Devin Bland, DPM discusses techniques in evaluation and management of digital and forefoot soft tissue and bone infections. Dr Bland also describes different studies to consider ordering in patients with digital infections of bone and/or soft tissue when considering amputation as a treatment.
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TAPE STARTS – [00:00]
Male Speaker: Our next speaker is new to Desert Foot. I’m happy to introduce Devin. Toe Amputations are the most amputations that you are going to be doing, because the toes that get the brunt of the trauma for the most part, and you must be very familiar and comfortable with the need for Toe Amputation. A very simple procedure, but it must be done right, it must be properly assessed as Chuck Anderson had said.
So I could think of nobody. I would like to hear from more than my past resident Dr. Devin Bland who finished his training at the Phoenix VA and went on to really good Fellowship Training in Limb Salvage and Reconstructive Surgery in Alamogordo, New Mexico. And he now works up at the Indian Health Service Hospital in Tuba City up in Northern Arizona. So let’s welcome Devin Bland for the first time.
Dr. Devin Bland: All right. My fellow colleagues, it’s a pleasure to be here today. As Dr. Friberg alluded to I am new to the group and really anxious to share some of the cases and some of the patients that we’ve taken on recently. Before I get to that, however, I attended a conference approximately six weeks ago and one of the lectures said that you should always pay tribute to those who’ve had a large amount to do, I should say, with your retraining and so I do have to absolutely recognize Dr. Friberg for the time I spent with him and for his continued impact in the way that I treat patients in my thought process and especially in my clinical decision-making, I really do appreciate that, not to mention the rest of the faculty at the Phoenix VA that’s where I trained and that’s where I finished up.
So moving on to Digital Amputations. I have no financial interest to disclose. My learning objectives this morning are going to be three fold, Treating Advance Digital Pathology you’ll find most of my lecture will be clinical based. I feel with the change in the recent law are now allowing amputations that I could show some pictures or we could highlight some of the cases that we’ve done, some of the more difficult cases, and maybe share some thoughts or some ideas with the practitioners here in the group to help guide the patients that you will be called to take care of. My second point of course what studies can be assistance while treating the Digital Pathology and Dr. Friberg did a magnificent job of outlining those. So I will hit on those briefly and then also surgical techniques of the Digital Pathology.
So, here are some pictures that we have collected and you’ll see here the Digital Pathology really does come in all shapes, forms and fashions. Each one of these are patients that my team up there at Tuba and then back in New Mexico actually took on. And each one is a little different to be honest so it’s good to really appreciate the nuances between the different types of pathology there. Things to consider when taking on Digital Amputation, patients with forefoot ulceration, cellulitis, necrotizing-type fasciitis, the blood flow status first and foremost of course I’m going to hit on this. This is in my opinion one of the absolute most important things when you’re trying to treat patients with forefoot ulcerations.
So I look first and foremost an ABI. It’s quick, it’s easy we get it and it gives me a good starting point as to exactly what I’m dealing with. Secondary to that, I like to make sure that the tissue is actually being perfused. We will order at TcPO2 and then of course your PVRs are going to be paramount that as well.
Second to that, the infection. Do we really know what we are treating here. And so we’ll obtain cultures. We try never to do a swab I know that’s been brushed upon a couple of times. I would like a deep tissue culture. Most of my patients are neuropathic and so that can very easily be done at bedside or if there is a mucopurulent drainage we can absolutely culture that as well. How are we offloading this if at all? The cam boot is a nice choice. Some providers have even single as far as a postop shoe. I think that to that like I said is a good starting point but you actually need to put some felt or some plastazote or whatever it is you have in your clinic to actually offload that ulceration within your cam boot or whatever it is that your choosing. I think another thing that gets overlooked is a mechanical deformity as well. So many times we’ll see patients who come in, they have a history of Charcot and they have a rocker bottom type foot and obviously that is going to be one of the deforming forces that is going to your cause ulceration.
