Forefoot Infection Research Articles

Midfoot Amputations as Adjuncts to Limb Preservation

Midfoot amputations are viable options for limb preservation in cases of forefoot infection, diabetic ulcers, critical limb ischemia, trauma, or malignancy to avoid major lower-extremity amputation. Each level of midfoot amputation has limitations to consider including wound healing problems, soft-tissue contracture, or need for revisional amputations. However, some of these facets can be addressed perioperatively. Each midfoot amputation has benefits as viable options for limb and functional preservation and to avoid major limb amputation. There currently is no set guideline for level of midfoot amputation in patients with critical limb ischemia. Levels of amputation are determined by multiple factors including but not limited to degree of tissue loss, vascular status, the ability to preserve function, surgeon experience, and pertinent patient factors. This approach to limb salvage is best performed from a multi-disciplinary perspective.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm

BackgroundThe treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes. MethodsThis is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation. ResultsOutcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level. ConclusionsBone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

A rare case of cutaneous mucormycosis in the forearm: A case report.

Introduction and importanceCutaneous Mucormycosis (CM) is a less frequent type of fungal infection that can present with different skin lesions. Although these lesions appear to be benign and silent, CM rapidly progresses into the deeper layers. Given that no specific laboratory or imaging finding is described for the disease, the diagnosis is mainly based on history and physical examination. In addition, immediate debridement and antifungal agents must be commenced.Case presentationWe present a 43-year-old septic man who was hospitalized for his forefoot infection. During his admission, he developed a necrotic-like ulcer in his antecubital fossa. After initial debridement, pathology examination revealed the infection with mucormycosis. We administered intravenous liposomal Amphotericin B, and also multiple surgeries were performed. Unfortunately, the sepsis progressed to multiorgan failure, and the patient passed away.ConclusionCM requires emergent diagnosis and treatment. Early surgical interventions like extensive debridement and repetitive wound irrigation alongside systemic antifungal therapy are the key steps to preventing the progression of the disease.

Forefoot infection by Staphylococcus lugdunensis following a stonefish sting: A case report

Several orthopedic injuries caused by marine creatures envenomation have been reported in recent years all around the world, occurring mainly during water sports practice. We reported a case of an Italian tourist who developed an acute forefoot infection by Staphylococcus lugdunensis following a penetrating wound at the plantar region of the fourth toe, caused by a Stonefish, during a session of snorkeling in Indonesia. Diagnosis by microbiological methods, soft tissue and bone biopsy, surgical debridement and administration of antimicrobials led to a successful treatment of this potentially severe infection in this case. From this experience, we suggest to consider this bacterium in the differential diagnosis of bone infection following stonefish envenomation in tropical areas.

Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update.

Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, “conservative” surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.

Forefoot infection by Staphylococcus lugdunensis following a stonefish sting: a case report

Forefoot infection by Staphylococcus lugdunensis following a stonefish sting: a case report

Outcome of Ray Resection as Definitive Treatment in Forefoot Infection or Ischemia: A Cohort Study

Ray resection is frequently performed in cases of infection or ischemia, but the literature is scarce concerning its outcome as a definitive treatment. In this retrospective cohort study, we reviewed our cohort with transmetatarsal ray resection with a mean follow-up of 36.3 months. Reulcerations, transfer ulcers, and reamputations were determined. Risk factor analysis for revision surgery was conducted. Among 185 patients, 71 (38.4%) had revision surgery within a mean of 1.4 ± 2.6 years (range 2 days to 12.9 years), 22 (11.9%) had major amputations, 49 (26.5%) had minor amputations, 11 (5.9%) had same-ray reulceration, 40 (21.6%) had transfer ulceration, and 2 (1.1%) had both reulceration and transfer ulceration. Occurrence of a postoperative ulcer was statistically significantly associated with revision surgery (p < .01). In conclusion, metatarsal ray resection is a reasonable treatment option in cases of forefoot ischemia or infection to prevent major amputation but fails in 11.9%, and reulceration is associated with further revisions, making ulcer prevention paramount.

