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This patient is a 36 y/o incarcerated Hispanic male, s/p right total trans-metatarsal amputation x 2 months as r/o suspected osteomyelitis with a long history of complications r/t IDDM.
The surgical incision healed relatively quickly except the far lateral edge which required packing due to rolling edges. Shortly after sutures were removed and wound was considered essentially healed, the patient returned for a follow up visit to have calluses removed. Upon partial removal of a callus around the end of the 5th metatarsal, a 2.5mm open area was uncovered. A moderate amount of serosanguinous fluid was expelled and after cleansing area was found to have small sinus tracts towards the lateral aspect of the foot. Area was packed and dressed, etc.
24 hours later during follow up, the area was found to be completely covered with epithelium. (The patient stated the dressing had gotten wet and he removed it). Dressing changes were increased to BID and area healed in about 2 weeks, but this process has been reoccuring since then. The patient is evaluated/dressings changed daily, but will sometimes have a complete layer of tough, thickened skin present over the immature wound bed in as little as 24 hours. At the moment it requires sharps debridement every 1-2 days.

If anyone has any suggestions I would be very appreciate; I am getting extremely frustrated with the situation and welcome any help.

*Kellie M Miller LVN*
Wound Care Nurse
Big Spring, TX

 

Kellie

The foot has gone into equino-varus due to muscle imbalance following the trans-MT amputation. This is a common complication, leading to overload of the remaining 5th metatarsal stump and a transfer lesion.

The solution is typically to combine the amputation with a simultaneous percutaneous tendo Achilles lengthening at the time of surgery.

Fortunately, this can also be done at this time also. The procedure can often be safely performed in the outpatient setting by someone competent in the procedure. The main issue is to avoid overcorrection leading to a calcaneal gait pattern, creating a new transfer lesion to the plantar calcaneus.

There are several leading podiatric surgeons with expertise in this procedure in Texas.

Hope this helps,

LL

 

Hi,
We commonly perform a split tibialis anterior tendon transfer (STATT) in conjunction with gastroc lengthening (as opposed to Achilles lengthening) in our TMA patients.
Previous cases where this STATT hasn't been performed, resulted in the same frustrating problem you have reported and only resolved after carrying out this adjunct procedure at a later stage.
Regards,
Ryan