So let’s get into some clinical patients that I have seen here. This young man was actually one of my favorite patients to treat. We’re the same age, so it was kind of interesting. 33 years old, he is diabetic, his A1C is elevated as you can see there. He retired from military service three months prior to me seeing him in the clinic. I put on that he was suffering from depression. I think managing patient’s expectation is also something that we need to take into consideration. When I met him he said, I’ve had this wound, I don’t know how long it’s been there, I don’t really care what you do, cut it off. And I shared with actually some of the data that has been brushed upon now a couple of times saying, you know if we amputate it sets you up for further amputation down the line and I shared with him the data and tried really to get him to understand the magnitude of what he was saying.
So taking a look there, there is no question that we absolutely need to carry out some form of surgical debridement. This was done at bedside as far as talking or as far as managing a patient expectation when I carry out an incision and drainage such as this, I have no reservation telling the patient that they may lose the digit and we are going to try everything we can to not only save the digit but to save the foot, the leg and ultimately the life.
So you can see here what our next steps? What are our options and how do we monitor patient’s compliance with this? We’ll get into that as we go through the presentation here of this patient. I did as you can see it obviously was very close to the bone, so I did harvest a bone biopsy three separate sides to negate any type of a sampling error, antibiotic management we’re waiting for cultures to be returned to us. So we did start with broad-spectrum antibiotic. And then I am a big advocate of the Antibiotic Bead Therapy. I’ve got some pictures in the lecture of different modalities that we can use. I did place a vascular consult. I have a very low threshold on that even if I think that they have decent blood flow, I still really value the vascular console. And then ultimately I got a CT Scan for two folds, one to make sure I didn’t miss any occult pus pockets and then two to make sure that there was no gas given the primary presentation.
So here is a picture of my antibiotic therapy. I’ve got actually two different products here, the one on the right is your typical calcium sulfate product.
if I’m treating a wound or an ulcer that tunnels deep inside, this is actually not my favorite given the high amount of drainage and I feel that it does lacerate, so the product in the left is actually a form of a DBM Putty that we mix antibiotics with. Of course, they have to be something they can standup to the heat and so the antibiotic of choice is going to be Vanco and Tobra typically is what mix up. So I have two different options there, one for superficial, one for deep. Now with our patient that we’re talking about today, we actually went with the product on the left. I don’t want to over macerate anything. Now unfortunately this light kind of does get to me a little bit and the reason that I say is we were doing so well, we had him in the hospital, he was improving, we carried out incision and drainage and I’m thinking that we are all in the same page, and I’ll see him clinic for a follow-up, but he was suffering from the depression and ultimately decided he didn’t care so we lost him to follow-up for quite some time.
Now, when we finally did see him back at the emergency room, we obtained foot x-ray that’s a great imaging modality. it’s quick, it’s easy and low-and-behold we have osteomyelitis. Now this is not a shocker to me as the original incision and drainage was fairly close to the bone, I had a high suspicion at that time. This is just confirmatory exactly of what I was thinking. So he did in fact have the osteo. He underwent a hallux amputation. The reason I show this slide is I think it’s important when you give a lecture such as this to show not only the good pictures, but some of the bad too especially with the providers in the room who are going to start taking on amputations now.
One of the bullet points that I placed at the start of my slide was how compliant are they. Now given this picture, you can tell that it’s macerated and obviously dehisced. I don’t think he was compliant to be completely honest and so this is how he presented back into the clinic. So now you ask yourself for what options do we have? I don’t have a picture of the wound VAC. I wish I did, but we of course placed him right on a negative pressure therapy, got him on a wound VAC and tried to re-granulate the tissue there. I also I’m very cognizant when I’m using my wound VAC to picture frame or to place a border around those skin edges you can tell in that picture just how macerated he is.
