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Salvage/amputation case

Discussion in 'Diabetic Foot & Wound Management' started by suresh, Sep 27, 2007.

  1. suresh

    suresh Active Member

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    dear all.
    52 year old man, diabetic for last 10 years,
    had septic knee 3 months back
    following developed blebs over the leg and had undergone
    debridement and ssg
    now admitted with open wound over the knee with active infection
    non ambulant but with glycemic control

    opinion regarding management..
    arthrodesis knee/Ak amputation.


    Attached Files:

  2. javier

    javier Senior Member

    Re: salvage/amputation

    Hello Suresh,

    I am not surgeon thus I can not advice you about the surgical procedure. But, from my experience due to diabetic amputees I would consider quality of life and prosthetic options before choosing a surgical procedure. Also, what about the infection?

  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Re: salvage/amputation

    Hello Suresh

    You always bring such interesting cases to this discussion group. Thanks for sharing them with us...please let us know how they turn out.

    I understand the resources available to this patient might be limited so I would offer the following thoughts.

    1. It is obviously not prudent to fuse the knee whilst it this state. You will just end up with septic hardware and more problems than you started with.

    2. If the wound can be closed (?do you have Vacuum Assisted Closure), and infection treated, then options are better. I think this would be of enormous help here. You don't mention what the actual state of the knee joint is - will it really need a fusion?

    3. I would rather see this man have a BK rather than a AK amputation, for long term mobility and prognosis. So it the knee can be closed, and infection resolved to below the knee, that might be an idea.

    Difficult choices, but if you have the resources, I would try to save the leg if possible...

  4. bob

    bob Active Member

    Re: salvage/amputation

    Suresh, do you have access to MR? This poor gentleman needs an assessment of the extent of osteomyelitis within the limb. I presume you've x-rayed the leg? This will give you a guide, but an MR scan will give you a better idea of how far the infection has tracked into the femur. I presume he's not responding to IV antibiotics and the medical route is being exhausted. Arthrodesis of the knee is likely to be optimistic/ a waste of time and cause of tears for your unfortunate patient. LL's comment on adding fixation/ hardware is fair - it's an excellent place to harbour bacteria and reduce blood supply to an already compromised area.
    You haven't told us about the vascular supply to the foot/ leg - how likely is good antibiotic penetration and healing? Is he systemically well? No sign of sepsis?
    These factors (along with medical management, quality of life, home support, etc..) need to be weighed up. Looking at it, I suspect an above knee amputation might be the likely outcome.
  5. suresh

    suresh Active Member

    dear javior,LL and bob,
    thanks for your response.

    x ray the knee shows, destruction of both tibial and femoral
    codyles, you can see the granulation tissue covering the
    coundyles..(sorry i dont have x ray pics atpresent)
    MRI not taken so far...

    vascularity of the foot was satisfactory

    we are planning to use external fixator , no hardware inside..

    my initial plan was amputation, after few days dressing now feel salvage by doing
    arthrodesis.(if seenig only the limb)

    after this discussion, now i feel
    i will go by staged procedure
    1. infection control and wound cover

  6. bob

    bob Active Member

    I would seriously recommend getting an MR scan of this patient's leg. Your x-ray has shown destruction of femoral condyles (and tibial plateau), in your 2nd picture you can clearly see into the joint cavity, there is considerable granulation tissue around the condyle of the femur. To treat this case as a simple septic arthritis without suspecting tracking osteomyelitis proximally is very optimistic. You might like to try surgical debridement of the infected bone with implantation of antibiotic impregnated beads to attempt to attain closure prior to your arthrodesis if your motivation is fear of future law suits and having not offered this patient an option. However, you need to assess how far the infection has tracked. If your arthrodesis is to be performed with external fixators, where are you going to put the pins? Into/ through an already infected area of bone? You need to MR scan the leg or do bone biopsies to attempt to guide your assessment of spread of this infection. Scan the guy's leg, then discuss the options with him. I suspect there will be 2 - continue with medical management and hope the necrotic tissue just falls off naturally (joke!), or above knee amputation at a level that's appropriate.
    MR the leg.
  7. suresh

    suresh Active Member

    dear bob,
    i too agree with you.

    recently we lost a patient post TKR, wound infection,
    implant removal and arthrodesis done,subsequently
    he had pin site infection, septicemia and died.

    in this patient , now i realize the importance of MRI.

    still my plan is for Ak amputaion. since i am doing post graduation,
    in institution, decession making is not in my hand

    i let you know about the case

  8. suresh

    suresh Active Member

    today , we posted for arthrodesis,
    but on table we deiceded and ak amputatation
    was done.
  9. suresh

    suresh Active Member

    intra operative pics attached .
    even mid thigh level i am not satisfied with
    the healthy soft tissue .we did gullitine amputation at the level of

    Attached Files:


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