Functional Limb Salvage

Functional
Limb Salvage
The Multidisciplinary
Team Approach
Christopher E. Attinger
John S. Steinberg
Editors
123
Functional Limb Salvage
Christopher E. Attinger
John S. Steinberg
Editors
Functional Limb Salvage

The Multidisciplinary Team
Approach
Editors
Christopher E. Attinger John S. Steinberg
Department of Plastic Surgery Department of Plastic Surgery
Georgetown University School of Georgetown University School of
Medicine and MedStar Georgetown Medicine and MedStar Georgetown
University Hospital University Hospital
Washington, DC, USA Washington, DC, USA
ISBN 978-3-031-27724-5 ISBN 978-3-031-27725-2 (eBook)

https://doi.org/10.1007/978-3-031-27725-2
© Springer Nature Switzerland AG 2023

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Foreword
Diabetes: The Twenty-First Century Epidemic
It was a few years ago that I had the honour to share the stage at a large
Diabetes conference in Bangalore, South India, with the then Prime Minister,
Sri Narendra Modi. He spoke passionately about the problems facing the
health of the Indian population, but of greatest relevance to this book was his
comment that the biggest threat to the health of the Indian population and
indeed the world was no longer communicable diseases such as tuberculosis,
malaria, and others, but it was now non-communicable diseases such as dia-
betes. He was, of course, entirely correct in this statement: indeed, lower
extremity complications of diabetes contribute greatly to the morbidity, mor-
tality, and costs of diabetes across the world. At the time of writing this intro-
duction early in 2021, the world is in the midst of the COVID-19 pandemic.
Understandably, there has been a massive global effort in devising new treat-
ments for this all-too-often fatal viral illness as well as rolling out a mass
vaccination programme. My fear is that this might detract from recent
increased interest in the importance of non-communicable diseases such as
diabetes, cancer, and heart disease across the world. Early during this pan-
demic in 2020 there was evidence that the management of the numerous very
ill patients had necessarily led to the neglect of many conditions, particularly
non-communicable diseases [1]. In the area of diabetic lower limb disease,
the threat to routine diabetic foot care has been outlined in several publica-
tions [2–5].
At the same time, we are experiencing a global epidemic of diabetes with
approximately 500 million people with the condition across the world in
2021. The most recent edition of the International Diabetes Federation (IDF)
Atlas published at the end of 2019 estimated that this number would increase
to more than 700 million in the next 20 years or so [6]. Data from this publi-
cation suggest that the prevalence of diabetes in the United States is 13.3%,
affecting approximately 34 million individuals. It is well recognized that cer-
tain groups such as native Americans, Hispanics, and Blacks have higher
prevalences of diabetes, although recent evidence suggests that in certain of
these groups, the prevalence has decreased in recent years [7, 8]. The average
expenditure on diabetes per patient per year in the USA is approximately
$10,000, one of the highest in the world. Other parts of the world have even
more frightening prevalences, with Mauritius at 25% and rising in some of
v
vi Foreword
the Polynesian islands to 33% [6]. A recent study from Pakistan [9] reported
that 26.3% of all adults in Pakistan had diabetes. Thus, there are a number of
reasons why it is vital to raise the global profile and importance of diabetes.
One such reason is the grim statistic that was recorded for diabetes in 2019
when it, for the first time, was listed in the top ten causes of death across the
world [10]. At a time when one of the largest declines in the number of deaths
witnessed was from infectious diarrhoeal diseases, diabetes entered the top
ten with a significant percentage increase of 70% since 2000. Diabetes also
represented the largest rise in male deaths among the top ten, with an 80%
increase since 2000.
Diabetic foot ulceration (DFU) and its sequelae are associated with sig-
nificant impairment of quality of life, increased morbidity and mortality, and
place a huge drain on healthcare resources [11]. DFU occurs as a conse-
quence of the combination of factors most commonly peripheral neuropathy,
peripheral arterial disease, and some form of trauma. Foot problems are
amongst the commonest of all the diabetic complications and are associated
with very significant morbidity, mortality, and cost to the healthcare system.
Although a decline in the lower extremity amputations (LEA) had been
observed in decades before 2010, Gregg et al. recently reported a resurgence
of diabetes complications with an increase in diabetes-related LEAs from
2010 to 2015 [12]. Similarly, Harding and colleagues reported a stalling of
the progress in non-traumatic LEAs in the very high-risk population of
patients with diabetes and end stage renal disease [13]. It should therefore be
apparent that the chapters in this book, which emphasize the multidisciplinary
team approach to functional limb salvage in diabetes, are of great importance
at the beginning of the third decade of the twenty-first century. The editors
have assembled an impressive number of authors with true expertise in this
area, which will provide the reader with eminently practical information on
the diagnosis, medical and surgical management of these all-too-common
problems.
References
1. Godlee F. Surviving the long road ahead. BMJ. 2020;369:m1840.
2. Shin L, Bowling FL, Armstrong DG, Boulton AJM. Saving the diabetic foot during the
COVID-19 pandemic: a tale of two cities. Diabetes Care. 2020;48:1704–9.
3. Boulton AJM. Diabetic foot disease during the COVID-19 pandemic. Medicina.
2021;57(2):97. https://doi.org/10.3390/Medicina57020097.
4. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck – the role of
podiatry during the COVID-19 pandemic: preventing hospitalizations in an overbur-
dened health care system, reducing amputation and death in people with diabetes. J Am
Podiatr Med Assoc. 2020. [Epub ahead of print]. https://doi.org/10.7547/20-051.
5. Caruso P, Longo M, Signoriello S, et al. Diabetic foot problems during the COVID-19
pandemic in a tertiary care center: the emergency amongst emergencies. Diabetes Care.
2020;43:e123–4.
6. IDF Diabetes atlas. 9th ed. 2019. www.diabetesatlas.org.
7. Cheng YJ, Kanaya AM, Araneta MRG, et al. Prevalence of diabetes by race and ethnic-
ity in the United States, 2011-2016. JAMA. 2019;322:2389–98.
Foreword vii
8. Bullock A, Sheff K, Hora I, et al. Prevalence of diagnosed diabetes in American Indian

and Alaska Native adults, 2006-2017. BMJ Open Diabetes Res Care. 2020;8(1):e001218.
https://doi.org/10.1136/bmjdrc-2020-001218.
9. Basit A, Fawwad A, Qureshi H, Shera AS. Prevalence of diabetes, pre-diabetes and
associated risk factors: second national diabetes survey of Pakistan. BMJ Open.
2018;8:e020961. https://doi.org/10.1136/bmjopen-2017-020961.
10. WHO. The top ten causes of death. 9 December 2020. www.who.int/news-room/
fact-sheets/detail/the-top-10-causes-of-death.
11. Boulton AJM, Whitehouse RW. The diabetic foot. In: Feingold KR, Anawalt B, Boyce
A, et al., editors. Endotext 2020. South Dartmouth: MDText.com, Inc; 2020.
12. Gregg EW, Hora I, Benoit SR. Resurgence in diabetes-related complications. JAMA.
2019;321:1867–8.
13. Harding JL, Pavkov ME, Gregg EW, Burrows NR. Trends of nontraumatic lower-
extremity amputation in end-stage renal disease and diabetes: United States, 2000-
2015. Diabetes Care. 2019;42:1430–5.
Division of Diabetes, Andrew J. M. Boulton

Endocrinology and Gastroenterology
Manchester Royal Infirmary
University of Manchester
Manchester, UK
University of Miami
Miami, FL, USA
Preface
Functional Limb Salvage has been our professional passion for decades. We
have had the great fortune of building and working with a large multidisci-
plinary team based at MedStar Georgetown University Hospital in Washington
DC. We find the work of wound healing, amputation prevention, and limb
salvage to be a true privilege and a hidden gem of the healthcare profession.
We are truly energized by this work and the motivated people that it attracts.
So why write a textbook on limb salvage? We have published, spoken,
taught, and researched on this topic through numerous formats and media…
but the missing piece for us has been a true reference text on how limb sal-
vage really works and how to build a team approach to this crucial specialty.
We meet around the world several times a year at key meetings and confer-
ences to exchange the latest ideas and innovate together, yet there really is not
a foundational text that someone new to the specialty could use as a corner-
stone. We hope that this will serve to fill that knowledge gap and can be used
as a tool by many who wish to learn more about the challenges that are pres-
ent in the limb salvage specialty.
Functional limb salvage is an ongoing journey, just like much of medicine
and surgery. In our short time doing this work, we have evolved from ‘saving
length at all costs’...to restoration of function as the key clinical goal.
Functional limb salvage is about getting the patient and those around them
back to functional capacity. That may mean a well-performed amputation, a
surgical wound closure, palliative care to control pain and prevent wound
infection, or advanced reconstructive options such as microvascular free tis-
sue transfer, external fixation, and surgical deformity correction. One of the
key challenges is to identify the correct course of action for the patient, the
problem, and those around them. We must remember that some of our most
grateful patients are those with a well-performed amputation and a prosthesis
or even those with a wound that we acknowledge we may never heal but that
we work to palliate with infection prevention and pain control.
ix
x Preface
We hope that you enjoy the talented authors we have curated for this
unique text. Many are close friends and all are subject matter experts. We
hope that this text helps you establish your own multidisciplinary functional
limb salvage team, or helps you enhance the one you already have. When
done correctly and with the right motivation, this work can be some of the
most rewarding in all of healthcare.
Washington, DC, USA John S. Steinberg

Washington, DC, USA Christopher E. Attinger
Contents
1
Building It from Scratch: The Team Approach
to Functional Diabetic Limb Salvage �� 1
Areeg A. Abu El Hawa, Kevin G. Kim, John S. Steinberg,
Katherine Hubley, Cameron M. Akbari,
and Christopher E. Attinger
2
Staffing and Day-to-Day Management: The Nuts
and Bolts of Running a Wound Care Center�� 13
Amara Ellis and Tara Wallace
3 Case Management of the Complex Limb
Salvage Admission�� 35
R. N. Thalia Attinger, M. S. W. Heather Daniels,
R. N. Teodora Deperio, and Allen H. Roberts II
4
Integrating Inpatient Care to Your Outpatient Wound
Care Center: Key to Successful Patient Management�� 47
Nancy R. Megas, Katherine S. Hubley,
and Margaret C. Kugler
5
Diabetic Foot Ulcers by the Numbers:
Epidemiology of Limb Salvage �� 57
Romina Deldar, Adaah A. Sayyed, Zoe K. Haffner,
and John S. Steinberg
6 Unlocking the Mystery of Peripheral Neuropathy
in Diabetes�� 65
Andrew J. M. Boulton
7
The Science and Utility of Offloading the Diabetic Foot�� 73
Caitlin S. Zarick, Kurtis D. Bertram, and Thomas F. Milisits
8
Medical Management of the Limb Salvage Inpatient�� 87
Marie M. Alternburg, Jennifer M. Haydek, Sara Kiparizoska,
Nina K. Weaver, and Margot G. Wheeler
9
Evaluation and Examination of the Diabetic Foot�� 107
Michael Edmonds, Rajesh Kesavan, and Arun Bal
10
Frailty and Mobility Degeneration in Diabetes
and Diabetic Foot Ulceration�� 133
Bijan Najafi and Gu Eon Kang
xi
xii Contents
11 Anesthesia
for the DLS Patient: Minimizing Risk
and Maximizing Safety�� 147
Kasra Razmjou and Andy Liao
12 Debridement
of the Diabetic Foot and Leg�� 157
Christopher E. Attinger and Jayson N. Atves
13 An
Evidence-Based Approach to Treating Osteomyelitis�� 175
Benjamin A. Lipsky and Suzanne A. V. van Asten
14 Practical
Lessons Learned in Managing Diabetic
Foot Infections�� 187
Andrew I. Abadeer, Mark R. Abbruzzese, and William Davis
15 Managing
Soft Tissue Infection in the Diabetic Foot:
Cultures, Drugs, and Source Control�� 193
Eric Senneville and Romina Deldar
16 Surgical
Management of Diabetic Foot Infection
and Osteomyelitis �� 203
Venu Kavarthapu and Javier Aragón Sánchez
17 Charcot
Foot Syndrome: Aetiology and Diagnosis �� 215
William Jeffcoate and Fran Game
18 Charcot
Foot: Conservative Management�� 227
Armin Koller
19 Charcot
Foot: Surgical Management and Reconstruction�� 237
Dane K. Wukich and Venu Kavarthapu
20 Diagnostic
Evaluation of Arterial Disease in Limb Salvage�� 251
Michael Siah and Cameron M. Akbari
21 Arterial
Disease Management in the Limb
Salvage Patient: Endovascular and Open Bypass�� 263
Michael C. Siah, Roberto Ferraresi, Alessandro Ucci,
Andrea Casini, Giacomo Clerici, and Cameron Akbari
22 Venous
Disease Management in the Limb Salvage
Patient: Diagnostics, Compression, and Ablation �� 285
Bianca Cutler, Nikita Patel, and Misaki Kiguchi
23 Science
and Practicality of Tissue Products
in Limb Salvage�� 305
Alexandra N. Verzella, Allyson R. Alfonso, and Ernest Chiu
24 Limb
Wounds of Dermatologic Disease:
Dermatopathology, Biopsy, and Medical Management�� 329
Helena B. Pasieka, Nicholas Logemann, Felix Yang,
and Alexandra Gosh
25 Prosthetics,
Orthotics, and Amputation Rehabilitation �� 349
Benjamin G. Higgs
Contents xiii
26
Surgical Offloading, Tendon Balancing, and
Prophylactic Surgery in Diabetic Limb Salvage �� 359
John S. Steinberg, Paul J. Carroll, Jayson N. Atves,
and John D. Miller
27 Negative Pressure Wound Therapy�� 391
Paul J. Kim
28
Hyperbaric Oxygen Therapy in Functional Limb Salvage�� 401
Kelly Johnson-Arbor
29 Skin Grafting�� 415
Adaah Sayyed, Paige K. Dekker, Caitlin S. Zarick,
and Karen K. Evans
30
Local Flaps for Reconstruction and Limb Salvage
of the Foot and Ankle�� 429
David Z. Martin and Gabriel Del-Corral
31
Free Tissue Transfer in Diabetic Limb Salvage: Lessons
Learned and Best Practices for Functional Salvage �� 449
Paige K. Dekker, Kevin G. Kim, Kenneth L. Fan,
and Karen K. Evans
32
Advanced Plastic Surgical Reconstruction Options
in the Lower Extremity�� 467
John M. Felder and Joon Pio Hong
33
Partial Foot Amputations: Technique and Outcomes�� 521
Jayson N. Atves, Ali Rahnama, and Tiffany K. Hoh
34
Below Knee Amputation: Techniques to Improve
Rehabilitation, Pain Management, and Function �� 545
Tanvee Singh, Kevin G. Kim, Grant M. Kleiber,
35
Complications and Revision Surgery in Complex
Limb Salvage�� 559
Ali Rahnama, Noman Siddiqui, and Janet D. Conway
36
Establishing and Running an Amputee Support
Group to Empower Your Patients�� 587
Firras Garada and Holly Shan
37
Analyzing the Population Dynamics of Limb Salvage�� 591
Kevin G. Kim, Paige K. Dekker, and Kenneth L. Fan
38
DLS Innovations: Landmark Publications
and Innovations from Our Team�� 603
Samuel S. Huffman, Christopher E. Attinger,
John S. Steinberg, Karen K. Evans, and Kenneth L. Fan
Index�� 615
Building It from Scratch: The Team
Approach to Functional Diabetic
1
Limb Salvage
Areeg A. Abu El Hawa, Kevin G. Kim,

John S. Steinberg, Katherine Hubley,
Cameron M. Akbari, and Christopher E. Attinger
Background approximately 23% of new DFUs will ultimately

result in a lower extremity amputation.[1].
Diabetic foot ulcers (DFUs) are a major concern When faced with such sobering statistics, it is
in health care systems. The World Health essential to treat patients with aggressive wound
Organization (WHO) estimates that roughly care to prevent major amputation. Unfortunately,
8.5% of the global adult population has diabetes, this often proves to be difficult, which may be
of which one-in-four will develop a DFU within attributable to several factors. For example,
their lifetime [1]. The chronically wounded wound care continues to lack standardization,
patient consistently reports lower quality of life, despite the publication of strategies and evidence
worse physical functioning, and higher levels of intended to improve patient outcomes. To illus-
pain. The 5-year mortality rate for the diabetic trate, 70% of chronic leg ulcers have an etiology
with a foot ulcer is reported to be as high as with a venous component, for which the gold
43–55%, with rates jumping to 80% after pro- standard of treatment is compressive therapy.
gression to major lower extremity amputation [2, Despite these recommendations, only 17% of
3]. This rate is concerning, considering that venous leg ulcers receive compression therapy in
the USA [4]. Furthermore, additional reports
have shown that diagnostic examinations were
only performed in 51% of wounded patients and
A. A. Abu El Hawa · K. G. Kim · K. Hubley a diabetic assessment in only 34% of patients
Department of Plastic Surgery, MedStar Georgetown
with foot ulcers [5].
University Hospital, Washington, DC, USA
e-mail: [email protected]; To optimize wound care treatment and
[email protected] improve patient outcomes, various care models
J. S. Steinberg · C. E. Attinger (*) have been proposed, each with their own set of
Department of Plastic Surgery, Georgetown advantages and disadvantages (Fig. 1.1). Within
University School of Medicine and MedStar these models, several collaborative approaches
Georgetown University Hospital,
can be pursued (Fig. 1.2). The multidisciplinary
Washington, DC, USA
e-mail: [email protected]; care team (MDT) model has established a posi-
[email protected] tion internationally as the gold standard of treat-
C. M. Akbari ment for DFU). The MDT model can achieve its
Department of Vascular Surgery, MedStar highest beneficial potential in treating DFU when
Georgetown University Hospital, utilized within a tertiary referral wound care cen-
Washington, DC, USA
ter housed within an academic medical center.
e-mail: [email protected]
© Springer Nature Switzerland AG 2023 1

