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Larry Fallat, DPM
Director of the Podiatric Surgical Residency
Beaumont - Wayne Hospital
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TAPE STARTS -- [00:00]
Larry Fallat: I wanted to share this with you as residence. This is important for you because I don’t know how much you get in school with this. These are may be more, a little more involved than simple ankle fractures, these are open fractures, dislocations and so on. So, you know, you have to have a protocol for open fractures and sometimes when we interview students, we ask about that they just, you know, cut off guard, they don’t know what the protocol is other than we need to operate fast. But if they know that already, they’re on the right track. So to expedite, I’m going to just show you this part here. Kindsfater determine that a few operative within five hours of an open fracture, the infection rate was approximately 7%, but if you waited after the five hours the infection rate grows to 38%. So we like the six hour rule, if at all possible we’d like to operate immediately. This is usually medical emergency and we need to jump on it. So, this is the part the residence do, I’m not so much involved with this. The patients goes to the ER, they have an open fracture, the residence will assess it, they’ll determine if there’s arterial damage of nerves have been cut, tendons have been cut. Do we take cultures? Well I think for legal purposes you can, but the study by Lee indicated they are virtually useless, not a correlation between the cultures taken in emergency room and whether post operatively they develop infection or not. Antibiotics are started, they’re given tetanus prophylaxis. We get our imaging studies, we can irrigate them in the emergency room. And then the residence with sedation will do a close reduction, apply splint and then we’ll discuss our surgical planning, if it’s open fracture we jump on it as soon as we can. You got to know this, and by the way this is a lecture in itself and I don’t have time to go into, therefore you, but you need to know the Gustilo Anderson classification and most of the injuries we treat are going to be type 2, type 3 type of injuries. And so we’ll classify this and then we take him to surgery and initially we’re going to debridement, irrigation, fracture stabilization and we’re going to take cultures. And we do the culture after the irrigation. We’ll throw in retention sutures, so let me show you a couple of things here. Now this is a gunshot wound, but look at those necrotic edges of the skin. You know, as a resident, this is what you’re going to excise. You want a nice, clean, smooth surface. On the image on the right Anaheim stab were pulling has sock out of the wound. And if it’s a gunshot wound, you pull socks out, parts of their shoe, parts of a bullet. Look at on the right, there is a grass embedded. This guy was cutting his grass when he stepped in a pot hole and had an open fracture. And then on the image on the left, I’ll show you this if we have time. The dirt was embedded in the body of the talus and then we scrubbed it, couldn’t get the debris out, so we use the burred that kind of grain some of the debris out. So, our goal is to really clean up the wound. Then we admitted him, and we wait for our cultures usually, then if everything is clean we do a definitive surgery. We remove the external fixator, we irrigate again, we do open reduction and then, you know, retention sutures. I want to explain some of this and show you this woman. 39-year-old female, she fell transitioning from to a car. We don’t know the mechanism of injury, she is mentally impaired, couldn’t tell us, but still can’t tell us what happened. Many comorbidities, many allergies, BMI is 71.9. So, that’s tough, you know, that’s tough well not me, I’m the residence because they’re the ones that have to position her and transfer her and manipulate her, but look at this wound that we have to deal with. You know, that’s pretty significant and look at the imaging studies on the lateral view you see the laceration on the dorsal surface. Ad then the X-ray is on the right, so she has a really not a displaced but bimalleolar ankle fracture. So we get an MRI to check out the tendons and tibialis anterior still intact, and I would have bet at my house that tendon was cut, let’s see what we’re faced with.
