The patient was taken urgently to the operating room and underwent a radical Incision and Drainage procedure. Intra-op findings included extensive necrosis of the soft tissues of the entire plantar central midfoot deep to the plantar fascia but not involving osseous structures. The lateral foot and dorsal lateral foot were also involved to the level of the Peroneal tendons. Extensive soft tissue was removed and a large defect was packed open. The next day, the patient was seen, dressing changed and he was presented with the following options:

1) Chopart level amputation with closure using a dorsal flap or, 2) Prolonged course of wound care with attempt at limb salvage.

The patient opted for limb salvage knowing all the potential risks, benefits, complications and alternatives to each option presented. He was stabilized medically and admitted to our Extended Care Unit followed by a myriad of wound care therapies and procedures. Intra-op cultures yielded Proteus Penneri for which he received 14 days of IV Vancomycin.

He returned to the OR 5 days after the original surgery for a repeat wash-out and Wound VAC (KCI) placement. The Wound VAC was changed 2-3 times per week and with each VAC change, a liberal amount of CellerateRx Powder (Wound Care Innovations LLC) was applied. Hyperbaric Medicine was consulted and he underwent a total of 38 hyperbaric treatments. Provant therapy (Regenesis Biomedical) was also utilized twice daily for 30 minutes eachsession. He underwent 2 Apligraf applications over the course of the hospitalization.

He was encouraged to quit smoking but did persist to smoke but admittedly less than prior to hospitalization. After 95 days in the Extended Care Unit, he was felt stable for follow-up as an outpatient where he continues to receive twice weekly wound care. The VAC was stoppedfollowing rapid filling in of the wound with healthy granulation tissue. The VAC negative pressure device was used to facilitate fluid movement through the wound and promote wound contracture. CellerateRx functioned independently as a biologic dressing facilitating fibroblast migration over the collagen fibrils and contributing important amino acids needed for granulation tissue production and associated re-epithelization. He has undergone 2 more Apligraf applications and Acticoat-7 with Profore dressings. The attached pictures show near resolution of the wound, which we expect within the next 4-6 weeks with continued local care.

Practicing within an academic institution like the VA setting allows us to be very liberal with our attempts at limb salvage and other treatment modalities that might not be as easily accessible to the average private practitioner. In this case, we have demonstrated that limb salvage creating a functional foot can be accomplished over the course of a 6-month period for a very complicated soft tissue infection with extensive tissue loss using many different therapies and procedures. A mid-foot amputation may ultimately have been quicker for healing but this patient desired foot salvage and our team and setting made that possible.