C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_1
2 A. A. Abu El Hawa et al.
Advantages Disadvantages
Private-Practice Convenience Other practice interests
Unintimidating environment Limited wound-specific
resources
Outsource for ancillary
services
Limited communication with
other specialists
Stand-Alone Center Convenience Outsource for ancillary
Efficient delivery of care services
Barriers to communication
among specialists
Hospital Based Full range of ancillary services Difficult access
available Intimidating environment
Shared EMR
Continuity between clinic, OR,
inpatient
Academic Hospital Same as above Same as above
Based Research and innovation focused
Fig. 1.1 Wound center models. (Reproduced from Kim et al. 2016)
a b c
Multidisciplinary Interdisciplinary Transdisciplinary
Fig. 1.2 Team working models (a) Multidisciplinary care The roles of team members can extend beyond the confines
involves various specialties working together as a unit with of their discipline. (c) A transdisciplinary model involves
clearly distinct roles. Information between team members is sharing of roles across disciplinary boundaries. Roles and
shared. (b) Interdisciplinary care expands upon multidisci- responsibilities across the transdisciplinary model are blurred
plinary care but emphasizes collaborative communication. (Attinger et al.; MacRae et al.; Seidu et al.)
Successful implementation of a MDT has led to a

greater than 50% improvement in outcomes by The Multidisciplinary Team
reducing both amputation rates and wound
related complications [6]. Given the complexities of multimodality treat-
Despite the clear advantages of a MDT), its ment for DFU), no single professional can pos-
implementation within an academic institution sess the knowledge repertoire necessary to make
remains challenging and requires thorough prep- all treatment decisions for any single patient.
aration. As such, an organizational framework for Recognition of this limitation can be traced back
the launch of a multidisciplinary diabetic limb to the turn of the twentieth century. Maurice J.
salvage team is warranted. Development of such Lewi, MD (1857–1957), founder of the oldest
a model will be the focus of this chapter. college of podiatric medicine, was vocal on the
1 Building It from Scratch: The Team Approach to Functional Diabetic Limb Salvage 3
need for specialized diabetic foot care and the • Australia: National Health and Medical
role of chiropodists as allies in providing care. In Research Council (NHMR) [16]
agreement was Elliott P. Joslin, MD (1869–
1962), whose efforts paved the way for the intro- Results of this approach has led to signifi-
duction of the first hospital foot clinic: The New cantly improved clinical outcomes. Studies have
England Deaconess Hospital established in 1928. reported higher levels of patient satisfaction in
The multi-dimensional burden of the diabetic institutions that have adopted a multidisciplinary
foot was beginning to be recognized. Joslin team approach [17]. A comparison of diabetic
believed that a team approach to foot care, infec- patients with ulcers in a multidisciplinary teach-
tion management, surgical care, exercise, and ing hospital setting with those treated in a tradi-
nutritional therapy could remedy complications tional setting showed a significant improvement
that arose secondary to the diabetic foot. The in scores pertaining to health-related quality of
multidisciplinary team approach to diabetic limb life [18]. Team interventions in the care of chronic
salvage continued to evolve and as early as the wounds can also lessen the financial burden
mid-1990s, it was recognized that the introduc- experienced by the patient. Studies have shown
tion of these teams, both in Europe and the USA, that by reducing clinician time, consolidating ser-
could reduce the development and progression of vices, and the potential for downstream revenue
diabetic foot ulcers [7]. production a multidisciplinary team approach
reduces the cost of care [6].
Evidence consistently shows that a MDT
Benefits of a Multidisciplinary Team approach improves wound healing rates and
Approach: A Global Perspective reduces the rate of amputations, the most feared
complication of diabetic foot ulcers. Krishnan
In recognition of the complex care needs of the et al. reported a 70% and 82% reduction of total
diabetic patient, a multidisciplinary team and major amputation, respectively, following
approach has emerged as an essential component introduction of a multidisciplinary approach in a
of evidence based chronic wound management. hospital-based wound care center in the UK [19].
Implementation of multidisciplinary in-hospital A significant reduction in major amputations was
teams is globally recognized as a benefit to also associated with a multidisciplinary diabetic
patients. Although management guidelines for foot care team at the Dokuz Eylul University in
diabetic foot ulcers differ internationally, a multi- Turkey [20].
disciplinary team approach is consistently rec-
ommended. Professional organizations that have
recommended a team approach include: Composition of the Team
• USA: American College of Foot and Ankle Diabetic foot ulcers often arise secondary to a
Surgeons, Association for the Advancement of myriad of problems, necessitating management
Wound Care (AAWC), American Diabetes spanning across several disciplines. The strength
Association [8–10] of a multidisciplinary approach to functional dia-
• Europe: National Institute for Health Care betic limb salvage lies within the combined
Excellence (NICE), Scottish Intercollegiate insight of several professions all working toward
Guidelines Network (SIGN), International the overarching goal of improving care and out-
Diabetes Federation, the Association of British comes, specifically for this patient population.
Clinical Diabetologist, and the Primary Care The team should consist of healthcare profes-
Diabetes Society [11–13] sionals with skills and competencies that reflect
• Canada: Registered Nurses’ Association of the holistic management required for DFU treat-
Ontario (RNAO), Canadian Diabetes ment. To achieve functional diabetic limb sal-
Association [14, 15] vage, the MDT should consist of both a core and
peripheral group of specialists. Although the lenge of soft tissue reconstruction, employing
composition varies between institutions, the core free tissue transfer, advancement flaps, or skin
group of specialists often consists of plastic and grafting.
reconstructive, vascular, and podiatric/orthopedic Podiatric/Orthopedic Surgery / Podiatrist:
surgery. The core team should work closely with The expertise of the podiatrist or orthopedic sur-
a peripheral group of specialists which can geon centers on foot-related risk factors exacer-
include infectious disease, internal medicine, bating wound development or progression, such
rheumatology, hyperbarists, general surgery, as peripheral neuropathy, tendon imbalance, and
wound nurses, nurse practitioners, physician damaged bony architecture. Apart from utilizing
assistants, dieticians, and other essential person- local wound care modalities, podiatrists provide
nel. A MDT comprised of the aforementioned treatments to address lower extremity biome-
specialties ensures that each patient receives indi- chanics, such as total contact casts and other
vidualized care tailored to his or her unique med- offloading devices. Even with adequate wound
ical situation based upon input from all directions; healing, DFU) recurrence is common, with
ownership of the patient is disseminated among roughly 40% of patients having a recurrence
all team members. within 1 year of ulcer healing [23]. Through
The 1995 definition of multidisciplinary teams expert identification and management of the
includes the concept of a “gatekeeper” [21]. This high-risk diabetic foot, the podiatric and orthope-
specialist, a physician within a core specialty, dic specialists can potentially circumvent the
will serve to champion communication between issue of recurrence. Those trained in foot and
members of the multidisciplinary care team, pose ankle surgery can employ lower extremity skele-
innovative ideas, and serve as the overarching tal reconstruction, contributing heavily to ambu-
champion fostering collaboration between the latory limb salvage, especially if more proximal
team’s many members. Additionally, this physi- extremity reconstruction is required.
cian assumes the responsibility of inviting other Vascular Surgery: Diabetic patients are at
disciplines into the team and ensuring growth of significantly higher risk for developing a range
the MDT program in its home institution. Their of both macro- and microvascular complication.
commitment is pivotal to the overall success of There is a reciprocal risk relationship between
the MDT program. Without a dedicated pioneer- DM and PAD with PAD being present in up to
ing champion, efforts to build a program may be 30% of diabetics, contributing to both ulcer-
futile; teams in which the team leader lacks a per- ation and failed wound healing in at least one-
sonal commitment struggle to cope and manage third of DFU [24, 25]. As such, the role of the
difficult situations [22]. While a single member vascular surgeon to promote ulcer healing is an
should champion efforts, all team members essential component of multidisciplinary wound
should be fully committed to the overarching care. Apart from performing and interpreting
goal and mission of the program. The specifics noninvasive and open vascular studies, bypass
regarding the roles of individual team members and endovascular interventions, the vascular
are further described below (Fig. 1.3). specialist is also able to perform wound debride-
ment, forefoot, guillotine, and major limb
amputations [24].
ole of Team Members in Functional
R Endocrinologist/Diabetologist: The rising
Diabetic Limb Salvage: prevalence of diabetes necessitates the involve-
ment of specialists who are well versed in the
Plastic and Reconstructive Surgery: care of the diabetic patient requiring complex
Conventional wound healing modalities are often insulin regimens and newer therapies. Within the
not sufficient to achieve healing by secondary MDT, diabetes consultants should lead the role of
intention for DFUs. In these situations, the recon- providing comprehensive and long-term manage-
structive surgeon is often tasked with the chal- ment of the patient. Poor glycemic control not
Member Contribution
Core-Team
Plastic Surgeon Soft tissue reconstruction
Wound coverage
Vascular Surgeon Vascular assessment
Open and endovascular Intervention
Podiatric Surgeon Wound care and diabetic foot risk assessment
/ Podiatrist Surgical and Biomechanical Management
Peripheral-Team
Orthopedic Surgeon Lower extremity skeletal reconstruction
Infectious Disease Specialist Medical management of infections
Endocrinologist/Diabetologist Glucose control
Internal Medicine Management of comorbid conditions (i.e chronic kidney
disease, autoimmune conditions etc.)
Hyperbarist Hyperbaric oxygen therapy
Nutritionist Nutritional counseling and supplementation to optimize
healing
Physical Therapist Mobility training
Rehabilitation
Wound Nurse Wound Care
Patient education
Medical Assistant Casting and Dressing application
Nurse Practitioner/Physician Patient education
Assistant Perioperative care
Wound care
Orthotist/Prosthetist Orthotics
Prosthetics
Administrative Staff Clinic and surgery scheduling
Administrator Human resource management
Finance Management
Training of administrative staff
Fig. 1.3 Members of a multidisciplinary wound care team. (Adapted from Kim et al. [6]; Kim et al. (2016); Attinger
et al.)
only increases postoperative complications in the or intermittent suppressive antibiotic therapy to

surgical DFU patient, but also contributes to augment wound healing.
delayed wound healing and increases risk of General Surgery: General surgeons that are a
infection [26]. It is therefore imperative to part of the diabetic limb salvage MDT should not
achieve and maintain adequate plasma glucose only be skilled in acute wound management but
control during both the operative and wound also display competence in chronic wound heal-
management period. ing. The general surgeon experienced in wound
Infectious Disease: The diabetic patient may management can provide aggressive surgical
require chronic management of foot infections as debridement and lower extremity amputations
up to 30% of infections recur, especially in those when necessary.
with underlying osteomyelitis [27]. The infec- Other Essential Personnel: Care for the
tious disease specialist offers invaluable expertise wounded diabetic is complicated and requires
in managing infections that often cooccur with additional personnel to achieve optimal outcomes.
DFU. Their expertise on current guidelines for A prosthetist can modify footwear to aid in healing
microorganism management of DFUs is essential an ulcer. Their specific role is further detailed
when empiric antibiotics are required for timely in Chap. 25. Hyperbarists offer adjunctive hyper-
limb salvage and culture and sensitivity results baric oxygen therapy, which has shown to assist
cannot be reasonably obtained. Further, when the with wound healing in approximately 10–15%
patient is not a surgical candidate, infectious dis- of patients [28]. Given that wound care is both
ease plays a pivotal role by providing prolonged time and labor intensive, the wound nurse is
essential in providing multi-dimensional care, mined, core team members should meet and dis-
assisting in care coordination, and offering wound cuss whether the patient’s presentation warrants
care education. Similarly, nurse practitioners and involvement from peripheral team members. For
physician assistants can be involved in wound example, a patient admitted to the inpatient ser-
care, discharge planning, postoperative care, and vice with poor glycemic control and osteomyelitis
patient education. The nutritionist/dietician pos- will warrant consultation with both an endocri-
sesses expertise that can ally the efforts of the dia- nologist and infectious disease.
betologist in preventing abnormal electrolyte Based on the needs of the patient, an individu-
excursions and optimizing nutritional status by alized care of plan is created and executed with
providing education on adequate nutrition [29]. the ultimate goal of wound healing. Once the
wound is healed, the patient is recommended to
continue ongoing diabetic foot care at intervals of
ound Management Pathway:
W 1–3 months by a podiatrist within the wound care
Multidisciplinary Framework center to assess for any risk of recurrence. In the
event of recurrence, the patient will have an
Immediately following the identification of a already established team of care knowledgeable
wound, the patient must be referred to the wound on the history of their condition and ready to rig-
care team either through an outpatient clinic or orously address their wound.
inpatient consultation, depending on the severity
of the wound. This first step is heavily reliant on
a well-established referral system between pro- ragmatics to Delivery: Ingredients
P
viders (Fig. 1.4). In the inpatient setting, wound for Success
care service is initiated immediately following
consultation by another provider. Although ideal, the implementation of a multidis-
Those being referred via an outpatient setting ciplinary wound care team may be hindered by
will arrange an appointment to be seen in the many factors. For example, patients may have lim-
wound care center. It is recommended that the ini- ited education on the care required to treat their
tial visit be with a discipline comprising the core DFU and may not appreciate the value in seeking
wound care team, such as podiatric, plastic, or out these centers, resulting in a reluctancy to travel
vascular surgery, to determine the acute severity to a distant academic medical center. Insurance
of the wound. This ensures that examination of plans may also restrict access to specialists by
the DFU and appropriate therapeutic process are requiring preapproved referrals. These factors
not delayed. Regardless of setting, a DFU should combined can manifest as delays in presentation,
be evaluated and treated accordingly. The initial leading to poor clinical outcomes. Unclear referral
assessment is followed by further examination; pathways may confuse both patients and providers
wound measurements are recorded, biomechani- on whom to see for wound care. Wound centers
cal abnormalities are identified, and vasculature is offer a variety of services to provide optimal care
assessed. This is followed by an extensive discus- for the diabetic patient suffering from a lower
sion with the patient to (1) identify factors that extremity wound. Unfortunately, despite the clear
can contribute to wound propagation, (2) eluci- benefits, a functional gap exists regarding the
date patient expectations, and (3) establish shared establishment of an efficient MDT. In the follow-
decision-making necessary for optimal care. Once ing paragraphs, pragmatics of service delivery will
an extensive history and wound profile are deter- be discussed (Fig. 1.4).
Fig. 1.4 Multidisciplinary wound management frame- quent development of individualized wound care plan that
work, which begins with patient referral to wound service, is implemented to achieve wound healing
followed by wound evaluation by core specialist, subse-
Identifying the Patient Location

with Multidisciplinary Needs
Optimal care is heavily reliant on the structure of
While the concept of a multidisciplinary approach the MDT which is primarily geographically
to DFU healing may seem simple in theory, the dependent [5]. The optimal environment for a
delivery of such is complex. It relies on the recogni- multidisciplinary team is colocation within a sin-
tion of the multidisciplinary needs of the DFU gle location, often within a tertiary referral center
patient by a champion physician possessing the housed within an academic institution. This
leadership qualities to build such a service. In an model allows for the ability to coordinate inpa-
ideal model this provider, upon identification of a tient services, diagnostic studies, complex treat-
diabetic foot problem, should transfer wound care ment options, and close monitoring. Colocation
responsibility off to a multidisciplinary care team of facilities readily provides access to team
within 24 h of presentation [30]. An additional layer members and communication, both of which are
of complexity in managing DFU is added when vital to the success of a MDT.
considering comorbid conditions that adversely A shared infrastructure facilitates seamless
affect wound healing. In an ideal team approach, the care from either outpatient clinic or inpatient
professional will be required to have a broad under- admission to the operative room, postoperative
standing of the services offered by different person- stay, and discharge. Wound care centers housed
nel. It is imperative that personnel understand the within an academic hospital often have dedicated
services offered by different professions and are inpatient floors with nurses who are skilled in the
aware of which patient will benefit from them. postoperative needs of the wound patient. Seeing
as the majority of patients with DFU will likely et al. established a care pathway in this region
undergo surgery, their postoperative admission allowing for early triage and remote review of
within an institution experienced in the care of diabetic foot problems with a multidisciplinary
the chronically wounded patient will undoubt- care team [36]. In this study, two community
edly be a benefit to the patient [31]. Colocation podiatrists evaluated patients either at their home
within a hospital-based center may also provide a or in a local clinic. Using a tablet device, the
scholarly atmosphere that encourages advances podiatrists were able to capture images and
in wound care through research. These centers remotely access a clinical database. Face-to-face
often have infrastructure that enables research, consultation by community podiatrist with mem-
such as internal institutional review boards, that bers of a multidisciplinary diabetic foot care team
are not easily accessible in other settings. was enabled by an Omnirouter miniTM device,
A common infrastructure not only enhances which aided in connectivity. The RAPID team
efficiency of care but also provides logistical ben- was able to provide patients with timely decision-
efits to the patient, which are particularly valuable making around hospital admissions, provide a
when timely treatment is necessary. When care is MDT care plan and wound care education [36].
provided at a single location, the patient can attend
several appointments in one day, reducing trans-
portation costs, time taken from work, and overall Team Communication
number of visits [32]. Colocation also increases
timely access to multiple specialties The diabetic DFUs presenting with the threat of limb amputa-
patient admitted with an infected or ischemic tion need to be treated swiftly and efficiently.
lower extremity wound often requires a series of Central to the provision of such care is frequent,
surgical intervention, all which can be addressed continuous, and collaborative communication. A
during a single admission, as opposed to having to working MDT bears its value from the unique
be referred to an outside institution. A study per- expertise of individuals from varying medical
formed by Maximillian et al. demonstrated the disciplines; having so many different individuals
importance of centralization of wound treatment at play requires clarity of roles and responsibili-
through a patient’s perspective. Their work showed ties. Establishing a communications framework
that the adoption of a MDT within a shared facility that supports interactive participation of key team
not only improved patient outcomes but also members at regular frequencies is imperative.
reduced the cost of treatment [33]. Gaining consensus on the responsibilities of the
team and meetings aims is required prior to orga-
nizing MDT meetings. This should be carried out
earls for Practice: Wound Care
P by a team leader, a member who champions ini-
in the Rural Setting tiatives and is integral in maintaining support for
the meetings. The role of this “champion” is
Although ideal, colocation of a MDT within an especially important during the initial stages of a
academic institution is not always feasible. team’s formation. Examples of a potential frame-
Limited access to comprehensive care health work of meetings are described below.
resources coupled with a lack of diverse medical Daily discussions between core team mem-
specialties complicates the provision of team ori- bers, residents, and medical students regarding
ented wound care. Patients with diabetic foot admitted diabetic patient to allow updates and
wounds living in rural communities suffer from modifications for the plan of care. In addition to
poorer outcomes [34, 35]. Innovative solutions to the members above, nurses, medical assistants,
widen access to multidisciplinary teams in rural and administrative staff participate in weekly
settings have been proposed. The Reducing interdisciplinary problem solving and wound and
Amputation in People with Diabetes (RAPID) department grand rounds. These meetings serve
Study was implemented in the NHS Highlands, to improve the type of care provided by the team
UK. By utilizing innovative technology, MacRury and address factors that may hinder the success
of the MDT. Members also participate in monthly and improved patient outcomes largely recoup,
department morbidity and mortality conference. and exceed, any losses from initial investments.
Factors that can improve communication:
• Electronic Medical Record (EMR): A atient Centered Care and Role

P
shared EMR offers easy access to all diagnos- of the Patient
tic results, photo-documentation, operative
reports, and clinical assessments. The driving force of any decision made by the
• Set Meeting Times: Having set times to meet MDT reflects the patients’ needs and preferences.
among specialists within the MDT is essential In partnership with core members of the MDT,
as members are less likely to attend meetings the patient should be heard and be able to make
without protected time [37]. This also avoids informed decisions about their care. Having a
confusions and facilitates sustainability of the DFU may be overwhelming for many patients
MDT. and easing the process of care is necessary. The
• Personal Commitment: The most central patient should be assigned a contact personnel
component to successful communication is who will simplify the pathway of care, offer the
possessing a shared purpose and willingness patient information about their treatment plan,
to address the task at hand. elucidate their expectations, communicate clini-
cal information, and support them through their
wound care. Although any member of the team
Barriers to Communication can fulfill this role, it has been suggested that a
clinical nurse specialist is the preferred team
Although many health care professionals claim member to carry out this duty and represent the
to work in the best interests of a team, studies patient’s views in meetings [37].
have demonstrated that individuals may work Adherence to treatment plays an important
autonomously [38]. Other barriers to a collabora- role in the clinical outcome of DFU. Wound cen-
tive team environment may include perceived ters with a focus on multidisciplinary care have
loss of autonomy, unawareness of the services of been shown to promote patient adherence to
transdisciplinary colleagues, and distrust in deci- treatment recommendations [39, 40]. Patients
sions of others. Communications and collabora- who do not follow treatment recommendations
tion barriers existing among the clinicals staff face significantly worse outcomes than those
can jeopardize efforts to improve health care who do. This should guide clinical practice to
safety and quality care. identify patients who are at nonadherent and
adopt strategies aimed at improving patient
adherence.
Support from Above
The success of a multidisciplinary care team is Conclusion

reliant on the hospital administration’s ability to
provide the infrastructure for the development The implementation of a multidisciplinary team
and sustainability of a wound care center. A com- approach to diabetic limb salvage is complex and
mittee comprised of leaders from team members difficult; however, when successfully initiated in
respective institution facilitates administrative an academic hospital-based wound care center it
coordination for care organization, resource allo- can significantly improve patient outcomes.
cation, and data collection. Multidisciplinary teams possess the diversity of
Although administrators may be initially hesi- skills knowledge and expertise necessary to treat
tant to take on a seemingly financially and the complex diabetic foot ulcer. In the chapters to
resource demanding endeavor, the cost benefits follow we will attempt to highlight some of the
essential features within a multidisciplinary team vention and management of diabetes in Canada. Can
J Diabetes. 2018.
that were discussed in this chapter. 16. NHMRC. National evidence-based guideline on
prevention, identification and management of foot
Financial Disclosure Statement The authors have no complications in diabetes (part of the guidelines on
inancial disclosures, commercial associations, or any management of type 2 diabetes). Natl Health Med Res
other conditions posing a conflict of interest to report. Counc. 2011.
17. Mickan SM. Evaluating the effectiveness of health
care teams. Aust Health Rev. 2005;29:211.
18. Rerkasem K, Kosachunhanun N, Tongprasert S,
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JN, Koulack J, et al. Multidisciplinary treatment
Staffing and Day-to-Day
Management: The Nuts and Bolts
2
of Running a Wound Care Center
Amara Ellis and Tara Wallace
Page 1: Page 3: Who Page 5: Why is Page 7: Page 9: Page 11: Page 13: Page 15: Page 17:
How Does What? Co-Management Staffing Roles: What Makes Scheduling: Scheduling: Scheduling: Associate
Clinic Nurse Manager Important? Our Administrative for Triage Outlook Master Upcoming Clinical Engagement
Runs Roles and Personal Desk Calendar Clinic #s Staff
Responsibilities Perspectives Success Schedules
Page 2: Page 4: Patient Page 6: Staffing Page 8: The 10: Page 12: Page 14: Page 16: Page 18:
CWH/ Services Roles: Clinical Triage Desk Scheduling: Scheduling: Scheduling: Managerial Leadership
HBOT Manager Roles Clinic Provider and Plans of the Tracking of Philosophies:
Staffing and Master Orthotic/ Day Clinic The
Structure Responsibilities Calendar Prosthetic Operations Managers’
Coverage Perspectives
Template
Page 1: How Clinic Runs –– Some Providers also host limited Telehealth
(Remote) clinics during the week.
aily Operations, Center for Wound
D • Staggered Staff Schedules:
Healing (CWH) –– Earliest associates are scheduled to arrive
at 0700; last associates leave at 1730.
• Open on Weekdays (No Nights, Weekends, or –– Registered Nurses (RNs) and Nurse
Holidays): Practitioners (NPs) work 10-hour shifts to
–– Triage Line takes calls from 0800 to 1700. ensure the entire clinic day is covered.
–– Patient Appointments are booked at 15, 20, They have a rotating day off each week.
or 30-min intervals from 0800 to 1550. –– Our Certified Medical Assistants (CMAs)
Booking intervals are dictated by that work 8-hour shifts. They stagger start- and
Provider’s preferred Scheduling Template. end-times to ensure the entire clinic day is
–– Appointment types include New Patient, covered. First arrival is 0730; last departure
Post-Operative, or Follow-Up Evaluations. is 1700.
• Provider Clinics:
–– We have 10 Exam Rooms and 2 simultane-
ous clinics running daily.
A. Ellis (*) · T. Wallace
Center for Wound Healing/Hyperbaric Oxygen –– Exam Rooms are split between Providers
Therapy, MedStar Georgetown University Hospital, (5 each).
Washington, DC, USA –– Each clinic is staffed with 1 Attending and/
e-mail: [email protected]; or NP, 2 RNs, and 2 CMAs.
[email protected]