Long Term Outcomes Following Syme’s Amputation

Category: Ankle, Diabetes, Trauma Introduction/Purpose: The metabolic cost of walking following Syme’s ankle disarticulation amputation is minimally more than similar non-amputees. The ability to end-bear makes prosthetic fitting relatively simple, and very few patients require extensive rehabilitation or placement in a skilled nursing or rehabilitation facility. In spite of these potential benefits, there is a paucity of objective information on the actual long term outcomes. Methods: Fifty-one patients were identified who underwent single stage Syme’s ankle disarticulation amputation with excision of the lateral and medial malleoli by a single surgeon during a twenty three year period. None of these patients had sufficient tissue to allow amputation at the transmetatarsal or tarsal-metatarsal levels. Thirty-three underwent amputation due to diabetic forefoot infection, eleven secondary to crush injury, three for non-diabetic infection, three for non-correctable acquired deformity and one for neoplasm. The average age at surgery for the di-abetic patients was 62.1 (range 36-81) years, with a follow-up of 6.8 (4-11.6) years. The nondi-abetic patients averaged 37.8 (range 21-65) years, with a follow-up of 9.3 (range 2.2-25.0) years. Patients who were alive and could be contacted were invited to complete a Short Musculoskele-tal Functional Assessment (SMFA) questionnaire that was scored for functional, mobility and bothersome indices. Results: Seventeen of the 33 diabetics died. Four (12.1%) were converted to the transtibial amputation level. One of the non-diabetics had died and one (5.5%) was converted to the transtibial amputation level. Eleven of the thirty-three patients who were con-tacted completed the SMFA. All of these patients demonstrated favorable outcome scores in the mobility, functional and bothersome indices (non-diabetic mean mobility score of 17.2, function-al index of 14.7 and bothersome of index of 16.7 compared to 34.7, 29.9 and 30.6 in the diabetic patients, respectively). Conclusion: The objective information derived from this investigation supports the opinion that patients with Syme’s ankle disarticulation amputation appear to fare better than sim-ilar patients with transtibial amputation. This data also refutes the notion of high complication rates and difficulties with prosthetic fitting. These patients require less rehabilitation and achieve improved levels of functional independence as demonstrated by favorable functional, mobility, and bothersome indices.

Long-term Outcomes Following Syme's Amputation.

The metabolic cost of walking after Syme's ankle disarticulation amputation is minimally more than that for nonamputation. The ability to end weightbearing makes prosthetic fitting relatively simple, and very few patients require extensive rehabilitation or placement in a skilled nursing or rehabilitation facility. In spite of these potential benefits, there is a paucity of objective information on the actual long-term outcomes. Fifty-one patients were identified who underwent single-stage Syme's ankle disarticulation amputation with excision of the lateral and medial malleoli by a single surgeon during a 23-year period. None of these patients had sufficient tissue to allow amputation at the transmetatarsal or tarsometatarsal levels. Thirty-three underwent amputation due to a diabetic forefoot infection, 11 secondary to a crush injury, 3 for a nondiabetic infection, 3 for a noncorrectable acquired deformity, and 1 for neoplasm. The average age at surgery for the diabetic patients was 62.1 years (range, 36-81 years), with an average follow-up of 6.8 years (range, 4.0-11.6 years). The nondiabetic patients had an average age of 37.8 years (range, 21-65 years), with an average follow-up of 9.3 years (range, 2.2-25.0 years). Patients who were alive and could be contacted were invited to complete the Short Musculoskeletal Function Assessment (SMFA) questionnaire that was scored for functional, mobility, and bothersome indices. Seventeen of the 33 diabetic patients died. Four (12.1%) were converted to transtibial amputation. One of the nondiabetic patients died, and 1 (5.5%) was converted to transtibial amputation. Eleven of the 33 patients who were contacted completed the SMFA. All of these patients demonstrated favorable outcome scores in the mobility, functional, and bothersome indices (average mobility index of 17.2, functional index of 14.7, and bothersome index of 16.7 for nondiabetic patients compared to 34.7, 29.9, and 30.6 for diabetic patients, respectively). The objective information derived from this investigation supports the opinion that patients who underwent Syme's ankle disarticulation amputation appear to fare better than similar patients with transtibial amputation. These data also refute the notion of high complication rates and difficulties with prosthetic fitting. These patients required less rehabilitation and achieved improved levels of functional independence as demonstrated by favorable functional, mobility, and bothersome indices. Therapeutic Level IV, retrospective series.

