAFTJACKET sutured with Prolene

Cotton balls were used for direct compression.  A dry sterile dressing was applied.

The patient tolerated the aforementioned procedure well.  Arrangements will be made after the first dressing change to utilize VAC therapy.

Bone was sent for biopsy and aerobic, anaerobic, fungal and AFB cultures.  Biopsy was indicative of "pressure ulcer."  The bone was negative for osteomyelitis.  The cultures were negative.  The patient was started on Vancomycin and then switched back to Zyvox.

GRAFTJACKET in place, one week post op.		Three weeks post op. Notice reduced depth of wound

Despite negative x-rays, bone cultures and MRI, there is still a high suspicion for osteomyelitis. Although pulses were palpableone has to be alert to small vessel disease associated with years of smoking.   

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