14 A. Ellis and T. Wallace
–– There is 1 Triage Nurse for the day, 1 on- • Inpatient rounds and coordination with
site Radiology Technician, 1 Clinical other hospital services for ongoing Plans of
Scribe for each Attending, 1 “floating” Care.
CMA, and an on-call Orthotist/Prosthetist. • Consultations for other hospital services.
–– We share Wednesday clinics with Vascular
Surgery each week (5 Exam Rooms).
• Patient Volumes: Operating Room (OR)
–– Attendings generally see 20–30 patients in
AM, 10–15 patients in PM. • Daily OR cases which are published to the
–– NPs generally see 10–12 patients in AM, team via email and saved in our practice Share
8–10 patients in PM. Drive.
• These cases involve Attendings, Residents,
OR staff, and Observers/Vendors.
aily Operations, Hyperbaric Oxygen
D
Therapy (HBOT)
age 2: CWH/HBOT Staffing
P
• Hours are Monday–Friday, 0630–1530 (with Structure
occasional weekend/inpatient cases).
• Each day is staffed by 1 Covering Attending, 1 Providers Affiliated
– 2 Plastic Surgeons – Vascular Surgery
Nurse Coordinator, and 2 HBOT Techs (1 of
– 2 Podiatric – Infectious Disease
whom is also their Safety Director). Surgeons
• There are four chambers available, enabling – 2 Outpatient NPs – Plastic Surgery/Nerve
treatment for up to 12 patients per day. Specialist
• Authorization for treatments is submitted – 3 Inpatient NPs – Radiology Tech (allows for
in-clinic X-ray capability)
through each patient’s insurance company,
– 1 Rheumatologist – Plastics/Podiatric Residents
who will determine how many total chamber – 1 Hyperbaric – Physical Medicine and Rehab
sessions and “dives” for which a patient will Medicine (Wound Treatment and
be covered. Specialist Lymphedema therapy)
– Orthotics/Prosthetics Clinics
– Visiting Nurse Agencies
– Clinical Scribes
Attendings/Residents Coverage
– Dermatology
• Weekday outpatient clinic visits.

• Daily OR Cases, both inpatient and outpatient
cases.
2 Staffing and Day-to-Day Management: The Nuts and Bolts of Running a Wound Care Center 15
Wound Center Staffing (Fig 2.1)
Administrave
Director
Administrator III
Tara Wallace
Amara Ellis, RN
Paent Services
Nurse Manager II
Manager
Hyperbaric Cerfied Medical

Administrave Nurse Specialist II Nurse Praconer
Technologist Assistant
Hyperbaric Tech
Paent Srvcs
#1 (Also HBOT CMA #1 CWH RN #1 Outpaent NP #1
Coordinator #1
Safety Director)
Hyperbaric Tech Paent Srvcs Outpaent NP #2

CMA #2 CWH RN #2
#2 Coordinator #2 (20h)
Part-Time
Paent Reg
Hyperbaric Tech CMA #3 CWH RN #3 Inpaent NP #1
Associate #1
30h
Paent Reg Inpaent NP #2

CMA #4 CWH RN #4
Associate #2 (36h)
Inpaent NP #3
CMA #5 Billing Analyst CWH RN #5
(20h)
Execuve HBOT Nurse

Assistant Coordinator
Fig. 2.1 Org Chart

Page 3: Who Does What? (b) Attends various Hospital/Administrative

meetings for these issues as scheduled
Leadership: Co-Managers and/or as appropriate.
(c) On-site CWH representative and contact
The Clinical Nurse Manager and Patient Services point for department audits—Safety,
Manager (PSM) work in tandem to oversee the Infection Prevention, Dept of Health,
day-to-day Clinical and Administrative opera- Joint Commission, Magnet, etc.
tions of the CWH/HBOT. As delineated in the (d) Acts, documents, and follows up on all
Organizational (“Org”) chart in Fig. 2.1, the Nurse patient-safety related issues with Legal,
Manager’s direct reports are all Nursing staff; the Risk, Administration, Safety, Patient
PSM’s direct reports are the Administrative and Advocacy as appropriate.
Medical Assistant staff. (e) Preparation of and follow-through with
CWH staff for these audits or issues.
7. Directs and archives weekly all-staff Thursday
Nurse Manager Roles Meetings. Attends all other Department-
and Responsibilities related meetings as appropriate.
8. Liaison between CWH/HBOT and Nursing/
1. Direct oversight and coordination of day-to- Hospital Administration.
day Clinical operations, staffing, and trouble- 9. Updates and maintains departmental archives
shooting. Direct oversight and management in Shared Drives and Spreadsheets.
of the department’s RNs and NPs.
2. Updates and maintains clinical staffing and
Provider clinic schedules, as well as the CWH Page 4: Patient Services Manager
Master Calendar. Makes all clinical staffing Roles and Responsibilities:
assignments (daily, weekly, monthly).
3. Performs in simultaneous Nurse Specialist 1. Manages the entire patient registration pro-
role in Clinic and at the CWH Triage desk, per cess, ensuring and obtaining complete demo-
daily staffing assignment needs. Assists with graphic and insurance information for each
any other CWH tasks as assigned or patient appointment.
indicated. 2. Oversees the entire patient scheduling pro-
4. In coordination with the PSM, approves cess, including adherence with all established
staff leave requests and monitors Time and policies, determining, and accurately docu-
Attendance. Performs preliminary approval menting the appropriate appointment type,
of Nursing/NP staff timesheets in our referral and/or authorization requirements,
clocking system, MyTime (PSM does them and procedure orders.
for Medical Assistant and Administrative (a) Supervises the scheduling of surgical
staff). cases, procedures, and admissions for the
5. In coordination with PSM, site Administrators, department, including staff adherence
Nurse Recruitment, and Human Resources, with the appropriate communication of
performs interviewing, hiring, and orientation hospital policies and procedures to
for new associates, as well as coaching/men- patients and families.
toring or counseling existing staff. (b) Directs implementation and mainte-
6. Performs monitoring, documentation, clinical nance of approved organization elec-
education, and follow-up on department tronic scheduling and billing system,
Quality and Safety Issues. triaging referrals and/or orders to the
(a) Reports or presents on these issues to appropriate physician master schedul-
Administration as called upon. ing functions. Ensures the performance
of daily schedules edits as necessitated 8. Implements cross-training schedules between

by Provider changes. all administrative positions to ensure adequate
3. Manages patient check-in and check-out pro- staff coverage.
cesses for the department, including patient
reception, validation of patient identity, scan-
ning of patient documents to the appropriate Page 5: Why is Co-Management
system, and resolution of conflicting chart Important? Our Personal
alerts. Ensures immediate updates and resolu- Perspectives
tion for missing or inaccurate information
prior to patient arrival, insurance verification, In our experience managing the CWH/HBOT, we
collection, and electronic position of time-of- have come to realize that having two Managers is
service payments, and preparation of charge essential for cohesive and comprehensive cover-
batches. age of all day-to-day Clinical and Administrative
(a) Monitors staff adherence to billing proce- operations. Foremost, the departmental workload
dures and copayment reports on daily rec- and its scope is such that it requires at least two
onciliation department activities. people’s involvement, and two differing areas of
Oversees batch management. Monitors expertise. The Nurse Manager acts as an available
encounter form completion and reconcili- resource, coach, and informational source on the
ation and batching process of front- and Clinical side, and the Patient Services Manager is
back-end billing practice, in order to opti- able to offer the same on the Administrative side.
mize charge capture and Provider Managers are also both able to cross-cover any of
reimbursement. their associates’ duties when needed. Both of us
4. Directs referral, pre-certification, and autho- regularly fill in as staff around the clinic - The
rization processes to all Managed Care Nurse Manager as a clinical and Triage nurse, and
Department requirements and contracts. the Patient Services Manager in any one of our
Ensures managed documentation of referrals Administrative positions which are vacant on
and authorizations in the approved organiza- either the short- or long-term.
tions’ electronic scheduling and billing We have also found that chemistry to the part-
systems. nership is key - as much as possible, it is impor-
5. Ensures medical records meet departmental tant that your Co-Manager possesses shared
managed care, Joint Commission, HIPPA, values, motivations, and goals for the practice and
and other regulatory standards. team. We Managers share an office and discuss
6. Collaborates with the healthcare team the minutiae of the day in real time. We can put
members, patients, Physicians, and our heads together to solve any challenges which
Department Administrators to identify and arise, both small- and big-picture, and we brain-
troubleshoot barriers to efficient, quality storm together and offer each other different per-
service. spectives as to how to best approach these issues.
(a) Audits staff productivity and utilization of We talk things out and welcome the other’s
billing systems to include indexing, scan- insights and advice - even if we sometimes ignore
ning, phone notes, files in error and other them, the input is always appreciated. This rela-
appropriate measures. tionship also allows for the mental security and
7. Actively participates in departmental and hos- relief that yours is a shared burden; that someone
pital meetings, such as Clinical Practice and else appreciates what you are experiencing; that
Managed Care Compliance. Relays relevant you are supported and championed; and that you
information to administrative and clinical are not alone in your responsibilities.
staff and provides training and associated We Managers look at ourselves as a unit. We let
documents as appropriate. all of our associates know, from before hire, that we
work as a team. Our associates and Providers know alternating each patient assignment (every
that we are aligned, and that they can come to either other exam room). They start the Office Visit
of us at any time for assistance or guidance. They note, adding and updating the History of
know we approach things in tandem and keep each Present Illness (HPI), Review of Systems
other updated to the minute, which we feel is nec- (ROS), and performing a Medication List
essary for informed and overall management of the Reconciliation. They complete the Wound
team. We have found that the symbiotic nature of Assessment documentation and finish with a
this partnership has allowed us to manage our prac- Visit Summary. This Summary is given to and
tice effectively and successfully, to recruit, hire, reviewed with the patient, providing details on
and retain excellent associates, and to ensure conti- all their instructions and ongoing Plan of Care.
nuity and the highest standard of patient care. RNs assist the Providers during the visit with
any patient exam or bedside procedural needs.
They are also involved in on-site, real-time
Page 6: Staffing Roles: Clinical care coordination for consultations from/
referrals to other practices or team members,
This section is meant to provide a consolidated any diagnostic testing needs, ensuring any
overview of our CWH/HBOT staffing team and orders or updates are sent out to the appropri-
their roles in our Clinical setting. ate parties, and updating anyone involved with
the patient’s care. Our nurses are also cross-
trained with the CMA role and will perform
Clinical Associates those tasks as well when needed.
• Triage: Our nurses assist with anything that
Certified Medical Assistants (CWH): Our comes through our Triage desk, either as their
CMAs see patients with the Providers and Nurses coverage assignment for that day, or in any
throughout the clinical day. They are responsible downtime at the beginning and end of the day.
for rooming the patients into Exam rooms, get- These tasks are all related to patient requests,
ting the patient and exam room prepared for the surgical or admissions planning, patient-
visit, and removing existing casts and dressings. related calls and paperwork, and ongoing vari-
They also perform the initial patient intake, able tasks in coordination of patient care and
which includes Vital Signs and general screening follow-up.
for Pain and Fall Risks, Smoking and Allergies,
any Specialized Needs, and currently, COVID-
related risk factors. The CMAs then conclude the N urse Practitioners (CWH)
patient visits by cleaning and re-dressing any
patient wounds as directed, assisting the patient • Outpatient: Our outpatient NPs act in partner-
with their mobility devices, escorting them to ship with our Attendings in their clinics and
where they need to go from there, and then turn- host clinics of their own. They evaluate and
ing over the Exam Rooms for the next visit. The examine the patient, assist with or perform
CMAs also coordinate for the retrieval and return any indicated bedside procedures, and recom-
of our Sterile Instruments and the ordering and mend and document the Assessment and Plan
stocking of clinic supplies. They are occasionally (A&P) for the patient. They follow up on our
called upon to assist with complex Inpatient specimen results and coordinate with
dressings as well, in order to help expedite patient Infectious Disease for any subsequently
discharges. updated recommendations. They are also
Nurse Specialists (CWH): Trained in a dual cross-trained in the RN, Triage, and CMA
Clinical/Triage role. roles and will perform those tasks as well
when needed.
• Clinical: Our RNs see patients with our • Inpatient: Our inpatient NPs work with our
Providers in the clinic each day, generally Residents and Attendings in ongoing patient
care, monitoring, and discharge coordination verification system called Tavoca, through which
from the inpatient side. They round on patients patients can cancel their appointments. In the
at the bedside and work closely with Case event of cancellation, the PRAs reach out to the
Management for ongoing complex discharge patient to reschedule. The Front Desk also scans
planning and patient follow-up needs. They in new patient paperwork, submits Medical
also compose our Discharge Summaries and Records Requests, and checks our virtual
stay in constant communication with all of Administrative Inbox for urgent appointment
those involved in the patient’s care, to ensure requests from the clinical staff.
streamlining and cohesion to their clinical Patient Services Coordinators (PSCs):
journey through all systems. Though we have two positions with this same
title, they encompass completely different roles.
Nurse Coordinator (HBOT): This position
is responsible for the safe and effective operation • Patient Services Coordinator (A), sometimes
and maintenance of the hyperbaric chambers and referred to as our Surgical Coordinator, is
related support systems, and oversight of the day- responsible for booking all inpatient and out-
to-day operational activities required to maintain patient surgical procedures for the Providers.
and grow the Hyperbarics Program. Our Nurse When the patient has completed all their pre-
Coordinator monitors quality and safety issues surgical requirements, PSC (A) is then tasked
and provides nursing care and treatment for with coordinating the surgery booking. If this
incoming patients. They supervise the techni- is an outpatient procedure, PSC (A) is respon-
cians and assist in specialized clinical and sible for obtaining authorization for the proce-
research projects. They also assist in Triage tasks dure through the patient’s insurance company.
such as insurance authorizations and anything For inpatient cases, authorization will already
needed in patient follow-up. have been obtained and is handled by the inpa-
tient billing team. Once the procedure is
authorized, the case is sent to the OR sched-
Page 7: Staffing Roles: uler for posting. PSC (A) will then update the
Administrative patient’s Electronic Medical Record (EMR)
and a posting sheet for the Residents, which is
This section is meant to provide a consolidated located on our practice’s Share Drive. Once
overview of our CWH/HBOT staffing team and the surgery has been completed and entered
their roles in our Administrative setting. into the surgical billing system, PSC (A) then
Patient Registration Associates (PRAs): checks over the submission for errors and
Our two PRAs are responsible for a multitude of makes any needed corrections. When the sur-
tasks at the Front Desk. These associates oversee gery bills have been committed, a copy is
patient check-in and check-out, insurance verifi- printed and then entered into the patient’s
cation, and registration updates. Before the EMR for physician billing. PSC (A) is also
patient arrives for their office visit, they verify the responsible for communicating with the
appointment type, check eligibility, and contact patient throughout the process of booking
the patient if a referral is needed. If a patient is their procedure and post-op follow-up appoint-
within or out of their global period, the correct ment and providing instruction and guidance
appointment type is allocated. At check-in, the for the day of surgery.
patient is given a demographic form and asked if • Patient Services Coordinator (B) is responsi-
any information needs to be updated in our sys- ble for filtering and navigating all incoming
tem. The patient’s insurance card, ID, and con- phone calls to our department’s Triage line.
sent to be treated are scanned into their chart at This direct line is given to all patients in their
check-in. If the patient’s insurance requires a Visit Summaries, with directions to call if they
copayment, it is collected before the patient is have any clinical questions or concerns
seated. MedStar also has a virtual appointment between their appointments. This position is
in partnership with the Triage nurse and ment report, which lists the targeted amount vs.
involves addressing the patients’ needs, direct- the actual amount collected for the day. On the
ing the calls elsewhere as needed, prioritizing second column of the copayment report, it lists
the urgency of the message or request, check- the balances patients have accrued within
ing the status of pending outpatient surgery MedStar and compares it to the total amount col-
clearances, and coordinating for wound sup- lected at that patient’s appointment. An outstand-
ply orders through the patient’s insurance ing balance sheet is then given to the patient at a
company. PSC (B) either speaks with the subsequent check-in, so the patient is informed of
Triage Nurse directly throughout the day, or the amount owed. At the end of each business
they communicate through the patient’s EMR day, once the batches have been closed, the
messaging system. PSC (B) is also responsi- Billing Analyst takes any cash deposits to the
ble for collecting and distributing documents Cashier’s Office. Other duties include documents
from the fax machines, scheduling follow-up scanning, authorization for substitute skin graft
appointments for our inpatients on their dis- materials, code edits, and approvals for single
charge, and scanning urgent documentation case agreements (Fig. 2.2).
into the EMR system. This position is well- Executive Assistant (EA): The EA acts as
suited to an associate with previous clinical our most embedded Provider resource. Their role
experience in the CWH, as they are often able involves assisting with the needs and requests of
to address the patients’ questions directly all our Attendings and NPs. These tasks are all-
without having to route the call elsewhere. encompassing, but include travel coordination,
submission and tracking of reimbursements,
Billing Analyst: Since the CWH is consid- maintenance and distribution of Provider calen-
ered an outpatient facility, two bills are issued dars and the monthly on-call schedules, and
from each outpatient visit. One is the Physician’s meeting coordination. The EA is also responsible
charge, and the other is called a Facility Fee, for for the upkeep of an Excel sheet which details
the usage of the facility and those associated ser- Provider licensing renewals and credentialing
vices. It is the responsibility of the Billing Analyst updates. The position serves as a backup desk for
to submit all charges from the Facility Fee to the PSC (A)’s role in scheduling surgeries and sub-
patient’s insurance company. For each patient mitting the related Provider billing, and other
visit, the Front Desk prints out what is known as associated CWH-related tasks are substantial.
a Fee Ticket (Fig. 2.2), which is a list of proce- They include, but are not limited to, department
dures which may be done in the office. This is key copy and office supplies requests, coordinat-
completed by the nurse, following the patient’s ing staff lunches and potlucks, arranging and
visit. Once the Fee Ticket is completed and turned execution of staff retreats, and departmental mail
in, the Billing Analyst will call the patient’s distribution. Additionally, our EA coordinates
insurance company to figure out if Prior and oversees our monthly Amputee Support
Authorization is needed for an outpatient proce- Group, which has become an invaluable resource
dure. Once the authorization is either obtained or and forum in ongoing support of our patient
not needed, the charges are entered into the hos- population.
pital’s billing system. From charge entry a tally is Hyperbaric Technicians and Safety
generated, which compares the number of Director: The Hyperbaric Technician operates
charges with relation to the number of patients the hyperbaric chambers and ensures the safety
seen for the day. A reconciliation spreadsheet is and close monitoring of the patients throughout
then filled out and submitted to the Outpatient VP their HBOT sessions. They provide instructions
of the hospital weekly. This document accounts and documentation on the details of service and
for missing charges or an abundance of charges collect data points (e.g., vital signs, blood glu-
vs. the number of patients seen in the clinic. The cose monitoring, etc.). The Tech is responsible
Billing Analyst is also responsible for the copay- for reporting any abnormal reading or immediate
Fig. 2.2 Fee ticket