Severe forefoot infection complicated by Fusobacterium russii

We present the first case of a complicated foot infection caused by Fusobacterium russii in Austria. F. russii is highly associated with mammals such as cats and dogs. Our case underlines the difficulties in isolation and identification of anaerobes and the pitfalls in antimicrobial treatment of polymicrobial infections.

Functional outcomes of transmetatarsal amputation in the diabetic foot: timing of revascularization, wound healing and ambulatory status.

Transmetatarsal amputation (TMA) is an effective surgical approach to treat forefoot infection and gangrene in diabetic patients. However, a high rate of complications and failure to heal require reamputation in a large number of cases. We analysed the outcomes of TMA to define the role of revascularization, wound healing and ambulatory status. From January 2008 to January 2013, 218 diabetic patients with foot infection and gangrene, submitted to TMA associated to revascularization were followed until healing, amputation or death. Revascularization was done in 202 (92%) cases. In 16 (7%) no revascularization was required. The TMA was closed in 135 (62%) and left open in 83 (38%) cases. The reamputation rate was 34% and major amputation 12.6% at 1-year follow-up. Patient following ranged 2-30months with a mean of 15months. The functional outcomes, living at home and ambulation outdoors, were 60 and 36% at hospital discharge after TMA, 81 and 77% at 1-year follow-up. TMA associated to revascularization can provide an effective limb salvage and functional results in diabetic patients with forefoot tissue loss and infection.

Application of platelet-rich gel to enhance healing of transmetatarsal amputations in diabetic dysvascular patients.

Transmetatarsal amputation (TMA) represents an effective surgical procedure used to treat several clinical conditions such as forefoot infection, gangrene and chronic ulceration in diabetic patients. TMA permits walking without the need for prosthesis, but nevertheless is burdened with a high complications rate. The aim of this study was to evaluate the possibility to use platelet gel (PG) as an adjuvant therapy when performing TMA procedure in diabetic patients. In a 6-year period, 26 diabetic patients had undergone TMA procedure followed by autologous PG applications (group A) and 32 patients had undergone TMA as sole procedure (group B). After TMA procedure, the treatment is based on outpatient management and consists of a weekly platelet-rich plasma gel application on the surgical wound for 1 month in group A and on clinical evaluation only for group B. For group A, healing rate was of 96.15% and one patient (3.84%) presented wound dehiscence, and no postoperative wound infections occurred. For group B, healing rate was of 59.37%; severe infection of the stump prompted to the proximal amputations in 40.62% of patients during the follow-up period. PG application may be an effective adjuvant treatment to improve wound healing in diabetic dysvascular patients.

Ciprofloxacin-Induced Hemorrhagic Vasculitis

Ciprofloxacin-induced hemorrhagic vasculitis is a rare side effect. It has only been described in 10 case reports since 1989. However, recently we were confronted with two cases within 1 month. In one patient the vasculitis resolved after termination of the ciprofloxacin therapy; in the other patient the ciprofloxacin-induced hemorrhagic vasculitis was superimposed on a severe forefoot infection, leading to progressive gangrene and a below-knee amputation. Ciprofloxacin is among the standard treatments for infected ischemic ulcers; in the rare case of ciprofloxacin-induced hemorrhagic vasculitis, it might be interpreted as progression of infection, instead of a complication of the treatment, thus leading to faulty diagnosis and treatment. The intention of this case report is to raise awareness for anyone prescribing ciprofloxacin as treatment for infected diabetic and ischemic ulcers.

Transmetatarsal Amputations

Transmetatarsal amputation is a viable alternative to below-knee amputation in patients with deep forefoot infection, necrosis, or unreconstructible trauma. This treatment offers the patient maintenance of a full length limb, normal shoe wear, and more efficient ambulation when compared with a more proximal amputation. Careful evaluation of the patient, preoperative planning, and surgical technique will aid in minimizing complications. The technique is described, with importance placed on soft tissue care. Complications are expected in the diabetic and vasculopathy populations; techniques to help deal with them are described.