This is an interesting picture and I don’t typically show stuff like this, but once we got enough granulation tissue formed and I felt that it’s skin edges were adequate. I took him back to the operating room and I closed him the best I could. Now he still had a fair amount of soft tissue void present. I didn’t want to send him out for two reasons, one my trust level in the patient at this point was relatively low, and two I wanted this to be a one-and-done procedure. So what I’ve done here is a technique that probably isn’t used very often, but I felt that in this patient it was the right call. This is an acellular dermis, so I closed him as you can see on the right that’s what’s under it and then I actually sutured the acellular dermis right over the hallux amputation site. This was done for two folds, one to provide a tensile strength and then two this product actually incorporates blood flow into the area. So I trying to give him every advantage possible. You can see here two weeks postop that’s what the acellular dermis looks like when you see it in the clinical setting and then four weeks postop he is actually closed there. We of course took out the stiches and then this is completely closed at 12 weeks.
The next step when dealing with the Digital Pathology such as this I sent him for a shoe filler. I think that’s important both from a biomechanical standpoint but also to keep the hard work that we’ve put in on this patient, good and viable.
The next case, I want to show is actually an interesting case, 54-year old diabetic male, a gentleman showed up, he is a Mexican National. We saw a fair amount of those down where I was in Southern New Mexico. His A1C of course is elevated coming from the home life that he had there, he had no prior diabetic care and we were seeing this patient in the emergency room for the first time. Now, a couple of things that I’d like to highlight here in these pictures of course you can tell that he has an Ischemic Digit. Secondary to that -- that is his first metatarsal that’s completely exposed and of course denuded, so this was an interesting occasion, I see this all the time, so we offered him an immediate TMA, I really didn’t see any other treatment choice for the patient.
Now, you’ll note the green arrows there and why would I show this picture because when you’re dealing with Digital Pathology there are complications and I’ve tried to show a lot of good pictures, but then also a lot of my bad [laughs] or my tough pictures I should say. So the TMA flap is not looking great, however, you’ll note that the green arrows are pointing to areas in my opinion were still viable. Again sent for revascularization, I felt it’s absolutely paramount when you’re dealing with a tough patient such as this. So here’s four weeks postop, you can tell just how well the revascularization works also. Also I am of the school of thought that I will leave those sutures in until they either fallout or it is completely healed.
I recently encountered a case where we actually worked hand-in-hand with an orthopedic surgeon. We were doing a below-the-knee amputation. He was of the school of thought two weeks no matter what you take out your sutures, no matter what. I took those out and we had complete dehiscence and so absolutely if you are in doubt and some will say rip them out I know, but [laughs] I know that I do, I do, I leave them in just be honest. So just one of reasons I showed that. And then here’s our patient healed at six weeks. Really to be honest when I see a TMA that looks like that, it’s gratifying, but at the same time I just feel that this patient still has a viable limb. He can weight bear on it, we will modify his shoes as needed. The one thing that I failed to mention as with most my TMAs, we always do either a gastroc recession or TAL depending on how much correction we need there.
The third case that I brought today was a very similar in that we were consulted to see a post procedural patient that we didn’t operate on. He’d actually undergone two separate procedures. The first one being a hallux amputation as you can see there, and in the second being an incision and drainage of his plantar foot. Now when I walked in and saw this patient, I knew that I was kind of in for a little bit of a challenge given the TMA that would be required, but the large hole or soft tissue void that’s right in the flap that I’m going to try and flap-up. So this I think this is a good case to share with the group as well.
As I said consult has placed to podiatry. The patient was sent to the ED from a competing orthopedic surgeon, status post hallux amp, second incision and drainage. His white blood cell count was 13.5. Now Dr. Freiberg absolutely hit it on the head 13.5 in my opinion, yes it's elevated but is wildly abnormal, no when I walked in the stench that I appreciated in the room was very pungent we’ll say and he was a whole heck of a lot sicker than 13.5. I just feel when you get these really compromised patients, they’re not able to mount the response that typical healthy patient would. Also secondary to that, the resident called me on the phone and said don’t worry he is afebrile, well [laughs], yeah we got a situation here. So his A1C is now wildly terrible, and of course there are no vascular studies on file. So this is now the third case we’ve talked about, you start to kind of get a treatment pattern on algorithm down when we’re taking on patient such as this.