change in the patient’s condition to the Attending which are designated to and shared by our
and Nurse Coordinator. Each accredited practice exclusively.
Hyperbaric facility also has an on-site Safety –– Clinical Pool: Patient-related requests for
Director. The Safety Director is responsible for action are sent to these Pools at all hours by
ensuring the hyperbaric chambers and associated our own team, by other practices, or by our
equipment are fully operational, and that the patients, via our entity’s electronic Patient
safety guidelines are met daily. Before a patient is Portal system. The Triage Nurse attends to
permitted inside a chamber, they inspect for and the task requests and messages in the
remove any restricted or potentially hazardous Clinical inbox throughout the day, updat-
materials. The Safety Director also works in col- ing the notes with details as they go along,
laboration with the Program Director to coordi- and deleting them when the task is
nate all hyperbaric chamber upgrades, complete.
modifications, and repairs. –– Admin Pool: Any patient Scheduling
requests are sent to the Admin Pool, which
is checked on and addressed by our Patient
Page 8: The Triage Desk Registration Associates (PRAs) at the
Front Desk daily. They will also update
The CWH Triage desk is an integral operational these notes as they go along, until the task
component of our practice model. This element is completed and the note can be deleted
allows for us to gather and share information, from the Pool.
streamline ongoing coordination of patient care, • Patient Portal: Patients are provided with
and ensure that our patients’ needs are met effi- information at each visit as to how to sign up
ciently and in full. The Triage desk is staffed pri- for MedStar’s Patient Portal service. This
marily by our Patient Services Coordinator and allows them to create an online profile within
the designated Triage RN for that day. There are MedStar from which they can access their
also backup coverage plans for any associate medical records, diagnostic imaging and
absences, which involve Triage task designation testing reports, appointment information,
to various members of our team for that duration. and laboratory results. They can also use the
Portal to send their Provider an “email”
• Triage Line: The CWH Triage line is given to communication, which goes directly to that
every patient in their Visit Summary at every Provider’s practice-affiliated Clinical Pool
visit and included in every practice-related to address. Patients can attach pictures or
communication we send out—to patients, clini- documents to these messages, and we can
cal colleagues, referring Providers, etc. Patients Reply to them directly from the Pool. The
(or anyone) are encouraged to call this line if expectation or Triage is that patients will
we can assist them in answering any questions, hear back within 24 h of contacting us,
or with anything regarding their clinical needs, whether via phone call or sending a message
with relation to our practice specialty. From to the Pool.
0800 to 1700 this line is answered by either the
Patient Services Coordinator or the Triage RN,
and the voicemails are checked hourly. Off- age 9: What Makes for Triage Desk
P
hours there is a voicemail directive which reit- Success
erates our availability, but which also provides
instructions for how to reach the on-call Staff, Provider, and Patient involvement are the
Resident by pager if needed. keys to operational success in this aspect of
• GUH-CWH Pools: Triage works out of two ensuring continued, comprehensive support of
electronic Inboxes in our charting system our high-risk patient population.
• Staff: Much of why our Triage desk is suc- It is truly not possible to accurately convey
cessful is because of our staff’s dedicated con- the complexity and breadth of our Triage oper-
tributions on the day-to-day. Our on-site team ations. There are so many moving parts, so
is relatively small (<20 associates), and we many variables, and so many people involved,
stay in constant communication both in- that it would be an incredibly daunting task to
person and electronically throughout the clinic try and break it down in a way which could be
day, via the systems we have established. All straightforwardly understood. It is one of the
our associates are intimately involved in some most valuable services that we are able to offer
aspect of the patient’s journey through our with regard to continuity of patient care, and
practice, and thus every member of our team one of the shining achievements of our practice
contributes to this desk—by offering insight model.
and updates from the patient’s visits or his-
tory, by answering the incoming Triage calls
to their desks, and by following up on desig- Page 10: Scheduling
nated Triage-related tasks.
• Providers: Our Providers are accessible to Scheduling coordination is a complex but vital
our team as resources 24/7. They are diligent component of our operations. We have several
about checking their electronic inboxes and schedules in flux at any given moment, which
returning their messages, they check in per- require constant updating, monitoring, and dis-
sonally with the desk to see about any out- seminating. They provide the structural guide-
standing tasks for which they are needed, and lines of our operations and are essential for
they are at minimum reachable by phone. If tracking Provider and staff availability, and in
you cannot get in touch with one of them, you guiding our patient bookings. All of our pub-
can absolutely get hold of another. This avail- lished calendars and schedules are kept up-to-
ability allows us to ensure we are meeting date by the Nurse Manager and are accessible to
especially the most critically important patient our team 24/7 on our practice Share Drive. Any
needs in a timely manner and helps to instill a Provider booking template modifications are
mutually trusting and productive relationship done electronically by the Patient Services
between the Providers and staff, and the Manager.
Providers and our patients.
• Patients: We have been able to cultivate
patient buy-in to this desk and to the Portal Clinic Master Calendar (Fig. 2.3)
through a long and consistent history of effi-
ciently and successfully addressing their needs This calendar provides an upcoming look at our
by these routes. We often hear patients say that Provider Clinic Coverage schedules, so that we
they call our office first, no matter what their can see which Provider is available on what date,
needs, because we are “the ones who pick up” and where there is alternate coverage if a Provider
when they call, and because they know at the is out. The Nurse Manager updates and dissemi-
minimum we can assist them to get in touch nates this schedule to our team at least weekly,
with whomever they are trying to reach. Our and anytime there are changes to Provider cover-
patients are a high-risk population with multi- age. It is posted in every Exam Room and at
ple and ongoing complex care needs, and it every workstation to allow for at-a-glance guid-
gives them great comfort to know that we are ance as to how we can book patients in
reachable and reliable on the day-to-day. follow-up.
Fig. 2.3 Clinic master calendar

Fig. 2.4 Outlook master calendar
Page 11: Scheduling Page 12: Scheduling
Outlook Master Calendar (Fig. 2.4) Provider and Orthotic/Prosthetic

Coverage Template (Fig. 2.5)
This is our shared practice Master Calendar, which
our team is all able to access in Microsoft Outlook. This is another quick-glance reference which
It provides a more global overview of Provider lays out our standard, baseline Provider cover-
coverage plans and clinic breakdowns and includes age template for the Clinic and OR on the day-
additional notes for reference. These notes detail to-day. It also includes updated anticipated
staff who are scheduled out, upcoming team or on-site Orthotic/Prosthetic (Hanger Clinic)
patient-related meetings, shared clinics with other associate coverage. This template is available
practices, or any anticipated on-site Observers. The in our Share Drive and posted at the primary
Outlook Calendar includes both recurring and one- workstations around clinic. It is helpful to our
time events and allows for a look at our clinical associates as a reminder of our Master
operations both historical and upcoming. Managers Template for CWH operations and to see who
and varied members of our Administrative staff will be on-call that day for our Orthotic/
have editing capability for this calendar, and it is Prosthetic partners.
used by the Nurse Manager to guide practice cover-
age needs in creating the Clinical Staff Schedules.
Updated Provider Templates as of 1/4/21
Monday Tuesday Wednesday Thursday Friday

AM CEA Clinic KKE Clinic CEA Clinic CEA Clinic JSS Clinic
Atves Clinic Atves Clinic Akbari Clinic JSS Clinic Kerry NP Clinic
Benedict AM Benedict Benedict
PM Nicole NP Clinic KKE Clinic Nicole NP Kerry NP Clinic JSS Remote/Tele

Clinic
Atves Clinic Atves Clinic Benedict PM JSS Clinic Kerry NP Clinic
Benedict Benedict
(1/4/21, AE)
CEA Remote
1:40pm-4:00pm
OR JSS/KKE OR21 CEA AM/PM KKE Atves/KKE OR21 CEA AM/PM
OR22 CEA AM OR22 CEA AM/Atves
PM
(KKE)
Hanger Coverage as of 11/3/20
Elisa 8:30-2:30 8:30-2:30 8:30-2:30 8:30-2:30 8:00-5:00

Richard Fairfax 8-5 MGUH 8-5 MGUH 8-5 Fairfax MGUH 8-5
CWH John x x Ben/Charlie (alt) x
Hanger Schedule for CWH, 2021
Jan 4 John Jan 7 Charlie

Jan 11 John Jan 14 Ben
Jan 18 John Jan 21 Charlie
Jan 25 John Jan 28 Ben
1.8.21, AE
Fig. 2.5 Provider and orthotic/prosthetic coverage template
does an overview of the numbers and uses a

Page 13: Scheduling color-coding system to indicate which schedules
are full and should be “frozen” from further
Upcoming Clinic Numbers (Fig. 2.6) booking, which schedules are okay to add on for
emergencies only, and which schedules are open
This is an Internal Document which is published and available for booking. This schedule also
to our Outpatient Team on a once- or twice- serves as another reference point for upcoming
weekly basis. One of our nurses will be tasked to Provider coverage (who is here, who is out, and
do an overview of the upcoming patient numbers who is covering alternately). The Nurse Manager
on each Providers’ schedule, looking ahead sends this out to staff via email and publishes
about a month forward. The Nurse Manager then and disseminates color copies for that day to all
Fig. 2.6 Upcoming clinic numbers
schedulers’ desks for their reference. Upon pose of this schedule is to assist in getting our
receiving that day’s schedule, our EA will then patients scheduled evenly across Provider avail-
“freeze” any provider schedules (red or yellow ability, to limit overbooked schedules, and to
dates) in the virtual Provider template from fur- ensure our team has a quick-reference guideline
ther booking by Central Scheduling. Only our as to where there is immediate availability for
staff can add appointments from there. The pur- booking.
PLAN FOR THURSDAY, 1/28/21 Page 14: Scheduling

NOTES:
TIPS at 0800: Paent Case Presentaon HK Plans of the Day (Fig. 2.7)
Dr. Steinberg has room for add-ons today prn. These Plans are sent out daily via Outlook email
Amputee Support Group is tonight at 5 via Zoom. by the Nurse Manager, or by the designated cov-
ering Triage nurse for that day. They are sent to
Have a great day everyone! all our inpatient/outpatient team members, as
well as to our clinical partners—Radiology,
SCHEDULE/STAFFING
Scribes, Physical Medicine and Rehab, Hanger
Dr. Anger has AM (26) Clinic, our Chief Resident, and Case Management.
Kerry NP has PM (9) The Plan breaks down the clinic setup and assign-
NP: Kerry
RNs: Sara (7-5:30), Jacqueline (7-5:30)
ments for the day, any alternate Provider cover-
MAs: Donnell (7:30-4), Iris (8-4:30), Lloyd (8:30-5 float) age, any staff outages, and includes any pertinent
notes for that day’s operations.
Dr. Steinberg has AM (23) and PM (10)
NP: Nicole
RNs: Lauran (7-5:30), Amanda (7-5:30)
MAs: Anna (7-4:30), Amber (8-4:30), Lloyd (8:30-5 float) Page 15: Scheduling
Dr. Benedict has AM Clinic (2) and PM Clinic (2)
Dr. Johnson-Arbor has AM (2)
Clinical Staff Schedules (Fig. 2.8)
LUNCH: These are the weekly clinical staff scheduling

12:30 – Sara, Lauran, Donnell, Anna assignments, which also include notes about any
1:00 – Jaqueline, Amanda, Iris, Amber
1:30 –Lloyd anticipated alternate Provider coverage, staff
outages, and any important upcoming events.
x4-6161: Tynisha (8-4:30) They are made and distributed by the Nurse
Triage: Amara (6:30-5)
Manager, optimally about a month in advance
(i.e., send out the schedules for all of February
Hanger coverage/x4-1987: Ben H. in early January). These templates are used, in
conjunction with the Outlook Master Calendar,
Code Cart: Lauran
to make that day’s Plan of the Day. Note here
Out: the staggered staff start times for the CMAs, and
Shinea the longer hours and variable “Out” days for the
Margaret
Thalia
RNs (as they work four 10-hour shifts).
Fig. 2.7 Plans of the day


4 CLINIC 5 CLINIC 6 CLINIC 7 CLINIC 8 CLINIC
Dr. Anger (AM) Dr. Evans with Dr. Atnger (AM) Dr. Anger (AM) Dr. Steinberg (AM)
with Nicole NP (PM) Nicole NP Nicole NP (PM) with Kerry NP (PM) NO REMOTE PM
RNs: RNs: RNs: RNs: RNs:
Briana (7-5:30) Lauran (7-5:30) Briana (7-5:30) Jacqueline (7-5:30) Lauran (7-5:30)
Amanda (7-5:30) Amanda (7-5:30) Lauran (7-5:30) Lauran (7-5:30) Amanda (7-5:30)
MAs: MAs: MAs: MAs: MAs:
J
Iris (8-4:30), Anna (7:30-4), Anna (7:30-4), Amber (8-4:30), Amber (8-4:30),
Amber (8-4:30), Amber (8-4:30), Amber (8-4:30), Donnell (8:30-5), Donnell (8:30-5),
Lloyd (8:30-5 float) Lloyd (8:30-5 float) Donnell (8:30-5), Lloyd (8:30-5 float) Lloyd (8:30-5 float)
A
Lloyd (8:30-5)
Dr. Atves Dr. Atves Dr. Steinberg with Kerry NP
RNs: RNS: Dr. Benedict (PM) Nicole NP RNs:
N
Sara (7-5:30) Sara (7-5:30) RNs: Jacqueline (7-5:30)
Jacqueline (7-5:30) Jacqueline (7-5:30) Desk/Supply Amanda (7-5:30) MAs:
MAs: MAs: Orders: Briana (7-5:30) Anna (7:30-4),
Anna (7:30-4), Iris (8-4:30), Iris (8-4:30) MAs: Iris (8-12),
Donnell (8:30-5) Donnell (8:30-5) Anna (7:30-4), Lloyd (8:30-5 float)
Lloyd (8:30-5 float) Lloyd (8:30-5 float) x46161: Iris (8-4:30),
Tynisha (8-4:30) Lloyd (8:30-5 float) Desk: Iris (1-4)
Dr. Benedict (AM) x46161:
Tynisha (8-4:30) Triage: Anger Remote PM x46161:
2 x46161:
Tynisha (8-4:30) Triage:
Briana (7-5:30)
Sara (7-5:30)
x46161:
Tynisha (8-4:30)
Tynisha (8-4:30)
Triage:
0 Triage:
Amara (6:30-5) Admin:
Amara (6:30-5)
Out:
Ebrima
Amanda
Triage:
Sara (7-5:30)
Amara (6:30-5)
Out:
2 Out:
Ebrima Out:
Amara
Jacqueline Admin:
Ebrima
Margaret
1
Margaret Ebrima Thalia Amara (6:30-5) Briana
Velma Velma Dr. Benedict
Lauran Notes: Out: Nicole NP
Notes: Ebrima Sara
Notes: Mary Hicks RN Margaret Velma
(WOCN Student)
Shadowing Notes: Notes:
Happy Birthday Iris! No PM Remote
Mary Hicks RN visits for Steinberg
(WOCN Student)
Shadowing
Podiatric Residency
Interviews in PM
Fig. 2.8 Clinical staff schedules

age 16: Managerial Tracking

P know we track this performance aspect dili-
of Clinic Operations gently, and that they will be held to account
for any ongoing violations of our hospital and
In order to maintain historical context and stay departmental Time and Attendance policies.
up-to-date, the CWH Co-Managers keep con- We also make a Google spreadsheet to
stant, meticulous track of all small- and wide- track our associates’ Holiday Requests around
ranging clinical operations and events. This is Thanksgiving, Christmas, and New Year’s.
done using shared, secure Google Spreadsheets, This helps us to ensure adequate staff cover-
which are added to almost daily. These are as age for clinic and equitable distribution of
follows: time out for each staff member during these
holidays.
1. CWH/HBOT Manager’s List 3. Facilities Requests
This is an informal, voluminous document This sheet is used to track the timeline and
and an invaluable resource which we use to status for any outstanding departmental
comprehensively track everything which Facilities-related requests. These include
takes place in the department. We document items like department touch-ups, equipment
on all projects, maintain detailed notes on replacement, installation of new electronics or
associate or interdepartmental engagements, media, and requests for systems upgrades. It
and add continued updates on any Provider, is shared with and most regularly updated by
entity, staff, or administrative requests which our Executive Assistant.
cross our desks. We then continuously add As a practice, we also all utilize the Practice
notes on any progress, updates, movements Share Drive (“Limbshare”) to preserve, access,
on, or conclusions to these events. Current maintain, and update all clinic-related docu-
and active items are kept at the top of the list, ments, resources, workflows, handouts, paper-
divided by category; completed items are work templates, etc.
moved to the bottom of the list to keep on
hand for reference.
This document serves as a comprehensive Page 17: Associate Engagement
catalog and history for our department. It
helps us to track staffing structures and hiring For our Leadership to ensure a consistently open
efforts, associate histories from hiring, clini- dialogue and line of communication throughout
cal scheduling evolutions, timeline histories our practice, several forums are held with
and next steps for active projects, relevant consistency.
contact details throughout the hospital and
entity, and step-by-step workflow details for 1. Weekly Operational Meetings: “Ops”
future use and ease of return. This meeting takes place every Thursday
2. Time and Attendance just before our weekly all-staff meeting.
One of the most persistently frustrating Attendees are, at minimum, our two practice
issues we deal with in Management are incon- Chiefs/Providers (Dr. Attinger and Dr.
sistencies in our associates’ Time and Steinberg), the two CWH/HBOT Managers,
Attendance. Another of our shared spread- Tara and Amara, and our department’s
sheets is for tracking their lateness, absences, Practice Administrator. Our other Attending
and callouts. This allows for an at-a-glance Providers are also invited and make a point to
look at the distribution of any of these patterns attend when their schedules allow, as does our
among our associates, and for quick access to Administrative Director.
information when we need to document or This brief (30 min) weekly meeting allows
refer to the Attendance details in disciplinary for this group to catch up on clinic- and system-
documentation or sit-downs. Our associates wide operations and to address and strategize
on any new or ongoing issues. Constant com- tion to the group about their role with our
munication between our leadership teams is department and themselves as a person.
essential in keeping our operations up-to-date, We draw a random name for these at the
forward-moving, and as streamlined as possi- advance meeting, so they have some
ble from the ground up. It also helps to ensure notice, and provide a prompter question-
we are accounting for every perspective in naire/template if needed. It has been a
tackling an issue and allows us to maintain a truly enjoyable team-building tool to help
consistently unified lead and messaging to our people get to know and appreciate each
staff and individual teams. other as colleagues.
2. Weekly Thursday Staff Meetings (e) Team Kudos: This is our chance to
This meeting is also brief at 30 min and acknowledge standout efforts from any of
takes place every Thursday just after our Ops our associates or our team in general. We
Meeting. Under regular circumstances (i.e., review complimentary patient letters,
pre-pandemic), all present CWH/HBOT staff details of any earned personal or group
gather in our department’s conference room, awards or accolades, or any significant
before starting the clinic day. These meetings clinic- or career-related achievements.
are most often hosted by the Nurse Manager, We also share (with permission) any sig-
or by the Patient Services Manager in her nificant broader success or event in our
absence. Topics vary, and themes include associates’ lives. It gives us a reason to
(often a combination of) the following: cheer and celebrate and feel proud and
(a) Clinical Operations Updates: These happy together.
include overviews on staffing updates, (f) Guest Speakers and Multidisciplinary
Provider or clinical schedules, any new Calls: Occasionally we will have a Guest
practice recommendations, and ongoing Speaker come present to our team on a
facilities requests. multitude of topics. These have included
(b) Patient Case Presentations: These are Hand Hygiene, Research Updates,
put together and presented by our Workplace Violence, Associate Wellness,
Providers or one of our Clinical team. We Advancements in Prosthetics, Supplies
identify and review an especially chal- Vendors, International and Language
lenging patient case for which we are Services, and many others. We also have
seeking group input and suggestions for a monthly, first-Thursday group video
any more effective plan of care and call with our other system-wide Wound
treatment. Centers, where we alternate case presen-
(c) Safety and Audit Preparation: This is a tations and strategize on patient care on a
chance to refresh our team on the hot top- broader level.
ics and practice recommendations from (g) Education and Conferences: We take
Regulatory Readiness, the Joint every opportunity to send our team mem-
Commission, or the Department of bers to relevant, practice-related educa-
Health, in advance of any known or pos- tional conferences throughout the year.
sible upcoming clinic audit. This helps to Following their attendance, attendees are
keep them feeling prepared and ready to asked to present at the next weekly meet-
comfortably engage with any surveyors ing on their takeaways from the experi-
when they arrive. ence. This allows for continued gathering
(d) Staff Spotlights: These are generally and dissemination of current global prac-
everyone’s favorite sessions. We created a tices and research updates to the team.
template and forum for each of our team 3. Team Huddles and 1:1 Check-Ins
members (and sometimes, an ancillary Each Manager hosts regular smaller meet-
partner) to give a 10-min-long presenta- ings, or “Huddles,” with their direct reports in
their fields (Nurses, CMAs, Admin). This appreciation which our Attendings model.
allows for the chance to review any more role- They thank us as individuals daily for all of
specific practice updates or recommendations our efforts and support in caring for our
and for the gathering of suggestions or input patients and making the clinic run success-
on a more intimate engagement level. These fully. Our Attendings also believe that group
meetings take place approximately every 2 engagement, both internal and external, is
months, or when needed for anything more fundamental to our team’s cohesiveness. They
urgent. treat us to staff meals from a collective fund at
We also meet 1:1, or 2:1 with our associates least bi-monthly, they sponsor our attendance
anytime we feel it is indicated, anytime by at Conferences, and they include us in team
associate request, and for formal Mid- and celebrations like our Residents Graduation
Year-End Performance Evaluations. The infor- ceremonies. Every few months they host a
mal sit-downs are done to address any immedi- group activity like a Field Day or Happy Hour
ate issues or concerns. They can also be simply or an Escape Room event, all of which are
a “check-in” to see how the associate is doing, usually well-attended. This unwavering sup-
praise their performance, and see if there is any port and encouragement, plus the opportunity
way we can support or enhance their experi- to have fun together outside work, truly keeps
ence or continued development in our depart- morale boosted and makes us want to do our
ment or their more long-term career goals. If very best for them, for our patients, and for
there is any need to formally document or each other.
archive these interactions for Human
Resources-related or historical reasons, we uti-
lize our entity’s “Talent Manager” system to age 18: Leadership Philosophies:
P
input a Note in that associate’s virtual Employee The Managers’ Perspectives
File. This is done as soon as possible after the
meeting, and the Notes can be accessed at any We would like to close with some of our shared
time moving forward once saved. philosophies on what makes for a successful
4. Practice “Town Hall” Meetings Manager or Management Team. These insights
This was an initiative started just before have been gained from our day-to-day observa-
the pandemic, but which has been placed on tions and experience in the Nurse and Patient
hold for the time being. The “Town Hall” Services Manager roles, and from each of our
Meetings were meant to be held twice yearly own prior experience under Managers ourselves,
as an opportunity for all of our staff to sit from which we sometimes learned what was not
down with all of our Providers and have their effective.
undivided attention for 1–2 h. We envisioned
this as an opportunity for our associates to –– Know Your Team’s Roles: We strongly
engage in a safe and open dialogue as a col- believe that as leaders we should know how to
lective group and to solicit their insights and do everyone’s jobs, within our specialized
suggestions on where they feel we could be fields (i.e., Clinical vs. Administrative). This
more successful on all levels. We were only not only gives us an understanding and appre-
able to host one of these prior to the pandemic, ciation of our associates’ task scope and
but from feedback it was much appreciated by workloads, but also allows us to jump in and
the collective whole, and they were already cover their role when the need arises. This
looking forward to the next one. We will abso- also enables us to teach the roles when we
lutely plan to re-initiate this down the road. onboard new associates, and to serve as a
5. Staff Team-Building constant resource for our associates should
One of the best perks our practice offers to they have any questions or need any clarifica-
our associates has always been the show of tion during the workday. Additionally, if we
need to give any associate feedback, we are –– Be Present, Be Visible, Be Accountable:

well-equipped with an intimate understand- The Managers show up as scheduled, we
ing of what is being asked of them on the day- show up on time, and we make ourselves as
to-day, and how they are performing visible as possible throughout the day. This
comparatively. We also have all our associ- lets our associates know that they can rely and
ates cross-train within their field and set the depend on us and sets up an expectation that
expectation that they will be called upon on we want to see the same from them. As much
occasion to cover each other’s desks as well. as possible, we Managers try to do our jobs
This allows them to learn additional job skills from central clinic locations during the day—
and to feel secure that we will be covered in the clinic hallways from a mobile worksta-
the event of short-staffing. tion, or in the Administrative areas where
–– Lead By Example: This is modeled from the multiple other associates work. This allows us
very top on down. Our Providers have set an to keep a comprehensive eye and ear on the
admirable and reliable standard for keeping day’s events and interactions and helps
cool heads in challenging situations, main- encourage our associates to stay on task. We
taining near-constant good cheer and calm, also make sure to let our associates know
and projecting competence and confidence. where they can find us or how they can reach
They also “praise in public” when they notice us throughout the day, so they know they can
an extra or outstanding associate effort and always get a Manager if needed. Keeping in
personally say Thank You to their staff every the center of things helps us stay connected to
day. As Managers, we try our very best to and involved with all aspects of our opera-
practice this same approach. This is critical in tions, allows for us to troubleshoot any issues
establishing a trusting relationship with our which arise throughout the day in real time,
associates, as they know they can come to us and allows for our staff and Providers to stay
anytime for help in handling a difficult prob- in constant engagement with us in every facet
lem. It also engenders pride among the team of clinic.
when they are acknowledged for a job well –– Constant Communication and
done. These practices also encourage a “mir- Transparency: Over-communication is both
ror” effect among the team in their interac- practiced and encouraged by Management.
tions with our patients and each other, which We share information with our team in every
of course makes for smooth and positive way, and as soon as possible—via email, face-
engagements across the board. to-face communication, team meetings,
–– Be Available (Open-Door Policy): Another instant messaging, etc. We feel that as much as
example our Providers have modeled is con- possible, our team should have access and
stant accessibility. We can reach them at virtu- insight to the same information we have as
ally any time, and when they are on-site, their leaders (excluding any sensitive HR-related
office doors are generally open and welcom- issues). This helps them to understand how we
ing. Our associates also know that they are make decisions and to help them feel confi-
welcome in the Managers’ office, and wel- dent in their own engagements in their work-
come to call or message us, and we will make place and for their entity. They do not feel they
ourselves available. We do set boundaries and are being deceived or withheld from in any
expectations as appropriate, but have not way and appreciate that they are being kept
found in our experience that this has ever been up-to-date in real time. We have had many
much of a problem. Accessibility ensures that other practices tell us that often they find out
our associates can get the answers that they about major or minor hospital initiatives from
need in the interests of expediting patient care our practice first, since we are so proactive
and services, and this is an essential compo- about getting this information out to our team
nent of our practice success. as quickly as possible.
–– No Micromanaging: We believe that inde- –– Support Your Team: As also modeled by our
pendence and autonomy are key to successful Providers, our team knows the Managers have
workflow and Manager-Associate relation- their backs. We will do anything we can to
ships. Once our associates have demonstrated help them in their success or support them
sufficient comprehension of and ability to per- through a challenging situation. We have seen
form well in their role, and understand our them through school to higher degrees, been
expectations of their continued performance, their references for continued endeavors, and
we leave them to it. They know we are avail- received many words of gratitude for being
able as a supportive resource, and that we will strong examples and providing encourage-
follow up with them if we notice any red flags ment that was needed. There is truly no greater
or coaching opportunities, but generally we let gift or gratification in this role.
them know that we trust and respect them in –– Support Yourself: Lastly, we are huge propo-
their roles. nents of self-care and of a healthy work–life
–– Everyone Has a Voice: The reason we have balance. We encourage each other and our
so many meetings, huddles, check-ins, and team to use their Paid Leave, take time for
face-to-face engagements with our associates themselves when they need it, find an outside
is because we believe an open, constant dia- hobby or interest which allows them to escape
logue is essential, and that every member of and relax, and take fulfillment not only from
our team should have a voice and be encour- their achievements at work, but from their
aged to use it. Everyone’s contributions are external successes. Our team talks regularly
welcome, considered, and respected. This has about strategies for and research findings on
led to the development of so many valuable self-care in our weekly staff meetings and
operational modifications and patient experi- shares tips with each other on the day-to-day.
ence improvements and is always extremely We also laugh together, all the time, anytime.
appreciated. It truly is the best medicine.
Case Management of the Complex
Limb Salvage Admission
3
R. N. Thalia Attinger, M. S. W. Heather Daniels,
R. N. Teodora Deperio, and Allen H. Roberts II
It may be a fair assumption that few, if any, medi- Workers’ labor is difficult, nuanced, and largely
cal schools or residency training programs pro- behind the scenes; in many hospitals this work is
vide structured education in the art and science of never presented in Medical Grand Rounds, sel-
Case Management (CM) and Social Work (SW). dom celebrated in the Admin Suite, and largely
Most physicians who speak to CM and SW col- inaudible in the Board Room—except, of course,
leagues during their daily round and routine are when length-of-stay (LOS) is over budget, or on
unaware that these professional colleagues pos- the occasion when a prominent physician’s
sess a knowledge base and skill set that would patient’s discharge course is somehow less than
baffle the most accomplished of clinicians; it perfect! At such times, it seems easier to blame
may be similarly lost on many physicians that, CM/SW than to understand the unique challenges
absent of the work of Case Managers and Social these professionals face, and to commit, at hospi-
Workers, the flow of patients through the hospital tal and corporate leadership levels, to the success
to safe discharge destinations would grind pre- of their work in meaningful ways. We are fortu-
cipitously to a halt. Case Managers’ and Social nate, in our own institution and corporation, that
the contributions of all associates across all job
descriptions, not least our CM and SW, find rec-
R. N. Thalia Attinger (*) ognition and support in all these venues, and that
Center for Wound Healing and Plastic Surgery there is corporate commitment to process
Services, Medstar Georgetown University Hospital,
Washington, DC, USA improvement in these very areas.
e-mail: [email protected] In this chapter we shall step behind the cur-
M. S. W. Heather Daniels tains into the world and work of Case Managers
Department of Case Management, Medstar and Social Workers by way of several hypotheti-
Georgetown University Hospital, cal and composite case studies. The medical
Washington, DC, USA issues and a number of the social issues repre-
sented here will be all too familiar to medical
R. N. Teodora Deperio practitioners and nurses; we will all “recognize”
Limb, Wound-Care, and Orthopedic Services,
Medstar Georgetown University Hospital, these patients, despite their being fictitious. But
Washington, DC, USA the intent of this chapter is to introduce the reader
e-mail: [email protected] to issues that are at play behind the scenes and to
A. H. Roberts II how our CM and SW, in the handling of these
Medstar Georgetown University Hospital, complex issues, become the sine qua non of the
Washington, DC, USA successful transition of complex limb in-patients

36 R. N. Thalia Attinger et al.
to recovering and rehabilitated outpatients. This Worker (SW). The Case Manager Associate
chapter will showcase the integrated, multidisci- assists the Case Manager with daily tasks that
plinary efforts of CM, SW, nursing staff, make the Case Manager be more efficient.
advanced-care practitioners (such as Nurse Everyone has the same goal—to ensure that
Practitioners and Physician Assistants), and patients have a safe and cost-effective discharge
Hospital Administration to accomplish these very plan.
transitions. When a diabetic limb patient is admitted to
We shall begin with definitions and standard Georgetown, the CMDP is responsible, along
roles of CM and SW, acknowledging that staffing with the medical team, for coordinating and facil-
models and roles and responsibilities vary con- itating an effective plan of care for discharge.
siderably across institutions and corporations.1 Due to the complexity of the care and treatment
From there we shall consider several cases, mov- of this patient population, discharge planning
ing from the straightforward to the complex, that must begin on admission. The Case Manager
illustrate the interventions that are undertaken by meets with the patient within 24–48 h to obtain
CM/SW. Finally we shall engage administration- information such as verifying demographic
level considerations that are germane to through- information, insurance information, and social

put and discharge planning and will comment on status. The electronic medical records are
several process-improvement interventions reviewed to identify patient diagnosis, medical
which, in our local experience, have proved history, surgical plans, Consults from Infectious
beneficial. Disease (ID), General Medicine (GM), Acute
As of this writing, we are sadly in the midst of Pain Service (APS), etc. It is helpful to know
the COVID-19 pandemic, which, in addition to where the patient originated from—home (local
its medical and social tolls, has added layer upon or out of state), outside hospital (Medstar or non-
layer of additional complexities to the throughput Medstar facility), nursing home, rehabilitation
and safe discharge of all our patients, not least of facility or from an undomiciled (homeless)
them, those on our limb service. We have learned situation.
valuable lessons during this pandemic from The CMDP collaborates with the Utilization
which we hope to become better at what we do in Review (UR) Nurse to ensure patient’s hospital
the post-COVID era. stay is authorized by insurance. The UR Nurse
The Case Management Society of America reviews clinical information on admission and
defines case management as “a collaborative pro- performs concurrent reviews for continued stay.
cess of assessment, planning, facilitation, care Interqual Criteria3 is used as a guide when
coordination, evaluation, and advocacy for reviewing clinical information to determine med-
options and services to meet an individual’s and ical necessity. Through written or verbal commu-
family’s comprehensive health needs through nication, the Case Manager informs the UR nurse
communication and available resources to pro- if there are barriers to discharge, i.e., psychologi-
mote patient safety, quality of care, and cost- cal/social issues, expensive medications, lack of
effective outcomes.”2 At our hospital, the Nurse rehabilitation days, or type of isolation precau-
Case Manager/Discharge Planner (CMDP) works tions. When the insurance company issues a
with a Case Manager Associate (CMA), denial, the UR Nurse notifies the Attending
Utilization Review Nurse (UR), and a Social Physician and provides information for a peer-to-
peer review, which may result in the denial being
1
See S.K. Powell and H.H. Tahan, Case Management: A overturned by the payor. If the denial is upheld,
Practical Guide for Education and Practice, 4th ed., many cases may be appealed successfully. It has
2019, Wolters Kluwer, Chapter 1.
2
See https://www.nurse.com/ce/beyond-the-basics-in-
case-management accessed 2/5/2021 and https://lms. 3
https://www.priorityhealth.com/provider/manual/stan-
nurse.com/login.aspx, CE direct, Beyond the Basics in dards/utilization-management-program/interqual-loc-
Case Management, Chapter 1. criteria, accessed on 2/5/2021.
3 Case Management of the Complex Limb Salvage Admission 37
been our experience that a systematic monthly When the choices are deferred to the Case
review of all denials and appeals at the hospital Manager, the patient is referred to facilities to
administrative level may result in the identifica- which many previous limb patients have been
tion of documentation or coding issues, or other sent. These facilities are familiar with our plastic
themes, the correction of which will lend itself to surgeons’ treatment plans and there is a wound
recoupment of significant revenue. care Nurse Practitioner on staff. When an accept-
An important innovation in patient throughput ing facility is identified, the facility provides bed
was implemented by a MedStar Health Corporate availability and obtains insurance authorization
initiative known as the Integrated Model of Care prior to transfer. If the patient has Medicare, it is
(IMOC) which fosters a collaborative approach important to find out if the patient has available
to ensuring patient safety, streamlining patient rehab days. Each commercial insurance has a dif-
throughput, removing discharge barriers, and ferent coverage and benefits must be checked.
ultimately reducing LOS. One of the essential This is usually done by the facility considering
elements of this program is the Multidisciplinary the patient for admission. Depending on type of
Rounds (MDR), a dedicated, brief session exe- insurance, the CM is sometimes required to
cuted on each hospital ward, once daily, in which submit clinical information, especially PT/OT