Clinical outcomes after closed, staged, and open forefoot amputations

Surgical approaches for forefoot osteomyelitis include amputation with immediate wound closure or resection followed by either staged re-resection and wound closure or local care of the open wound for secondary healing. This study evaluated the effectiveness of closed, staged, and open forefoot amputations in preventing major leg amputation and identified those variables that are associated with successful limb preservation. From July 2002 to June 2004, 208 patients with forefoot osteomyelitis or gangrene underwent minor amputation according to a standard treatment algorithm. Wounds with limited cellulitis underwent immediate wound closure (CLOSED), wounds with marginally viable soft tissue underwent open amputation followed by wound closure at 2 to 7 days (STAGED), and wounds with tenosynovitis or extensive necrosis underwent débridement with no attempt at wound closure (OPEN). Patient demographics, need for further operative interventions, time to complete healing, and progression to major amputation were recorded. With four subjects lost to follow-up, 204 patients (98%) (94 CLOSED, 56 STAGED, and 54 OPEN) were monitored to complete healing, major amputation, or death. OPEN amputations had a significantly reduced initial healing rate (37%, P < .001) and a frequent need for repeat operative intervention (43%), although successful limb salvage was ultimately achieved in 70% of the cases. Initial healing in the CLOSED and STAGED amputation groups was similar (71% and 78%, respectively), leading to excellent early limb salvage (86% and 91%). The median time to healing for closed, staged, and open amputations was 1.2, 1.6, and 4.6 months, respectively (P < .001). Follow-up evaluation demonstrated the initial improvements in limb salvage with the CLOSED and STAGED groups were lost, resulting in similar amputation rates among the three groups of 30% to 35% over 36 months. Although open amputation of extensive forefoot infections frequently requires repeat operative interventions and a prolonged time to complete healing, this approach provides limb salvage rates approaching those observed for less invasive infections amenable to immediate closure. Staged closure offers an improved time to healing without negatively impacting the risk of major limb amputation. Independent of their initial operative approach, these patients frequently progress to early leg amputation.

Mycobacterium chelonae as a cause of forefoot infections

A 33-year-old lady presented to our unit after multiple failed debridements of a foot ulcer developing after wading in stagnant water. Despite culturing polymicrobial flora and receiving long-term antibiotics the ulcer failed to improve. After presenting to our unit, all antibiotics were stopped for 7 days and several deep samples were taken which grew avid fast bacilli in several samples. Mycobacterium chelonae was cultured. Appropriate antibiotics were given resulting in complete healing of the ulcer. Discussion: Chronic foot ulceration is usually associated with the presence of underlying vascular insufficiency or neuropathic disturbance. The presence of a persistent ulcer and the absence of these risks should alert one to initiate a search for alternative culprits. Atypical mycobacteria are ubiquitous. They have been recovered from water, soil, milk and food products. Risk factors for atypical bacterial infections should be ascertained and should involve a comprehensive review of their occupational and recreational activities in particular any history of penetrating injury or regular exposure to fresh water or seawater. Successful treatment involves suspecting and identifying the organism and treating with appropriate antibiotics.

Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status

Purpose: The intermediate success and outcome of primary forefoot amputations in patients with diabetes mellitus who have sepsis limited to the forefoot and presumed adequate forefoot perfusion, as determined by means of noninvasive methods, was studied. Methods: Cases of a university hospital-based practice from January 1984 to April 1998 were retrospectively reviewed. Patients included had diabetes mellitus with forefoot sepsis requiring immediate hospitalization for digit amputations who had adequate arterial circulation for healing based on noninvasive and clinical assessment: palpable pedal pulses (29%), “compressible” ankle pressure of 70 mm Hg or higher (48%), pulsatile metatarsal waveforms (67%), and/or toe pressure higher than 55 mm Hg (36%). All patients underwent a primary single- or multiple-digit amputation (through the interphalangeal joint, metatarsal head, or metatarsal shaft). Additional forefoot procedures (debridement, digit amputation) were performed during the follow-up period as needed for persistent or recurrent infection. The main outcome variables were recurrent or persistent foot infection (defined as requiring rehospitalization for antibiotics, wound care, and/or reoperation), the number of repeat operations and hospitalizations for salvage of limbs with recurrent or persistent infections, and time to complete forefoot healing or foot amputation. Results: Ninety-two patients who had diabetes mellitus with 97 forefoot infections comprised the study group. Ninety-seven primary digit amputations (34 through interphalangeal joints, 28 through metatarsal heads, 35 through metatarsal shafts) were performed. The median length of hospital stay was 10 days. There were no operative deaths. The mean follow-up period was 21 months (range, 3 days to 105 months). The primary amputation healed (without persistent infection) in only 38 limbs (39%), at a mean time of 13 ± 10 weeks. Twenty-three limbs (24%) had not healed the primary amputation without evidence of persistent infection at last follow-up (mean, 12 weeks). Infection persisted in 35 limbs (36%), and infection recurred in 15 of 38 (40%) healed limbs. An average of 1.0 reoperations (range, 0 to 3) and 1.6 rehospitalizations (range, 1 to 4) were involved in salvage attempts in these recurrent/persistent infections. Five persistent and five recurrent infections ultimately healed (mean, 53 weeks). Complete healing was achieved in only 33 of 97 limbs (34%). Twenty-two foot amputations (20 transtibial, two Syme’s) were performed (mean, 49 ± 74 weeks; 20 for persistent infection). Eighteen persistent/recurrent infections remained unhealed at the last follow-up examination (mean, 105 weeks). Conclusion: Patients with diabetes mellitus who have sepsis limited to the forefoot requiring acute hospitalization and undergoing primary digit amputations have a high incidence of intermediate-term, persistent, and recurrent infection, leading to a modest rate of limb loss, despite having apparently salvageable lesions and noninvasive evidence of presumed adequate forefoot perfusion. (J Vasc Surg 1999;30:509-18.)

The Diabetic Foot

The pathophysiology of foot problems in diabetic patients is poorly understood by many physicians. Two major factors that frequently lead to a delay in appropriate treatment with subsequent limb loss are failure to appreciate the presence and severity of underlying infection and attribution of gangrene of the toe and forefoot to microvascular disease. To evaluate the consequences of delayed recognition and treatment, we reviewed the records of 55 diabetic patients with localized gangrene or infection of the forefoot in 62 limbs, treated consecutively on a single vascular surgical service over a 2-year period using a standard protocol. All appropriately treated neuropathic ulcers and forefoot infections healed in patients with palpable pedal pulses. If foot pulses were absent and arteriography confirmed large-vessel occlusive disease, foot lesions and infections likewise healed if concomitant revascularization was done. In our series, 33 bypasses were required because of severe atherosclerotic occlusive disease. Only one patient had "unreconstructable" arterial disease. Limb salvage was 86% at a mean follow-up of 12.4 months. In 16 of the patients (29%), there was a prolonged delay between initial treatment and referral for definitive care. The specific causes of delay were underestimation of the severity of foot infection in 10 patients, and lack of recognition of ischemia due to large-vessel occlusive disease in six. These delays led to more proximal levels of amputation in six patients, including three below-knee amputations in patients with limbs that were initially salvageable.

Open transmetatarsal amputation in the treatment of severe foot infections

Severe forefoot infections may lead to limb loss, even if addressed aggressively. Infection or gangrene that compromises the plantar skin flap may preclude a standard transmetatarsal or midfoot amputation, thereby culminating in a below-knee amputation. We report a series of forefoot infections with loss of the distal plantar skin. Open or guillotine amputation at the mid-metatarsal level led to a high rate of healing and a durable stump, provided that the level of infection did not extend beyond the metatarsal heads. Wound closure was obtained by wound contracture alone or by use of partial-thickness skin grafting. Rehabilitation was dependable. The association of diabetes mellitus or gangrene did not adversely affect outcome. Open transmetatarsal amputation is a safe surgical option preferable to midfoot or below-knee amputation for the treatment of severe forefoot infection that does not extend proximally beyond the metatarsal heads.