Again, patient underwent an open TMA. Now I felt comfortable using the calcium sulfate type of antibiotic bead here. This of course had the Vanco and the Tobra, and it was packed open. I’m showing what was remaining of the first metatarsal there. If I can give one bit of advice bone biopsies every time you can if you’re dealing with infection and you look at the bone biopsy it every time, and take more than one, so many times at least when I’m dictating or when I’m talking to other providers, you will want to make sure that you avoid any sampling errors and so by taking multiple bone biopsies that’s a great way to do that. A fairly straightforward case, he was healed at 10 weeks, really I wish I had a picture of the bottom because we just did a little rotational flap to cover the soft tissue void on the patient.
Now, this case is slightly different, but it still falls in the realm of digital pathology. This gal was 45 years old, female. She had a procedure known as a Debulking Procedure three years prior. I was not at the facility three years ago and so I don’t know exactly what it looked like at that time, but from her account and from her history it looked very similar to the presentation that I’m showing here. The wound was debulked and she of course was lost to follow up unfortunately. The Debulking Procedure came back at that time three years ago and showed that it was a malignant melanoma, so now were seeing her back for continued care.
What I’m showing here on the pictures, obviously you have a large lesion there, but then she also had two of the satellite lesions, which I think you really need to pay special attention to. So I’m just showing those, here are some intraop pictures. I knew looking at this as most of providers in the room would, this was a melanoma, so I went all the way down to the fascia as deep as I could and I’ll show you here are some pictures, so there is that. It was literally about the size of a golf goal to be honest once we got in there, and so there is my wide excision down well past the fascial plane, even seen some muscle belly there.
So now what we do with her. This is one week postop, I unfortunately didn’t put on the wound VAC, so that picture cuts me deep as well because you can tell how macerated that is, which really supports the point that you need to protect those skin edges and keep them viable. When dealing with a malignant melanoma such as this, I actually sent her for consultation with the oncologist in Flagstaff. that’s the nearest one that we have, they did a sentinel node biopsy and then they did a CT scan of course to rule out any other type of involvement.
Here she is at three weeks. The reason I haven’t taken her back and done any type of closure on this patient is I’m still waiting for the oncologist to give me the green light. I just I want to make sure that we have it all. And then here, she is at six weeks postop. Now, I wish I had pictures of her closed and I could show a final product, but like I said we are still dealing with this patient. I just thought this was an extremely interesting case and that it should be shared with the group. As soon as I get the green light from the oncologist for closure, we will go ahead and get her closed up, but I think she’s progressing very nicely, she’s well perfused and she’s doing very well.
So going back to the bullet points that I started with, things to consider when treating this type of pathology. Blood flow status I know it’s been alluded to a number of times now just how absolutely important that is. If you’re ever in doubt or you have a hard time palpating those pulses send them for a vascular consult, get an ABI, get a TcPO2 whatever it is, but something to make sure that you actually have water to let the grass grow is what I say.
Second point, infection, make sure you know what your treating swabs are not ideal, try and get tissue or in the face of infection try and get some bone. Make sure that we’re offloading our patients appropriately, cam boots, total contact casting is fantastic, postop shoe not ideal, but if that’s what you’ve got, just make sure that they’re not leaving in what they came in because most times it’s an athletic shoe that’s completely pounded flat and it’s not offloading at all. And then the last point is the mechanical deformities let’s make sure they were actually addressing what the source or the root cause of the wound is.
I appreciate you having me out this morning. If there are any questions, I look forward to taking them, thank you.
TAPE ENDS – [22:16]