all patients on that ward are concisely reviewed. notes to the insurance company for approval.
These rounds may be held virtually by video- or A real-time tracking of the progress of all
teleconferencing. At MDR, which is attended by referrals is kept and updated via task-lists. The
the Physician or Nurse Practitioner, patient’s CM reviews the task-list with the CMA daily.
Registered Nurse, Physical Therapist (PT), or The CMA sends the referrals out to facilities via
Occupational Therapist (OT), Charge Nurse, CM a web-based referral platform. He/she is respon-
and/or SW, the patient’s discharge plan is sible for following up with the facilities, deliver-
reviewed in a structured manner that employs ing durable medical equipment (DME) to the
checklists and the identification of all discharge bedside, setting up medical transport, and provid-
barriers. IMOC MDR rounds are held every day ing discharge packets. When referrals are made,
to talk about patient/family issues, surgical plans, it is important to inform the CMA name and
discharge needs, and expected discharge date. duration of intravenous antibiotics, presence of a
The Physician or NP orders PT and OT consults central line (if applicable), type of isolation,
to help determine patient’s level of care for dis- wound care, and discharge date. Both CM and
charge. PT and OT evaluations provide recom- CMA work together in delivering care and ser-
mendations for durable medical equipment, vices for a timely discharge.
home care or need for inpatient physical rehabili- The CM also collaborates with the SW on a
tation (subacute or acute rehab). IMOC MDR, regular basis. The Clinical Social Worker in the
now a part of the “culture” of the hospital, has inpatient hospital setting provides direct services
proved to be a fundamentally important contribu- to patients and families related to hospitalization,
tor to safe and efficient throughput. dealing with illness and post-hospital planning.
Once the initial discharge plan is determined, However, the role of a clinical social worker is
the Case Manager meets with the patient/family complex and is often specialized depending on
to discuss the plan. If PT/OT recommends inpa- the setting and population served. As a part of the
tient acute or subacute rehabilitation, a list of multidisciplinary team, a clinical social worker is
facilities that are in-network with the insurance often consulted by the case manager or medical
company is provided. The patient is asked to pro- team to address identified barriers to discharge
vide at least three choices to initiate referrals. The for the complex limb patient. The social worker
patient’s family is given sufficient—but not can help address financial or insurance concerns,
unlimited—time to visit the facilities but due to assess for home supports, coordinate and collab-
the COVID-19 pandemic; they are encouraged to orate with community agencies and resources,
research online or call the facilities themselves. and can also provide support and brief counseling
to the patients who are having a difficult time social worker will connect the patient and family
coping and adjusting to their medical situation. with community agencies such as A Place for
When consulted, the social worker reviews the Mom5 to assist in finding an appropriate ALF. If
patient’s chart for current and previous medical the patient needs acute rehab or short-term rehab,
and case management documentation, noting the case manager takes the lead in making refer-
interventions and outside resources. The social rals and facilitating rehab discharges with the
worker then will conduct a psychosocial assess- social worker remaining available as needed. If a
ment with the patient and/or family and collabo- limb patient cannot go home with supports and
rate with the case manager, medical team, and has no payor for rehab, the social worker can
outside supports in determining a social work request to subsidize a rehab stay with a partnering
plan. short-term rehab facility through the case man-
For patients who are uninsured, the Clinical agement department.
Social Worker refers the patient to Division of If the patient does not have insurance, does
Economic and Community Outreach (DECO)4 not qualify for Medicaid, and/or is out of rehab
for assistance in applying for Medicaid or days, the social worker will refer the patient to
Emergency Medicaid. If the patient does not have the case management directors to request a sub-
a secondary insurance, the patient is also referred sidy for home health aides through a local philan-
to DECO to apply for Medicaid as a secondary. thropic source which underwrites proprietary
In situations when a patient is undocumented and in-home nurse practitioner visits and services and
unable to obtain Medicaid, the social worker can may subsidize necessary medications needed to
then make a referral to charitable sources for ensure the patient has a safe and sustainable
assistance with follow-up medical care and will discharge.
consider and provide for potential discharge A small population of complex limb patients
needs: clothing, transportation home, or assis- are homeless and may also have mental health
tance with prescriptions. diagnoses and substance abuse issues which
The clinical social worker is also consulted to require extra coordination between the social
assess and provide needed support regarding worker, case manager, and often outside support
patients’ living environment. If a patient is par- agencies. A more traditional discharge plan often
ticularly vulnerable: homeless, older, and lives does not work out for these patients due to their
alone or has mental health or substance abuse documented histories of elopement or behaviors,
issues, the social worker considers what supports and so the social worker and case manager work
are available in their area based on their insur- together to build rapport with the patients, coor-
ance and community resources. If the patient has dinate with outside agencies and case managers,
DC Medicaid and is not safe to discharge home and communicate with the patients’ insurance
alone, they may be eligible for a home health aide case managers in order to find the best discharge
through Medicaid. The social worker will col- plan available for the patient. If a complex limb
laborate with the limb team in completing paper- patient needs rehab but is also homeless, most
work to schedule an assessment for potential rehab facilities will not accept them without a
home health aid service hours and work with out- plan for discharge after rehab. The clinical social
side case managers and agencies to arrange home worker and case manager work together to
care. If the patient needs assisted living facility explore different options such as discharging
(ALF) and has some means available to them, the from rehab with family members can also make
referrals to medical shelters. During the COVID
4
https://www.decorm.com, accessed 2/3/2021. DECO
Recovery Management assists hospitals by providing a 5
A Place for Mom is a nationally based senior living refer-
full suite of eligibility management services and by guid- ral agency that can assist patients and families in finding
ing patients through the complex process of applying for assisted living, memory care, residential care homes, and
federal, state, or local programs. non-skilled home care. https://www.aplaceformom.com.
pandemic, some vulnerable patients qualify for a include in their text a section on the Ethics of
homeless COVID prevention program, PEPV, Case Management, and assert, “Ethics in health-
designed to keep highly vulnerable individuals care is about choices, morals, and the basic rights
off the streets to prevent the spread of COVID. The of free choice, self-determination, independence,
clinical social worker can also refer the complex and autonomy.”6 In so stating, the authors reflect
limb patient to the PEPV program. the ascent, in recent decades, of an individual’s
The art and science of excellent patient care autonomy as the ranking determinant for ethical
and optimal patient hospital throughput are cen- decision making. At Georgetown, we affirm this
tered on collaboration and communication of the same principle of autonomy, in addition to the
clinical team with the CM/SW team. To this end, other three principles of ethics, namely the physi-
the discharge plan ideally begins—on the limb cian’s (and health care system’s) beneficence,
services as on all other services—on the day of non-maleficence, and distributive justice.7 We
admission to the hospital. Every patient admitted affirm a balanced approach to these four equally
to the hospital must have a discharge plan and a weighted principles, inasmuch as the unchecked
targeted discharge date (TDD). Limb patients, in assertion of autonomy, when taken out of the
particular, are fraught with many unique dis- contexts of community and moral order, inevita-
charge challenges. We have ideal protocols, but bly places the most vulnerable of the community
also the reality of what our patients can do physi- at risk.8 Case Managers are in the line of work of
cally, mentally, emotionally, and financially. protecting, among others, these most vulnerable.
Protocols, it should be remembered, are created We conclude our introductory section with the
for patients, not patients for protocols! A new acknowledgment that CM and SW thus bear the
below- or above-the-knee amputee might best be weight of carrying this ethical balance forward
served by spending time in acute rehabilitation, from the in-patient to the out-patient arena. Case
retraining her brain to avoid falling. A partial- Managers and Social Workers are thus the guar-
foot amputee will have the best potential for heal- antors and sustainers of ethically delivered care
ing by remaining non-weight bearing in a through the process of discharge planning. We
posterior splint. A free-flap patient would benefit turn now to exemplar cases.
from weeks of offloading in an external fixator.
But the truth of the matter is that non-weight
bearing is often unrealistic for this patient popu- he Straightforward Discharge:
T
lation. They are deconditioned and laden with The Amputee
comorbidities including contralateral weakness
or bilateral wounds. As a result, the ideal “dis- Case
charge” is just a hypothetical “starting point,” and
each discharge plan, pathway, and strategy must The patient is a 49-year-old male who presented
be tailored to the individual. Our inpatient nurse to Emergency Department (ED) with a chronic,
practitioners are uniquely skilled at bridging the non-healing, infected right foot wound. His past
gap between the ideal and the realistic discharge. medical history (PMH) included insulin depen-
Through extensive collaboration with the physi- dent diabetes mellitus (IDDM), hypertension
cians, case managers, social workers, and the
patients, they are able to create unique, patient- 6
Powell and Tahan, 286.
centered care plans. In order to better examine 7
For an exhaustive presentation of Principlism in Medical
such challenges as we face during the hospital- Ethics, please see Tom Beauchamp & and James
ization and the eventual discharge process, we Childress, Principles of Biomedical Ethics, 8th ed., 2019,
Oxford University Press.
present three case studies to highlight the nuances 8
Allen Roberts, Response to Sulmasy & Snyder, “Ethics
of this complex population. and the legalization of physician-assisted suicide: an
Powell and Tahan, in their magisterial and American College of Physicians position paper.” Annals
comprehensive treatment of Case Management, of Internal Medicine 2018; 168(11):834.
(HTN), hyperlipidemia (HLD), peripheral vascu- pain management in hopes of decreasing the
lar disease (PVD), and prior venous bypass to need for narcotic and improving overall pain
increase blood flow to the leg. He was admitted to control.
the Plastic Surgery (LIMB) service with several The Case Manager met with the patient to
consulting specialties: general internal medicine perform an initial assessment for discharge
(GIM) for blood pressure and glucose control, needs. During the interview, the patient stated he
infectious disease (ID) for antibiotic therapy, vas- lived with his spouse in a multi-level home but
cular surgery to evaluate blood flow, and acute was able to have first floor set up. He had been
pain service (APS) for pain management. An receiving wound care from a home health agency
angiogram was performed which showed little to three times a week and using a rolling walker for
no blood flow to the right lower extremity and in ambulation. Initial physical and occupational
light of failed vascular intervention in the past therapy evaluation recommended acute rehab
there was no further intervention possible. Given (AR) placement. It is generally our recommen-
the extent of the wounds and level of infection of dation that all new amputees spend at least 7–10
both the bone and the tissue the team recom- days in an AR to help retrain the mind to
mended an amputation. After years of pain, infec- acknowledge the missing limb. This helps to

tion, and multiple surgeries to the foot the patient reduce falls and in turn reduce risk of dehiscence
agreed to proceed with a below knee amputation. and hematoma to the residual limb. For those
The patient first underwent a drainage amputa- who do not meet criteria for AR (the ability to
tion where cultures were taken and then dressed participate in at least 3 h per day of physical
with a negative pressure wound therapy (NWPT) therapy), we recommend a subacute rehab facil-
or vacuum assisted closure (VAC) device along ity (SAR) with eventual upgrade to AR. CM dis-
with a knee immobilizer to protect the residual cussed referral process and the patient chose
limb and prevent contractures, intravenous anti- three facilities that are on par (within network)
biotics were ordered by ID and physical therapy with his insurance. The patient and his wife were
began to work with the patient to assess his phys- informed that he would transfer to the first
ical abilities. On the third post-operative day the accepting facility with a bed, authorized by
patient returned for his completion BKA along insurance when medically ready for discharge.
with targeted muscle reinnervation. Typically, patients stay in the hospital for 4–5
days post-surgery at which time the incisional
VAC is removed to assess the incision prior to
Plan discharge, pain can be well controlled and all
surgical drains can be removed. A discharge
Prior to surgery the patient met with prosthetists, summary outlining final ID recommendations
who gave him the opportunity to learn about the which were oral antibiotics as the infected tissue
process going forward and begin to get a glimpse was completely removed by nature of an ampu-
as to what life was going to look like for him tation, wound care, patient was placed in a short
after surgery. Whenever possible, we try to term, one time use incisional Prevena VAC
arrange peer support during the hospitalization; which stays in place for 7 days and is then
sometimes this comes in the form of our monthly changed to a dry sterile dressing, and an effec-
virtual amputee support group, other times the tive oral pain regimen was written for AR to fol-
prosthetists are able to arrange for one-on-one low. A follow-up in the outpatient clinic was
meetings. These visits/conversations with scheduled for 10 days from discharge.
patients prior to surgery is an invaluable resource Additionally, all amputees are invited to attend a
we often take advantage of for emotional support virtual support group which meets monthly. This
during this difficult process. On the day of sur- is especially beneficial if the patient happens to
gery, or the night prior, APS will place perineu- still be in-patient at the time of the meeting as
ral catheters in the operative leg for localized they are able to obtain real-time peer support.
he Moderately Complex
T Case
Discharge: The Free-Flap Patient The patient is a 65-year-old African American
male with a past medical history of IDDM
Background on Free Flaps HTN, CHF, prior left BKA and CKD Stage III,
who presented to the wound center with right
Patients undergoing a free tissue transfer (free plantar heel ulcer. He underwent several
flap) have the longest, often most complex debridements in order to get the wound bed
hospitalizations. They undergo multiple clean and the aforementioned screenings prior
debridements prior to their final closure, as to receiving the free flap. His post-operative
well as a number of pre-operative clearances course was uncomplicated but long and men-
and screenings such as angiography, vein map- tally taxing.
ping, lab studies to assess for any underlying Case management met with the patient and
hypercoagulable states, and cardiac clearance determined that he lived alone with his small dog
given the length of the surgery which often in an apartment. The apartment had approxi-
requires over 6 h under anesthesia. Their fre- mately 20 steps to enter and no elevator access.
quent need for a heparin drip and antibiotics His treatment regimen required Daptomycin, a
necessitates regular lab draws via a peripher- notoriously expensive antibiotic, to be
ally inserted central catheter (PICC) line early administered IV daily for approximately 4 weeks.
in their hospital course. The sooner we can He refused external fixation and nursing reported
identify these patients and begin the interdis- he was unable to maintain his non-weight bearing
ciplinary coordination of care the better for status (“he walks all over that foot”). He had ini-
both mental and physical health. As previously tially agreed to AR; however, due to delays in bed
mentioned, remaining non-weight bearing and availability he become increasingly dissatisfied
offloading any pressure to the flap is of the and eventually insisted on going home, as he was
utmost importance whether that be in a mulit- worried about his dog who was being watched by
podus boot with strict adherence to non-weight a neighbor.
bearing or with the use of external fixation.
Whether or not a patient can mentally handle Plan
external fixation is always a challenge. The patient was placed in a total contact cast to
Regardless of offloading method these patients offload the flap as best as possible. The cast
require long term IV antibiotics, frequent itself meant that the clothes he has worn into
wound care, and intense physical therapy. The the hospital were not suitable and he had no
post-operative period is an arduous one. one to bring him a proper set. Because of the
Patients are kept NPO (nothing by mouth) for PICC, he was unable to use traditional crutches
the first night in case an emergent revision sur- and so he was ordered a walker and platform
gery is required. They are kept in bed, under a crutches as well as rented a knee scooter. Given
bair hugger (warming blanket to improve the high cost of daptomycin, SW was consulted
blood flow), with a continuous audible to assess the patient for financial need and sub-
Doppler along with a Vioptix Doppler to mitted a request to the case management
assess skin oxygen saturation for 2 days post- department to cover the cost of the daptomycin
op. At that time, they can slowly begin to get through our contracted home infusion com-
out of bed to a chair with continuous leg eleva- pany. Social work was also able to provide him
tion until they are once week post-op and can the necessary clothes for discharge and to help
begin the dangle protocol where the patient guide him through the application process for
progressively places the limb in a dependent medical transportation and community food
position. Most free-flap patient remain in the assistance. Weekly follow-up visits were set up
hospital for approximately 12–14 days post to ensure regular follow-up visits and cast
final surgery. changes.
The Complex Discharge Plan
Case This patient had several outside case managers

with whom the social worker and case manager
The patient is a 31-year-old man with a PMH of collaborated throughout his admission and even-
IDDM and substance abuse who presented to tually a safe discharge plan was ultimately agreed
clinic with a right hallux abscess and cellulitis upon by all involved. After much deliberation his
with gangrene, noted at the dorsal aspect of the cousin agreed to let him stay with him temporar-
hallux. Osteomyelitis of the great toe was identi- ily. Our fear was that this welcome may be short
fied radiographically. He underwent several lived and therefore sent him home with dressings
debridements and ultimately a first metatarsal and medications that were as low maintenance as
head resection and amputation of the second to possible while still providing him the best possi-
fourth digits. Given the level of infection a 4-week ble chance to heal. He was placed in a well-padded
course of outpatient IV antibiotics was initially profore (multilayer compression) dressing9 with
outlined. Ideally, he would remain non- weight a controlled ankle motion (CAM) boot to offload
bearing but both nursing and physical therapy the forefoot. Given his substance abuse history he
documented that he is unable to do so. PT recom- was placed on oral antibiotics and set up with
mended SAR for the immediate post-operative weekly follow-up visits to ensure proper wound
period to help reinforce non-weight bearing and care and frequent monitoring. Much to every-
overall strengthening and conditioning along with one’s surprise and delight this gentleman went on
wound care and antibiotic therapy. He was nota- to heal beautifully.
bly aggressive toward staff throughout his stay,
often threatening to leave against medical advice
(AMA) and intermittently refusing care. Despite Other Barriers
his frequent outbursts and noncompliance, he
was deemed competent by psychiatry. Navigating the complex world of health insur-
Case management met with the patient and ance is an unfortunate reality in health care today.
learned that he was undomiciled and lived in his The limb salvage patient is, more often than not,
car, delivering food for a living. Patient is ada- a chronically ill patient whose time is spent in
mant that he wants to go home to “deal with and out of hospitals and rehabs. This compounded
things” which was worrisome to the medical with the fact that we work with patients from the
team, given that his surgery was on the right foot, District of Columbia, Virginia, and Maryland
and placing a total contact cast to offload the inci- which requires early inquiry on the part of case
sion would make driving hazardous. To further management and social work to help carve out
complicate matters, the patient had no health the best path. Patients having no insurance or
insurance, so social work helped assist in com- being out of rehab days or not qualifying for
pleting an application for Medicaid or disability; home health aide can drastically shift the dis-
however, sadly, the patient was “over income,” charge plan at the nth hour.
that is, his income, while low, was sufficient to The case manager and social worker review
disqualify him from Medicare eligibility. The the patient’s insurance status. If uninsured, the
SW, CM, and LIMB team spoke with him several social worker refers the patient to DECO for
times in order to convince him that going home assistance in applying for Medicaid or Emergency
(i.e., to his car) was not a good option, and he Medicaid. If the patient does not have a second-
eventually agreed to placement. He was referred ary insurance, the patient is also referred to
to a medical shelter, homeless hotel program, and DECO for possible Medicaid for secondary. In
short-term rehab, but was denied at all facilities
due to his substance abuse history and docu- 9
https://www.smith-nephew.com/key-products/advanced-
mented combative behaviors. wound-management/profore/.
the case that the patient is undocumented and ties. These situations are challenging and require
unable to obtain Medicaid, the social worker can the patience and professionalism of all involved—
then make a referral to Catholic Charities for and the support of hospital administration.
assistance with follow-up care and will consider The aforementioned ethics of the care of the
any potential needs: clothing for discharge, trans- patient also pertain to ministry to the greater
portation, assistance with home medications at good, especially when hospital beds are scarce
discharge. and hospital throughput must be optimized. In
The social worker is also consulted to help circumstances where a family or other surrogate
assess the patient’s home situation. If the patient becomes unavailable or uncooperative with dis-
is particularly vulnerable, homeless, or older and charge planning, it is incumbent upon the hospi-
lives alone, the social worker considers what sup- tal—and ethically imperative for the patient’s
ports are available. If the patient has DC best interests—that the hospital take expeditious
Medicaid, they may be eligible for a home health measures to obtain a court-appointed guardian to
aid, and the social worker will collaborate with move the patient’s care forward. At our facility
the limb team in completing paperwork for an this (thankfully) rare intervention is initiated by
assessment for home health aid service hours. If the SW, in consultation with senior administra-
the patient needs assisting living, the social tive physicians, and involves the hospital’s or
worker will connect the patient and family with system’s legal team and other consultants.
agencies like A Place for Mom or Care Patrol. If
the patient needs AR or SAR, the case manager
takes the lead in making referrals and facilitating Hospital Administration
rehab discharges with the social worker remain- and the Limb Service
ing available as needed. If the patient does not
have insurance, does not qualify for Medicaid, It is a common misconception that Length-of-
and/or is out of rehab days, the social worker will Stay reduction and patient throughput responsi-
refer the patient to the case management direc- bility is the sole domain of Case Management. As
tors for a subsidy for home health aids through noted previously, it is always easier to blame the
Georgetown Home Care, may refer to the subsi- “downstream” person, the non-physician, non-
dized Georgetown NP Program, or subsidize nec- nurse members of the team when throughput is
essary medications needed to ensure the patient suboptimal and LOS, over budget; however, it
has a safe and successful discharge. has been our experience that the persistence of
No account of the CM/SW aspects of care this misunderstanding is at the core of inertia in
would be faithful to real-life circumstances, the effort to ameliorate all aspects of inpatient
should it fail to acknowledge the infrequent but flow. Experience with throughput enhancement
unfortunate situations when the best efforts and in the COVID-19 era effectively has laid this mis-
intentions of physicians, nurses, and CM/SW— conception to rest. In this final section, we shall
to treat with medical excellence and to arrange explore the essential role of a robust and engaged
placement with diligence and compassion—are hospital leadership in the provision of responsi-
thwarted by a patient’s next-of-kin or other sur- ble and excellent care, while, simultaneously
rogate decision maker. A surrogate may suddenly tending to throughput challenges in an effort to
become unavailable to participate, for instance, “keep the doors open,” and thereby to keep the
in AR or SAR site-selection, refuse to make a public served.
selection from these sites despite the discharge As noted, staffing and tasking of CM vary
plan being safe and underwritten by insurance, or broadly across institutions and may be driven by
fail to be forthcoming on matters financial. the nature and scope of institution-specific ser-
Reasons for such disengagement by responsible vices. For example, hospitals which specialize in
parties are complex and may be related to cul- cancer treatment or orthopedic procedures may
tural, socioeconomic, and demographic dispari- have narrower and more specialized scopes of
CM/SW activities than a full-service facility. tive is one example of a standardized safety and
Within a full-service facility, the relative number throughput program that touches all service lines
and distribution of service line in-patients may equally.
dictate the distribution of CM. Small community Recognizing the toll of both COVID 19 dis-
hospitals may use a hybrid model wherein a sin- ease and other diseases in the early phase of the
gle CM executes both DP and UR actions, pandemic, a decision was made to maintain full
whereas larger city hospitals or academic medi- services at our institution during subsequent
cal centers, such as our own, require dedicated, waves of the disease. The challenge to hospitals
separate CM and UR specialists to support the within our network was to develop and sustain an
volume and complexity of each work-type. And, intensive process of safe patient throughput and
as in all things organizational, budgetary consid- efficient discharges. The organizational model to
erations and constraints may inevitably impact accomplish this was the formation of physician,
both the number of CM on staff and on how they nurse, and case management into executive
are deployed. When it comes to the correct staff- leadership triads, and through these groups, to
ing model in any hospital, one size does not nec- “connect the dots” of hospital access points, bed
essarily fit all. tracking, and individual service line throughput
At our institution we employ differentiated processes. Relying heavily on a proprietary elec-
DP and UR case managers, with 50% of our per- tronic system of bed reservation, utilization,
sonnel in each group. CMDP is deployed geo- cleaning, and reopening, we were able to identify
graphically by hospital wards, with each CMDP patients who are “ready for discharge today or
covering two wards. Several internal Performance will be by tomorrow.” A list of these patients is
Improvement initiatives, all of which maintained disseminated to the appropriate leadership of ser-
this model, resulted in the uncovering of several vice lines daily, and live video teleconferencing
common discharge barriers, but none in a reduc- held thrice weekly. The list of all patients ready
tion in LOS. More recently, however, a pilot pro- or nearly ready for discharge was run daily, dis-
gram in which a single CMDP was dedicated to charge barriers identified and escalated promptly.
the Limb Service over a 3-month period resulted Additionally, Executive Discharge Rounds were
in improved internal customer satisfaction among conducted by physician, nurse, and CM leader-
physicians and nursing staff; additionally, a 0.9 ship periodically and these rounds uncovered
day reduction in LOS was realized during this both barriers and process improvement
period when compared with a historical control opportunities.
of the same duration.10 These findings lend them- The result of these interventions was a signifi-
selves to consideration of funding for an extended cant reduction in LOS, in the use of full-capacity
pilot study of similar metrics which might sup- beds and the number of ER boarders, and in the
port augmentation of staffing. amount of time spent on hospital “red-light.”
Stepping back from the Limb Service specifi- Similar MD, RN, and CM triads were created
cally, more generalized efforts to enhance patient for our top five service lines, in-patient volume-
throughput bear mention, as all service lines may wise, and the executive triad the leadership triad
partake of a collective benefit. Just as the medical met with lower-volume service line leadership
and nursing teams collaborate with CM, PT, SW, separately. Procedural and consultative services
and others, so to, proactive engagement by the were engaged and a designation and prioritiza-
hospital administrative team with all service lines tion of “discharge pending” patients was estab-
in standardized as well as specific ways brings lished for procedure and consultation workflow.
programmatic unity to the diversity of clinical The Limb Service, among others, was beneficiary
services. The aforementioned Multidisciplinary of these enhanced throughput strategies.
Rounding of the Integrated Model of Care initia- Finally, in recent years, we have as a system
begun a program of “repatriation” of patients
10
T. Deperio and A. Roberts (unpublished data). from the tertiary care referral center, back to their
hospital-of-origin. At the time of the original Conclusion