This is her and all we’re doing is pulling. They had a pulls tissue back to try and evaluate. You know, that’s a mess, you can’t see anything in there, this is very difficult, but this why we have our imaging studies, you know, our MRI to help us with that. We’re showing you the tibialis anterior tendon, we couldn’t find the extensor tendon to the toes. That’s the saphenous vein, the artery was intact. So for irrigation, for all of these open fractures we’re using Haglund’s suggestion, this is not the hard science. Three leaders were Gustilo Grade 1, six leaders, Grade 2, nine leaders for a Grade 3 open fracture. We have multiple drains in there, so yes we did use retention sutures. And we have followed her up and she actually can move the toes and her ankle, so I don’t where her extensor tendons were, but she didn’t cut them and somehow she didn’t cut the dorsalis pedis arteries, so. But I want to show you one other thing real fast on the heavier patients. You know, if you have a broken ankle, how do you fix it? What do you do? You cannot make an incision in that tissue because with those folds, the incision site becomes macerated and it never heals, that ulcerate, it’s a source of infection. So just keep this in mind, this is a close reduction with trends articular fixation. It’s not pretty but it’s much, much safer. And you see we’ve use the big Steinmann rods to stabilize this. This is an acceptable way to manage something like this because you cannot get in there and do the same operation that you would on a 30-year-old with the BMI of 20. So that’s just a little tip. On our diabetic patients, look at this study, look at the non-diabetic infection rate, ankle fracture on 8% closed. Infection rates in the diabetes 10 to 60% increase amputation rate, increase mortality rate, especially when you combine all of these comorbidities. So these are bad news. But let me show you how we did that, I have two cases to show you here, one is a simple ankle open fraction, the other is a little more complex. This gentleman, 52-year-old-male diabetes, bipolar peripheral neuropathy, that’s the key, I highlighted for you guys. This is where we have to be more careful. This is him coming in through the ED and this is the X-ray, and you see the fracture dislocation. And then close reduction image, this is what he looks like here. At the time of surgery and I think we go right to the operating room with this. I don’t think he’d eaten all day wound assessment, almost like a mini degloving injury. So we’re checking the arteries, we’re checking how far approximal we can put our hand in to determine the amount of tissue disruption. We irrigate the wound, and then just so you know, high pressure pulse lavage, 70 pounds is usually what’s being used the higher pressure much more effective at reducing bacterial count especially if the injury is older than six hours, but it can cause microscopic damage to the soft tissue even to the bone, just be aware of that. He’s placed on antibiotics. So if you take a look at the image on the right, that’s exactly what you think it is. This is part of the real life management of these patients, he had diarrhea on the operating table and this is the first time in six months I did not wear shoe covers and I’m standing right there and I can feel it hitting the back of my ankle and I just cringed. So alright you can tell I am traumatized by that [laughs]. So, but anyway, so stool cultures, you know, and. But anyway here’s a delta frame, a great little frame, its stable, it’s easy to apply and it reduces the amount of pain that they have, it reduces the amount of soft tissue disruption, you know, say ankle flopping and moving around. We love this little device, this is what it looks like. So we’ve taken our cultures, we’ve done our primary initial procedure, now we’re waiting cultures comeback, everything is fine, then we can take him back and do a more definitive surgery. And here we’ve done open reduction internal fixation. Now, study by Caroline [Phonetic], 14% incident is skin necrosis and open fractures, not my experience 100% on these wounds do not heal well and everyone of them has gone on to form ulceration.
So I’ll make you guys aware of that. Here he is at four months post-trauma, doing better, eight months pain is down to one out of 10, he’s finished his therapy, he is on disability and we’ve essentially discharged him, so no osteomyelitis, no infection, we’re never able to culture anything out of there, so he’s done quite well, he walks, I’m sure with the cane but this has worked out pretty good. But let me show you another one. This gentleman, 59-year-old diabetic, he fell in his kitchen I believe but he walked 12 hours before his dad, notice there is blood in his shoe. Neuropathy was so pronounced that he didn’t feel anything. Osteoporosis, neuropathy, five cardiac stints, hypoglycemic, and so you see all the many comorbidities that we deal with. So that’s the assessment, here his X-ray. I want to show you this, this is what’s different, and one of the things different between this and the last case I showed you. Look at his lateral, it’s the distal tibia and you see the sclerosis that represents lateral osteonecrosis. Bad news, I hate seeing it because they rarely, rarely will heal and do well, almost always they go on to fusions. This bone is compressed, it takes the mortise out of alignment, but it just never seems to do well. But interesting James Thomas lecture on this and some best lecture I have ever heard on lateral osteonecrosis. So if you ever have the opportunity to listen to him, go hear this, it’s worth the effort. So, when I see this, especially in somebody with the comorbidities, and