What would you do part II?

[347932]

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Patient comes to the office with severe Bunion and Hammertoe pain. LE Physical examination is largely normal with fully palpable pulses, digital hair, Cap fill time less than 5 seconds. Neuro exam completely normal. Ortho exam show moderate bunion and semi rigid hammertoe 2nd right foot with pain. Derm shows foot is warm, texture, turgor within normal limits. Radiographs show what is expected with no cystic changes to bone with all the usual suspects.

Perform an Austin and 2nd PIPJ Arthroplasty and every thing goes very well intra op and immediately post op. About 2 weeks post, patient calls in severe pain, saying his foot feels cold and his incision site is starting to drain after a trauma to the foot. Seen in the office with a dehisced incision, tissue distruction, and so painful that his pain meds aren't working. Very little edema noted, and whole foot seems rather cold. Pulses are weak. Radiographs reveal normal bone healing, excellent correction and no fractures.

What is going on??? Questions/comments?

 

[Feli]

Irrigate the incision, wet-to-dry, avoid any ice or elevation, and STAT vasc surgery consult...

...and scratch my head on why anybody would do a plasty on 2nd (unless pt was really old?).

 

[347932]

Irrigate the incision, wet-to-dry, avoid any ice or elevation, and STAT vasc surgery consult...

...and scratch my head on why anybody would do a plasty on 2nd (unless pt was really old?).

Patient was admitted for observation as wound deteriorated overnight. Vasc decided to do ABI ASAP and patient had 0.89 B/L. They decided to keep him for obs and pain control.

What next?

A plasty as opposed to a fusion you mean? Do you fuse all 2nd PIPJs whether rigid, flexible?

 

[Feli]

Patient was admitted for observation as wound deteriorated overnight. Vasc decided to do ABI ASAP and patient had 0.89 B/L. They decided to keep him for obs and pain control.

What next?...

Probably an angio to find where the occlusion/stenosis/vasospasm is, but that's up to vasc surg. Gotta know when to punt.

...A plasty as opposed to a fusion you mean? Do you fuse all 2nd PIPJs whether rigid, flexible?

Yep, I would. Crazy toes from doing hammertoe plastys on the central digits is not really my cup of tea.

 

[347932]

Probably an angio to find where the occlusion/stenosis/vasospasm is, but that's up to vasc surg. Gotta know when to punt.

Yep, I would. Crazy toes from doing hammertoe plastys on the central digits is not really my cup of tea.

Within two days ABI dropped to 0.41. Angio done, foot pinks up, but wound gets worse. Tendon exposed. Now what?

Fuse ALL 2nd PIPJ? Hmmmm...no matter who or what?

 

[sinustarsi]

Where is the wound 1st or 2nd? Both? Where is the occlusion? Prob will get TCPO2 and MRI. Keep pt in house, another washout / cultures/start IV abx/labs if admitted. Discuss possible amputation toe, ray or transmet or proximal etc with the pt and also vascular surgeon. Just make sure you know why you proceeded with this case when cap. refill is less than 5 sec instead of 2-3 sec for legal reasons. I don't know if that will bite you but you never know.

 

[347932]

Where is the wound 1st or 2nd? Both? Where is the occlusion? Prob will get TCPO2 and MRI. Keep pt in house, another washout / cultures/start IV abx/labs if admitted. Discuss possible amputation toe, ray or transmet or proximal etc with the pt and also vascular surgeon. Just make sure you know why you proceeded with this case when cap. refill is less than 5 sec instead of 2-3 sec for legal reasons. I don't know if that will bite you but you never know.

Wound is at 1st MPJ incision site. After the balloon TCPO2 were normal. Culture negative, WBC WNL. No crepitus on palpation of the wound site.

Whoa..slow down, why amp? Patient has pulses back, but still has a large wound to the dorsum of the first MPJ with tendon exposed. Any other options to consider?

 

[sinustarsi]

Sorry. I was just expecting a disastrous case. Then I will cont with wet to dry wound care and possible apligraft if you are having hard time closing the wound. What am I missing?

 

[347932]

Sorry. I was just expecting a disastrous case. Then I will cont with wet to dry wound care and possible apligraft if you are having hard time closing the wound. What am I missing?

Well, an open wound's only hope for closure is amputation based on the info I gave so far? Does Apligraft have good outcomes over tendon?

Any other wound care technologies available besides wet to dry?

 

[krabmas]

was a venous ultrasound done? did the limb ever turn a shade of blue or white? thinking of phlegmasia cerulea dolens or phlegmasia albans dolens.

Is the patient no on anti-coagulants?

The wound could be delayed primarily closed if enough soft tissue. If not, Integra w/ VAC is great for covering tendons.

I hope up til now the wound/tendon was dressed with a hydrogel wound goop to ensure the tendon did not dessicate.

an asside: when you mention wet to dry as a wound dressing it needs to be specified what the wet will be; saline, acetic acid, Dankins?

After the integra takes then either apligraf for $1500 a pop usually takes 2 before the wound heals or STSG/FTSG (my preference).

If you wanted to avoid integra and the pt extremity was truelly back to normal vascular status we could talk about a radial fore-arm free flap. There are not any good options for pedicled rotational flaps for the dorsal 1st MPJ and based on vascular issues random based flaps would not be advised.

 

[347932]

was a venous ultrasound done? did the limb ever turn a shade of blue or white? thinking of phlegmasia cerulea dolens or phlegmasia albans dolens.

Is the patient no on anti-coagulants?

The wound could be delayed primarily closed if enough soft tissue. If not, Integra w/ VAC is great for covering tendons.

I hope up til now the wound/tendon was dressed with a hydrogel wound goop to ensure the tendon did not dessicate.

an asside: when you mention wet to dry as a wound dressing it needs to be specified what the wet will be; saline, acetic acid, Dankins?

After the integra takes then either apligraf for $1500 a pop usually takes 2 before the wound heals or STSG/FTSG (my preference).

If you wanted to avoid integra and the pt extremity was truelly back to normal vascular status we could talk about a radial fore-arm free flap. There are not any good options for pedicled rotational flaps for the dorsal 1st MPJ and based on vascular issues random based flaps would not be advised.

The limb was not ischemic after the balloon and what you recommend is in the process of being worked out as the patient lost his insurance. We're working with some companies to get the grafts we need.

Free flaps are always a great choice.