then neuropathy, you know, we tend to go right to arthrodesis procedure. This is the initial procedure, we wash the wound, we put a delta frame on and in here I’ve supplemented it with trends articular fixation and you can do this. A lot of residences think you can’t because you might take bacterium to the tibia. You know, theoretically the wounds are already contaminated and the literature supports doing this and it provides further stability. This is what we’re trying to avoid, combination of osteomyelitis and Charcot changes of the ankle joint. Now I’m going to move on from this one because of time, so we did a primary arthrodesis, this was the second operation. The first was irrigation and debridement. And look at the construction here. I have three layers of protection for him, I have a lateral neutralization plate, I have multiple syndesmotic screws, we have an IM now and we have an external fixator. What could possibly go wrong? This is what he looks like on the lateral view, this is what he look like clinically, this is beautiful. But let me show you something here. Do you see on his shorts, that’s a sweat suit, do you see the discoloration, that’s where he would pee. His sugar drops and as low as 17, he loses control of his bladder and he pees. And if you look, these are like the layers of the rings of a tree. You know, for each time he’s peed and it’s dried, and he’s not aware that he’s doing this. But can you imagine it’s running down into our wound. And so this is another problem that we’re faced with, this is what you don’t read in these articles in the medical literature. So eight and so we keep a closer eye on him, you know. Eight weeks post opt, take a look at the image on your right, the medial aspect of the ankle joint we’re starting to see loose since it there. So is this osteomyelitis, and this and blown it up. In addition to that screws are starting to back out. So he shows up for bone biopsy. This is what an external fixator can do in the patients opposite leg and he is using his frame. You know the way you start a motorcycle, you know, you jump start it, you kick start it, but look at his left legs. So we know we have to get that thing off his, for him this is not the way to go. So we did the bone biopsy, it came back negative; this was apparently normal resorption of bone. And then I took him back and revised his fixation, so here we have six syndesmotic screws and IM nail, and ultimately the wounds have healed, he has fused and he is discharged from our service. Now how much time do we have left here? I had until 9:25. Pardon me, are you saying two minutes? Oh boy.
Okay two-minute presentation, because this is a cool case, you guys will love to see this. So a 55-year-old male, he was working on a roof and fell of his ladder, 22 feet. And just before he hit the ground his foot and ankle got caught in the wrongs of a ladder and you see the injury that he has. He got in his car; he crawled to his car, drove to the emergency department and crawled into the emergency room. So this is what he has, complete medial subtalar dislocation and talar and neck fracture. Very rare case, with skin that literature we haven’t found another case exactly like this and I mean this is bad news for this guy, you know, he think he’s okay, is he going to keep his leg. So injuries like these, this medial subtalar joint have been called acquired clubfoot they make up 85% of subtalar dislocation, it’s a common. But after we washed him up, you take a look, you know, you’re looking at the interior aspect of his ankle. You see his tibia, his medial malleolus and this helps you appreciate how severe the dislocation is. And let’s see, I’m going to advance this. He is the one I showed you where the dirt was ground and so bad, I had to use a burred to kind of get it out and you see the antibiotic regiment that we had placed him on. You know, the mechanism so for experience, I’m going to pass through this. Open reduction was very, very difficult, certainly we distract, we plantar flaps and we supinate. And the Army Navy is being used actually to help reduce the fracture. We had my partner Dr. Morrison on Army Navy, and she’s got arms like twigs but they’re strong a still cable, she’s stronger than I am. So I had her do that. And here its pop back into the place, you know, we had to repair the capsule, the subtalar joint and the peroneal tendons were disrupted and everything. So if you look at this, knowing the vascular supply like we do, and knowing the injury, you know, you’re going to predict of what is happening to him. This is open reduction internal fixation that notch on the lateral view dorsally is where I took the burred to grind that. Watch his subtalar joint, let me backup. As he heals, and by the way here we have three months, two blabs that incision in drainage. She has infection in that area, that bone biopsy which was negative, we pack him with antibiotic beads. Then as he heals he becomes very stiff and fibrotic, did another operation interior approach, release the capsule. Most of the scar tissue that limited motion was at the tail on a vacular joint, some at the level of the ankle joint. A complete Achilles tendon lengthening, here’s the motion of the operating table. Hawkins sign, of course we see that, but look at his posterior facet. It almost like the telesis dislocating posterior, it’s not, but this is the arthritis that’s setting in. Six months post op, you can see the subtalar joining a little bit more the fracture has healed, he’s returned to work, one year post op, full activity, no problems. I’m going to leave you with that and hope I didn’t hold you up to too much. Thank you everybody.
TAPE ENDS -- [18:32]