concept development, there was very little, if any,
U.S.-based literature on why one might repatriate The comprehensive, safe, and ethical care of the
a patient from a tertiary care hospital back to the complex limb patient, like all patients, involves
more remote community hospital whence he had collegial coordination among physicians, nurses,
been transferred. This has not, to date, been a social workers, physical therapists, and others—
common practice in USA. But repatriation of all in dialogue with the patient or the patient’s
patients back to their referring hospital has been family. Discharge planning for individual patients
part of healthcare delivery in the UK, for some should ideally begin on the day of admission,
time, on the very justification that the practice is with a projected discharge date set in place up
necessary to keep the correct number of hospital front. Barriers to discharge may be identified and
beds at the correct level of acuity available to the resolved or escalated via standardized interdisci-
most people.11 plinary rounds and thrice weekly conference
It has been for this precise reason that our net- calls. Hospital administrators can facilitate the
work has adapted a capacity management strat- process by high-level barrier removal; repatria-
egy that includes the repatriation of select patients tion to referring hospitals is an evolving concept
to their hospital of origin, once the tertiary ser- with great potential for regional or system capac-
vice has been fulfilled, they are awaiting place- ity management. A Service Line-dedicated case
ment or discharge, and if they consent to the manager staffing model has been shown dramati-
transfer. During the COVID-19 pandemic, this cally to reduce length-of-stay and to improve
practice has been invaluable to minimizing time internal customer satisfaction.
on hospital red-light and maintaining patient
referral inflow.
See,
11
for example, https://sunnybrook.ca/
content/?page=discharge-planning-repatriation.
Integrating Inpatient Care to Your
Outpatient Wound Care Center:
4
Key to Successful Patient
Management
Nancy R. Megas, Katherine S. Hubley,

and Margaret C. Kugler
Introduction other services and responding to patient and fam-

ily concerns.
In 2020 the limb salvage service at MGUH per- As soon as an inpatient NP component was
formed over 2000 surgeries. In terms of patient added the limb service began to benefit from
demographics, 34% of their patients required greater continuity of care given the NPs were
hemodialysis, 79% were diabetic and 20% suf- permanently part of the service. The NPs also
fered from congestive heart failure. These were immediately provided unit-based clinical staff
not uncomplicated patients. A rotating team of with a consistent point of contact for the multi-
plastic surgery and podiatric surgery residents is disciplinary team. These are the same benefits
tasked with caring for and discharging these identified by Kleinpell and her colleagues in
patients. As patient volumes grew to MGUH’s their recent study of the benefits of integrating
current levels it became evident that the resident advanced practice providers in the acute care
team needed additional support. Within acute setting [1].
care hospitals, the use of nurse practitioners and
physician assistants is an established model of
care for acute and critically ill patients [1]. With ischarge Planning Begins
D
this in mind, in 2003 a full time nurse practitioner on the Day of Admission
joined the limb service to work exclusively with
their inpatients. As volumes continued to When a patient is admitted to the limb service,
increase, two additional nurse practitioners were nurse practitioners begin planning for discharge
added resulting in an inpatient care team of three by rounding on each new patient and discussing
nurse practitioners, six to eight residents, and one certain expectations with them (Fig. 4.1). These
fellow. While managing patients’ discharges is a guidelines address common barriers to discharge
key focus, the nurse practitioners function in the such as: patients wanting to wait for a bed at a
same clinical capacity as residents, fielding ques- preferred rehab or skilled nursing facility, patients
tions and order requests, being paged to the bed- wanting to be seen by other services for non-
side for emergent developments, interfacing with emergent conditions, patients without transporta-
tion, and patients without a discharge
recommendation from physical therapy. By out-
N. R. Megas (*) · K. S. Hubley · M. C. Kugler lining expectations on the day of admission and
Plastic Surgery, Medstar Georgetown University reiterating them regularly, the NPs prepare
Hospital, Washington, DC, USA

48 N. R. Megas et al.
GUIDELINES FOR PATIENTS ADMITTED TO THE HOSPITAL
We understand the enormous burden chronic wounds place on you and your family. We are here to help
heal and in turn, to lessen that burden. To do this we need your cooperation. Here are some simple
guidelines to maximize your success.
Physical and Occupational Therapy and Your Activity Level – Remaining as active as possible will
speed your recovery. You should work with PT and OT therapists whenever they come to see you. If pain
is an issue ask them to come back once you’ve taken pain medication. Without notes in your chart from
PT and OT you can’t be discharged to rehab. In terms of activity, you should eat at least one of your daily
meals sitting up in a chair and spend at least two hours a day out of bed and in a chair.
Prescribed Diets – You’ll be prescribed a diet specifically designed to help you heal. Eating foods not on
your diet can slow wound healing-especially foods that increase your blood sugar. PLEASE don’t ask
family and friends to bring you food that isn’t on your prescribed diet.
Leaving the Nursing Unit – Smoking/Vaping and use of any tobacco products is prohibited on the entire
hospital campus– including outside and parking areas. If desired, patients will be provided with
substitutes to help with nicotine withdrawal.
Interaction with Staff-

We strive to cultivate an environment of respect and responsibility. Patients, providers, and staff all
have the right to safe, civil, and non-derogatory relations. Failure to maintain these relations may
result in referral to an outside practice for continued care, and dismissal from our practice.
Interaction with other MGUH Specialties – During your hospitalization, other specialties may see you.
for conditions other than your wounds. You should follow up with these specialties after discharge. Your
discharge won’t be delayed for you to follow up with them.
Discharge –Depending on your needs, you may be discharged to acute rehabilitation, sub-acute
rehabilitation, or home with home care or outpatient therapy. (See descriptions on the back) If discharge
to a rehab facility is recommended for you, your Case Manager will help you select 2-3 facilities based on
your medical needs, your preferences, and what your insurance covers. You will be discharged to the first
of these facilities that accepts you. It’s not possible to delay discharge in order to wait for acceptance at a
specific facility
Levels of Post-Hospital Care:

· Acute Rehabilitation- Provides intensive rehabilitation and nursing services to patients who can tolerate 3
hours of therapy per day.
· Sub-Acute Rehabilitation Provides rehabilitation and nursing services to patients who can tolerate 1 hour of
therapy a day.
· Home with Home Therapy and Home Nursing –For patients who are “home bound” due to medical or
functional limitations. Your home care team will teach you and your family how to care for you at home. Home nursing
does not provide around-the-clock care.
· Home with Outpatient Therapy- This is for patients who are able to go home, and who are medically cleared
to travel between their home and physical therapy several times per week.
Fig. 4.1 Guidelines for patients admitted to the hospital

4 Integrating Inpatient Care to Your Outpatient Wound Care Center: Key to Successful Patient… 49
patients to expect to be discharged as soon as NPs advocate for free muscle flap patients to be
their surgeon deems them ready. discharged to a facility instead of home given the
initially fragile nature of these flaps and the need
for skilled assessment of any changes they exhibit
ultidisciplinary Discharge Rounds
M in the postoperative period.
Promote Information Sharing While the benefit of MDRs can be intuited, in
2019 Patel and colleagues developed quantitative
A second element of the NP led discharge pro- analyses of their benefit at the tertiary academic
cess is attendance at daily multidisciplinary dis- medical center where they practiced. During their
charge rounds (MDRs). These rounds include study, 1584 patients were discharged from all
case managers, bedside RNs and physical thera- medicine teams, 825 from teams utilizing MDRs
pists. Multidisciplinary rounds have been demon- and 759 from control teams. The proportion of
strated to improve care coordination including patients with discharge before noon (DBN)
discharge planning [1]. Multidisciplinary rounds orders was 41.2% on pilot versus 29.6% on con-
have also been shown to be an effective means to trol teams. Length of stay was 92.2 h versus
facilitate accurate assessments of the social needs 97.2 h, and 30-day readmission rate was 16.0%
of patients and their families, an area often over- versus 18.3% for the pilot versus control teams,
looked in the discharge process [2]. respectively. The 30-day readmission rate was
At rounds the NPs advise the case manage- 12.6% compared with 18.9% for the pilot versus
ment team of each patient’s surgical plan and control teams [3].
projected date of discharge. The feasibility of One outcome of MDRs is that limb NPs are
various discharge plans is then assessed. For made aware of barriers to discharge such as a
example, despite being recommended for dis- patient who cannot maintain their prescribed
charge home by the physical therapy team, cer- weight bearing status. In these cases the NPs will
tain patients requiring complex wound care and/ frequently reach out to the patient’s surgeon to
or IV antibiotics may require discharge to a develop alternative weight bearing restrictions. In
skilled nursing facility. Input from a patient’s some cases a total contact cast (Fig. 4.2) with a
bedside nurses is crucial in these discussions as walking boot may be applied on the day of dis-
they are the most reliable resources regarding a charge and the patient allowed to bear weight for
patient’s abilities and temperament. The bedside
nurse also often provides valuable information
regarding variables that can lead to discharge
failures such as family dynamics or a change in
living arrangements.
When vetting possible discharge options the
NPs draw on their experience with particular
types of surgery to frequently advocate for dispo-
sition to an acute rehabilitation or skilled nursing
facility. For example, young healthy patients, sta-
tus post below knee amputations are often recom-
mended for discharge to their home. Too often,
though, these patients experience falls in the
home especially after awakening in the middle of
the night. Invariably they report they simply for-
got about their amputation. NPs will advocate for
transition to acute rehab before going home to
give these patients the time to develop the mental
memory needed to be safe at home. Similarly the Fig. 4.2 Total Contact Cast-TCC-EZ®
transfers. In order to expedite discharges an need for future dialysis access and will receive
orthotics vendor is on site weekdays at MGUH. In alternative access such as a Hickman catheter.
the case of a patient with a heel wound and strict These placements require pre- procedure NPO
nonweight bearing orders, for example, the status and sedation which must be taken into con-
orthotics team may be brought in to cast the sideration in establishing a discharge timeline.
patient for a custom boot to offload the wound. Patients already on hemodialysis who require IV
antibiotics after discharge can often have their
antibiotic administered at their dialysis facility.
ommunication Between All
C The NP team interfaces with the patient’s hemo-
Services Is Critical dialysis facility, ordering the antibiotic and
appropriate lab tests. Keeping a close eye on dis-
With rare exception, internal medicine is con- charge antibiotic plans wards off unexpected sur-
sulted for the management of all limb patients’ prises such as discovering a patient ready to leave
comorbidities. As needed, other services such as does not have appropriate access for antibiotic
nephrology, endocrinology, and rheumatology infusions.
are also consulted. The limb service’s NPs serve
as critical liaisons with all consulting services.
The NPs review progress notes and speak with rovider Involvement Contributes
P
the residents and attendings of consult services to Successful Transitions
daily to confirm agreement with the planned date
of discharge and establish what their require- Kripalani and colleagues point out that the effec-
ments are for the patient in terms of new medica- tiveness of a patient transition is often enhanced
tion/supplies scripts and follow-up appointments. by the involvement of the attending physician
Communication like this is the type of collabora- [2]. The limb NPs are in constant communication
tion among providers that is repeatedly called for with the team’s attending surgeons, advising
throughout discussions of improved transitions them when they need to see a particular patient to
[4]. Prior to establishing collaboration between pave the way for that patient’s discharge. Prior to
limb NPs and consulting services, limb team resi- the NP team serving in this capacity, a well mean-
dents would often issue a discharge order only to ing resident would often walk into a patient’s
have to cancel the order when a consulting ser- room and advise them they were being discharged
vice advised that from their point of view the only to be told, “Absolutely. My doctor didn’t say
patient was not ready for discharge. anything about leaving.” By alerting patients to
their discharge plan and then bringing attending
physicians into the discussion the NP team medi-
ntibiotic Therapy Requires Early
A ates this frequent barrier to discharge.
Consideration The limb team’s surgeons further contribute to
maximizing a patient’s potential for successful
An important aspect of discharge planning for discharge by identifying those patients at risk for
limb salvage patients is planning for their antibi- surgical site complications and ordering appro-
otic therapy. MGUH’s Musculoskeletal Infectious priate interventions. One of these interventions is
Disease service is consulted for all limb salvage the use of negative pressure wound therapy
patients. The limb NP team confers daily with the (NPWT) on closed incisions. While closed inci-
services’ attendings to understand which patients sions are typically dressed with a sterile dressing,
may require IV antibiotics at discharge. They limb salvage patients are at a higher risk for post-
then meet with the patient, advise them of the operative wound complications, such as infec-
need for a central line, and then order the appro- tion, dehiscence, and hematoma and seroma
priate line. Chronic kidney disease patients are formation [5]. Shiroky and colleagues in a review
not candidates for PICC lines due to the possible of 44 randomized controlled trials with N = 5693
patients reported that patients treated with with the clinic staff, the limb NP team developed
NPWT) for closed incisions experienced nearly a a reference document called a discharge white
40% reduction in the risk of surgical site infec- sheet (Fig. 4.3) which they complete for every
tions relative to those with standard dry sterile inpatient seen by the limb service. The document
dressings. A statistically significant reduction in is available to all users of MGUH’s electronic
wound dehiscence and seroma incidence was medical record EMR (Cerner) and is found in
also reported [6]. MGUH’s limb surgeons began Clinical Documents-Discharge Documents.
applying NPWT to closed incisions with the Information contained in the one page document
introduction of disposable short term use NPWT goes beyond that found in a traditional discharge
devices and were among the early identifiers of summary and unlike a discharge summary which
the same benefits described by Shiroky and col- may not appear for weeks is available within 24 h
leagues. Now it is a frequent practice for our sur- of a patient’s discharge.
geons to place NPWT at the time they close an Before the implementation of the white sheet,
incision. clinic staff spent a frustratingly long period of
Once a patient is ready for discharge the sur- time trying to find answers to commonly asked
geons will decide if NPWT should be continued. questions such as, “How often should my dress-
These patients are transitioned from the standard ing be changed?” or “Can I bear weight on my
NPWT device that had been placed at the time of incision?” Home health nurses and skilled nurs-
closure to a disposable seven or fourteen day ing facilities also bombard the clinic with an
unit. The patient will be instructed to leave the assortment of questions. Using the white sheet,
device on and operating until clinic follow-up. In clinic staff can quickly answer just about any
cases where the device’s preprogrammed life will question regarding a recent admission.
end before follow-up can be arranged, the patient Part of completing a white sheet involves con-
will either be advised to disconnect the tubing, firming postoperative or follow-up appointments
discard the device, and leave the dressing on and for discharged patients. Before the document was
intact until follow-up or remove the NPWT introduced the limb service invariably lost some
dressing and place a dry dressing on the patients to follow-up. This was most likely to
incision. happen with patients who the limb team saw as
consults. By maintaining a patient list of all
patients both primary and secondary and not
One Page Snapshot of Each
A removing patients from the list until a discharge
Admission Provides an Invaluable white sheet is completed, limb NPs ensure appro-
Bridge priate follow-up is arranged for every patient
seen by their team.
Once the myriad elements involved in discharg- In addition to providing a snapshot of an
ing a limb patient come together and the patient admission, the white sheet can be used to manage
is discharged, ensuring appropriate follow-up post-discharge care. Some patients with less
and capturing and communicating key elements complicated, non-surgical wounds may not need
of the admission are the next priority. Given the to be seen in clinic immediately after discharge.
volume of patients discharged every day and the Instead the NP team will forward the white sheet
complicated nature of their care, an immediately to the clinic RN pool requesting the patient be
available, easy-to-reference resource is necessary called within a certain period of time and asked
in order for the limb outpatient clinic staff to be about the status of his or her wound. Based on the
able to field the barrage of questions they receive. patient’s response, the RN can then either advise
Literally within hours of discharge the clinic the patient to continue monitoring their wound or
receives calls from patients, their families, home arrange a clinic appointment for them.
health nurses, and rehabilitation or skilled nurs- White sheets are also forwarded to the outpa-
ing facility staff. As the result of close interaction tient clinic staff of other services such as the mus-
DISCHARGE WHITE SHEET
Discharge Date: 02/11/2021
HPI and Procedures: 65-year-old male with a PMH of DM TYPE2, HTN, CKD Stage 3, seen in clinic
since 1/2020 for chronic R heel ulcer. Presents with worsening drainage, odor and pain,
Procedures:
2/1 Debridement R heel, instill VAC placement
2/4 Debridement R heel, instill VAC placement
2/9 Debridement and closure R heel
When to Return to Clinic: 2/21 @ 9:00 with CEA
Discharged to: Home or Facility Name and Phone Number

Cliffwood Health and Rehab 301- 555- 1239
VNA Name and Phone Number:

n/a
Dressing Change Orders:

R Heel: every 3 days
Remove dressing, cleanse w/ normal saline, pat dry
Apply non adherent over incisions
Cover with gauze and wrap with rolled cast padding
Apply light ACE. Reapply shoe wear provided at discharge
Weight bearing status of operative extremity:W

Non-weight bearing R LE
Nascott / DME:
[X] CAM Boot
Antibiotics:
Prescriber, Medication, Dose, Duration:
Davis, Vancomycin 1.5gram IVPB q 12 hr thru 3/16/2021
Labs Required: Include Frequency and Fax Number:
CBC, CMP, ESR and vancomycin trough weekly to 202 555 1234
Anticoagulation:
none
Pain Medication, dosage and quantity prescribed:

Oxycodone 5 mg ,1-2 tabs q 4 prn, qty: 20 tabs
Fig. 4.3 Discharge white sheet

culoskeletal/soft tissue infectious disease. This tise to the triaging of patient inquiries. In the
keeps the service updated regarding patients who District of Columbia NPs have full independent
were discharged on IV antibiotics and may need prescriptive privileges which allow clinic staff to
follow-up with an ID attending. It also provides turn to them to handle patient medication
the necessary information needed to contact a requests, once again, freeing up the surgeons.
patient’s infusion company should dosing levels
or duration of therapy require adjustment.
ommunication Between the NP
C
Team and the Outpatient Clinic
killful Outpatient Clinic Care
S Staff Is Critical
Furthers the Progress Made During
an Inpatient Stay Recognizing their shared responsibility for a
limb patient’s outcome, the inpatient NPs and
MGUH’s Center for Wound Healing sees over outpatient nursing staff regularly communicate
300 patients a week; there are often ten exam with one another. In addition to the exchange of
rooms in use at a time. As the limb team’s information through discharge white sheets, an
volumes grew to this level, clinic staff learned to inpatient NP will often reach out to the clinic
maximize efficiency in order to see such a large nursing staff with information about a patient’s
number of new, follow-up, and postoperative admission or to discuss possible clinic follow-up
patients. Patients are first taken to an exam room options. Conversely the clinic nursing staff regu-
by a medical assistant who obtains vital signs, larly reaches out to the inpatient NPs to alert
removes any dressing, and starts the visit entry in them to details regarding a complicated admis-
the electronic medical record. An RN then sees sion such as a patient with poor venous access
the patient, documenting HPI and wound dimen- who will require a central line. In some cases
sions, updating medications, and further updating where very close monitoring is warranted,
the visit note. Next the attending sees the patient. arrangements are made for a patient to have RN
At this stage procedures such as debridements or appointments in addition to their regular provider
biopsies may be performed and imaging may be appointments.
obtained. Once the attending has finished with
the patient, the RN finalizes the visit, reviews
instructions, confirms follow-up plans, and initi- ay-After-Discharge Calls Flag
D
ates visiting nurse orders or starts surgery coordi- Problems
nation packets if necessary. If orthotic or
prosthetic needs exist, a specialist is available to The Joint Commission recommends hospitals
be called into the exam room. develop a process that provides for timely post-
In addition to the limb team’s attendings, two discharge follow-up with patients. Ideally tele-
outpatient NPs see patients in the outpatient phone or in-person follow-up should take place
clinic. These NPs have their own designated within 24–48 h after discharge [7]. At MGUH, a
independent clinic days and see a variety of case management staff member makes this phone
patient types of particular benefit, they often see call. During the call, patients are asked about
postoperative appointment patients and patients their understanding of their medications, home
with chronic wounds such as venous stasis ulcers care, and planned follow-up. Regularly informa-
that do not require surgical intervention. By man- tion gleaned from these calls is forwarded to the
aging these patients, the NPs free up time for the inpatient NPs who then reconnect with patients
team’s surgeons to spend with more complex and to clear up any post-discharge confusion. A fre-
new patients. When not running their own clinics quent issue encountered is the failure of home
the NPs work alongside the surgeons during nursing services to see patients as ordered. Prior
patient visits and contribute their clinical exper- to this program’s implementation, it was not until
the first post-op visit that the limb team became Systems (HCAHPS). HCAHPS is the survey
aware of the fact a patient was not receiving tool used by the Centers for Medicare and
wound care that had been ordered. These calls Medicaid to determine if a facility can collect
also identify problems regarding the medications 100% of its Medicare reimbursements or is
prescribed at discharge. Because medication docked up to 2% in the event of poor ratings on
errors are behind many of the adverse events the survey. The three questions that comprise
patients experience following hospital discharge the Care Transition Measures were:
[8], these calls are particularly important. In
some cases patients are found to be unaware of • Question 1:“The hospital staff took my prefer-
new medications prescribed for them or to not ences and those of my family or caregivers
have received scripts for new medications. into account in deciding what my health care
needs would be when I left the hospital”
(focus on when the patient was in the
ell Managed Transitions Impact
W hospital).
a Hospital’s Bottom Line • Question 2: “When I left the hospital, I had a
good understanding of the things I was respon-
Beginning in October of 2012 the Patient sible for in managing my health” (focus on
Protection and Affordable Care Act instituted the discharge preparedness).
Hospital Readmission Reduction Program. As • Question 3: “When I left the hospital, I clearly
part of the program hospitals were financially understood the purpose for taking each of my
penalized if they had excess readmissions among medications” (focus on medication under-
patients with select conditions. The initial round standing at time of hospital discharge).
of penalties was for readmissions after admission
for heart attack, congestive heart failure, or lung With the addition of these measures, well
infection [9]. Recently knee arthroplasty was managed transitions are important not only for
added to the program. It is reasonable to expect patients’ health and safety, but also for a hospi-
that over time, pressure on readmissions will be tal’s bottom line.
exerted on most admissions. In this environment, MGUH’s limb salvage patients consistently
an effective discharge process becomes critical rate their discharge experience very highly as
for a hospital’s financial health. shown in Fig. 4.4 benchmarking the limb salvage
Readmissions are not the only discharge team’s 2020 performance on the three care transi-
related events that can negatively impact a hos- tion questions against all hospitals and against
pital’s bottom line. 2013 Care Transition academic hospitals. The work that the limb NPs
Measures were added to the Hospital Consumer do to manage every patient’s discharge is felt to
Assessment of Healthcare Providers and be a significant driver for these results.
Percentile When Percentile When

Benchmarked Against all Benchmarked Against
Hospitals Academic Hospitals
Question 1 94th 96th
Question 2 98th 99th
Question 3 91st 90th
Fig. 4.4 MGUH limb service performance on HCAHPS care transition measures
Conclusion plinary rounds. Prof Case Manag. 2019;24(2):83–9.

https://doi.org/10.1097/NCM.0000000000000318.
PMID: 30688821
Effectively bridging inpatient admission and out- 4. The Joint Commission. Hot topics in health care,
patient care is a key element behind MGUH’s issue #2. Transitions of care: The need for collabora-
successful limb salvage program. The process, tion across entire care continuum. 2013. http://www.
jointcommission.org/assets/1/6/TOC_Hot_Topics.
spearheaded by a team of nurse practitioners pdf. Accessed 12 Jan 2021.
includes the fundamental elements for effective 5. Hyldig N, Birke-Sorensen H, Kruse M, Vinter C,
care transitions put forth by The Joint Commission Joergensen JS, Sorensen JA, Mogensen O, Lamont
in 2014: interdisciplinary coordination and col- RF, Bille C. Meta-analysis of negative-pressure
wound therapy for closed surgical incisions. Br J
laboration of patient care in care transitions, Surg. 2016;103(5):477–86. https://doi.org/10.1002/
shared accountability by all clinicians involved in bjs.10084. PMID: 26994715; PMCID: PMC5069647.
care transitions, and provision of appropriate 6. Shiroky J, Lillie E, Muaddi H, Sevigny M, Choi
support and follow-up after discharge [10]. The WJ, Karanicolas PJ. The impact of negative pres-
sure wound therapy for closed surgical incisions on
process enjoys unilateral support from the team’s surgical site infection: a systematic review and meta-
surgeons and residents and from the outpatient analysis. Surgery. 2020;167(6):1001–9. https://doi.
clinic staff. In addition patients and their families org/10.1016/j.surg.2020.01.018. Epub 2020 Mar 3.
often communicate to the providers and staff that PMID: 32143842.
7. The Joint Comission. Hot topics in health care: transi-
they appreciate the continuity of care provided by tions of care: the need for a more effective approach to
the inpatient nurse practitioners. The process’s continuing patient care. 2012. https://www.jointcom-
linchpins, timely, effective communication, and mission.org/assets/1/18/Hot_Topics_Transitions_of_
attention to detail ensure smooth transitions and Care.pdf. Accessed 26 Dec 2020.
8. Moore C, Wisnivesky J, Williams S, McaGinn
allow the team to maximize its rate of limb sal- T. Medical errors related to discontinuity of care from
vage successes. an inpatient to and outpatient sett. J Gen Intern Med.
2003;18:646–51.
9. McIlvennan CK, Eapen ZJ, Allen LA. Hospital
readmissions reduction program. Circulation.
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EA. Promoting effective transitions of care at hospi- Burns PR, Frykberg RG, Hellman R, Kim PJ, Lipsky
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J Hosp Med. 2007;2:314–23. https://doi.org/10.1002/ agement of diabetic foot disorders: a clinical guide.
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using a team-based structure for discharge multidisci-
Diabetic Foot Ulcers
by the Numbers: Epidemiology
5
of Limb Salvage
Romina Deldar, Adaah A. Sayyed, Zoe K. Haffner,

and John S. Steinberg
Introduction DFUs serve as a major source of global mor-

bidity and mortality due to repeated hospital
According to the International Working Group on admissions and increased risk of amputations,
the Diabetic Foot (IWGDF), a diabetic foot is an which may incur substantial healthcare costs [2,
infection, ulceration, or destruction of the foot 4]. Approximately 50% of DFUs will become
associated with neuropathy and/or peripheral infected, and about 20% will require LE amputa-
arterial disease (PAD) in people with diabetes tion [5]. In fact, diabetic foot wounds are the
mellitus [1]. Diabetic foot ulcers (DFUs) are a most common cause of non-traumatic LE ampu-
preventable complication of diabetes that can tations worldwide and are responsible for an esti-
lead to increased disability if left untreated, lower mated 67% of LE amputations in the USA [6–8].
extremity (LE) amputation. DFUs have profound Furthermore, patients with diabetic foot compli-
implications for the individual, community, and cations have a high rate of recurrent foot ulcers
health system at large. It is estimated that 4.8 mil- [9] and worse survival than that of many common
lion people (7% of the population) in the UK, cancers [10]. Recent advances in management
30.3 million (9.4%) in the USA, and 366 million have focused on limb salvage modalities and
(7%) of the world’s population carry a diagnosis multidisciplinary team collaboration to prevent
of diabetes [2, 3]. In 2019, the International DFUs and avoid amputations. This chapter pro-
Diabetes Federation (IDF) estimated that 463 vides an overview of the epidemiology of dia-
million people globally live with diabetes and betic foot wounds, including the associated
predicted that by 2045, more than 700 million healthcare costs and implications associated with
people will be living with the disease [4]. major amputations versus limb salvage efforts.
R. Deldar (*) · A. A. Sayyed · Z. K. Haffner

Department of Plastic and Reconstructive Surgery, Prevalence and Scope
MedStar, Georgetown University Hospital, of the Problem
Washington, DC, USA
e-mail: [email protected];
[email protected] The incidence of DFUs has risen secondary to the
increasing worldwide prevalence of diabetes and
J. S. Steinberg
Department of Plastic Surgery, Georgetown the prolonged life expectancy of diabetic patients
University School of Medicine and MedStar [11]. Among those living with diabetes, the life-
Georgetown University Hospital, time risk of developing a DFU is approximately
Washington, DC, USA 25%, with up to 40% of diabetics having a risk of

58 R. Deldar et al.
undergoing LE amputation [2, 4, 12, 13]. By cant reductions in all-cause inpatient admissions
2050, the number of people in the USA with dia- (RRR = 52%). Another study found that patients
betes is expected to exceed 48.3 million, which receiving preventive foot exams over 1 year had
will consequently increase the DFU burden [14, lower odds of hospitalization for any cause within
15]. The prevalence of DFUs is estimated to be that year (OR = 0.67) [24].
19–34%, whereas the recurrence rate of DFUs is
estimated to be 40% within 1 year and 65%
within 3 years [1]. Approximately 50% of patients Healthcare Costs
with DFUs will experience infectious complica- of the Diabetic Foot
tions that necessitate hospitalization [16, 17].
Patients with infected DFUs have a 55.7 times DFUs place a significant burden on healthcare
greater risk of hospitalization and a 154 times budgets worldwide due to the complex and
higher risk of amputation compared to patients lengthy course of treatment from prevention of
with non-infected DFUs [16]. In 2006, it was foot disease to LE amputation. Direct costs
reported that 1.6 million people underwent ampu- include admissions, wound dressings, antibiotics,
tation in the USA; this number is expected to rise and surgery, while indirect costs result from the
to 3.6 million in 2050 [18]. social and psychological impacts of diabetic foot
The annual prevalence of DFUs among disease [25]. Although the largest direct expendi-
Medicare beneficiaries with diabetes is approxi- tures are related to hospital admissions, the loss
mately 8% [19]. It has been reported that during of productivity and decreased quality of life fur-
foot ulcer episodes-of-care, all-cause inpatient ther contribute to additional expenses [25].
admissions were 2.8 times more likely, and death Compared to colorectal cancer, the costs derived
was 1.5 times more likely compared to periods from diabetic foot care contribute to three-fold
following healing within the same beneficiaries higher expenses [26]. Although many studies
[20]. Several possible physiological mechanisms over the past 20 years have published economic
for the independent association between foot analyses of DFUs, the exact costs related to this
ulceration and all-cause mortality have been complication are difficult to ascertain due to the
hypothesized, including acute consequences of complexity of the condition and variations in
DFUs, such as severe sepsis and its sequelae healthcare systems, reimbursement methods,
(e.g., multiorgan failure), and long-term conse- access to care, and research methodologies.
quences such as chronic inflammation of the car- From the time a patient is diagnosed with a
diovascular and renal systems associated with DFU, the patient and hospital systems experience
DFUs [21]. exponential increases in expenses; a five-fold
The provision of comprehensive preventive increase in costs occurs within the first year fol-
care to arrest the development of DFUs in high- lowing development of the ulcer, with costs rising
risk populations may improve healthcare out- as the severity of ulcers increases [27]. This
comes beyond those associated traditionally with necessitates team-based interventions and aggres-
diabetic foot syndrome. Evidence-based preven- sive treatment strategies at earlier disease stages
tive care includes routine foot exams by special- to try and prevent amputations. Other major
ist providers, structured education regarding sources of expenditure in patients with DFUs are
patient self-care, daily self-exams, use of appro- the use of emergency room services and repeated
priate therapeutic footwear worn by the patient at hospitalizations [27]. Compared to diabetic
all times, once-daily foot temperature monitoring patients without foot ulcers, DFU-related costs
to identify inflammation that could precede are estimated to add approximately 9–13 billion
DFUs, and aggressive and prompt treatment of USD to the costs already associated with diabetes
any pre-ulcerative lesions (e.g., callus or blister) [28]. From 2006 to 2010, DFUs further contrib-
[22]. A study by Isaac et al. [23] incorporated uted 1.9 billion USD to the US Emergency
these recommended practices and found signifi- Department and 8.78 billion USD to inpatient
5 Diabetic Foot Ulcers by the Numbers: Epidemiology of Limb Salvage 59
departments per year [14]. An estimated 10.5% of ated with risk of amputation [30]. Among
DFU cases underwent LE amputations, resulting diabetics, approximately 55% of all amputations
in 115,957 USD cost per major amputation [14]. occur in people over the age of 65 [2].
Few studies address the economic benefits of While our data shows that a well performed LE
interventions for prevention and treatment of dia- amputation in a multidisciplinary setting can
betic foot disease. The most common predictive greatly improve outcomes, the general literature
model used is the Markov model for cost- tells us that only two-thirds of diabetic patients
effectiveness, a mathematical tool utilized to obtain who undergo major LE amputation will ambulate
projections of costs and effects for interventions with a prosthesis [40]. This likely contributes to
[27]. Use of preventive strategies has led to reduc- why major LE amputees are three times more
tions in 5-year costs related to DFUs, with the likely to die within 1 year of surgery compared to
Markov model predicting cost-savings of greater patients who have not undergone major LE ampu-
than 90% if low-cost preventive measures are tation [40]. A retrospective review by Ducic and
implemented to reduce the incidence of DFUs and Attinger found that by preserving the limb in dia-
resultant amputations [26]. Educational interven- betic patients using advanced soft-tissue recon-
tions, therapeutic footwear coverage, and multidis- structive techniques, the survival at 8 years was
ciplinary team approaches can avoid up to 72%, 59% [41]. Oh et al. evaluated 121 cases of recon-
53%, and 47% of amputations, respectively. These structed diabetic foot and reported a limb salvage
cost reductions translate into $1,100,000, $850,000, rate of 84.9% and 5-year survival of 86.8% [42].
and $750,000 in potential savings within 1 year of Aggressive limb salvage attempts are justified in
use of each intervention, highlighting the signifi- diabetic patients with foot wounds, whenever pos-
cant cost-saving benefits of preventive measures sible...and especially when the patient has poor
[29]. prosthetic rehabilitation potential.
Guideline-based management of DFUs has Globally, the rate of major LE amputations is
been shown to improve survival, reduce diabetic decreasing. This is likely secondary to several
foot complications, and decrease cost when factors, including improved management of dia-
compared to usual care. Clinical and economic betes and its complications, advanced wound
outcomes illustrate reduced amputation rates, healing modalities, and increased pursuit of dia-
costs, and length of stay. Emphasis on early rec- betic limb salvage. Limb salvage is defined as
ognition and prevention of DFUs alongside early preservation of the ankle joint and avoidance of a
consultation of limb preservation services is of major amputation [43]. Partial foot (or minor)
immense importance in order to prevent signifi- amputations up to the level of the transverse tar-
cant pathologic abnormality and increased risk sal joint (Chopart’s joint) and calcanectomies are
of amputation. considered to be successful limb salvage proce-
dures. These surgeries are performed once the
diabetic foot wound has been adequately debrided
Amputation Versus Limb Salvage to healthy tissue. It has been shown that wounds
heal 30% faster when debrided weekly [44].
The incidence of non-traumatic LE amputations Evans et al. [45] reported a 2-year survival rate of
is at least 15 times greater in patients with diabe- 80% (70 of 88 patients) following proximal fore-
tes than with any other concomitant medical ill- foot and midfoot amputations, compared to 48%
ness [12]. Over 85% of major LE amputations in (12 of 25) in patients who underwent BKA. A
diabetics are preceded by foot ulcers [30, 31]. 2014 study of 154 diabetic patients who under-
Previous studies have reported that apart from went toe amputations or transmetatarsal amputa-
severity of ulcer, age [32], low socioeconomic tion (TMA) for forefoot gangrene reported the
status, smoking [33, 34], male sex [35], renal 5-year survival of the limb salvage group was
impairment [36], diabetic neuropathy [37], glu- 81.6% and 36.4% for the failed limb salvage
cose levels [38], and PAD [39] are factors associ- group [46]. A recent study evaluated diabetic
60 R. Deldar et al.
patients with ulcers of the heel, the second most much lower incidence of LE amputation than
common location of DFUs [47], who underwent Caucasian patients [55]. The lower prevalence
a vertical contour calcanectomy [48] and found of PAD and neuropathy among Asians may
that nearly one-third of patients had no ulcer serve as protective factors against LE amputa-
recurrence, amputation, or mortality 1 year after tion [56, 57].
the procedure. Limb salvage efforts in diabetic
patients should be considered before major LE
amputations due to increased morbidity and Mortality and Outcomes
mortality.
In the USA, diabetes-related mortality has sur-
passed the number of deaths due to acquired
Socioeconomic and Ethnic immunodeficiency syndrome (AIDS) and breast
Disparities in Diabetic Foot cancer combined [2, 3, 58]. In 2016, diabetes was
Management the direct cause of 1.6 million deaths [59]. There
is a significant mortality risk associated with
Research has shown a correlation between level development of DFUs. A 2015 study from the
of education and diabetes prevalence, with an UK demonstrated the 5-year mortality risk for
estimated 12.6% of adults with less than a high- patients with DFUs is 2.5 times higher than dia-
school level education having diabetes compared betic patient without a foot ulcer [60]. A similar
to 7.2% of adults with an education level greater study in Norway showed the 10-year mortality
than high school [3]. Furthermore, socioeco- risk was twice as high for patients with history of
nomic status and insurance coverage may influ- DFU compared to diabetic patients without his-
ence which diabetic patients will have an tory of foot ulceration when adjusted for age, sex,
opportunity for limb salvage. Multiple studies and various comorbidities [61]. The 1-year mor-
have found that nonwhite, low-income, Medicare, tality rate for DFU patients alone is estimated to
and Medicaid patients were more likely to be 5% [62]. This mortality rate increases up to
undergo amputation for leg ischemia and to have 25% if the DFU becomes infected [63]. The mor-
less access to limb salvage procedures compared tality rate dramatically increases up to 68% at 5
with higher-income patients who had private years, a rate comparable to several types of can-
insurance [49, 50]. A possible explanation for cer and congestive heart failure [58, 63, 64].
this observed disparity is that economically dis- Furthermore, DFU patients typically present with
advantaged individuals often present with more metabolic syndrome, the constellation of insulin
advanced ischemia probably due to a lack of resistance, central obesity, dyslipidemia, and
access to preventative care. hypertension, placing them at increased risk of
Amputation rates vary within ethnic popula- cardiovascular events [64].
tions across the world. Reports have shown a Even with aggressive management, many
higher incidence of major LE amputation in DFUs will eventually require LE amputation,
African-Americans compared to Caucasian peo- often within just 4 years of diagnosis. The risk of
ple with diabetes [51]. A Kaiser health study amputation in diabetics is 30–40 times higher
found that from 2011 to 2017, doctors in than non-diabetics [64]. Following major LE
California performed more than 82,000 diabetic amputations, 30-day mortality rates of 5.7% for
amputations; African American and Latino below-knee amputations and 16.5% for above-
patients were more than twice as likely as knee amputations have been reported [65]. A
Caucasians to undergo amputations secondary recent systematic review found that following
to diabetes [52]. Risk factors, such as smoking, major LE amputation, mortality is estimated at
low socioeconomic status, and poor access to over 33%, 53%, 64%, and 80% at 1, 3, 5, and 10
healthcare, may contribute to these ethnic dis- years, respectively [66]. A New Zealand study
parities [53, 54]. Asian diabetic patients have a evaluating 300,000 patients who underwent
major LE amputation observed an overall 30-day 6. Ahmad N, Thomas GN, Gill P, Torella F. The preva-
lence of major lower limb amputation in the diabetic
mortality rate of 11% and 90-day mortality rate and non-diabetic population of England 2003-2013.
of 18% [67]. Infected DFUs that require emer- Diab Vasc Dis Res. 2016;13(5):348–53.
gent amputation carry a mortality risk of up to 7. Wukich DK, Raspovic KM. Assessing health-related
50% due to severe sepsis and the effects of tissue quality of life in patients with diabetic foot disease:
why is it important and how can we improve? The
necrosis [68]. In general, more proximal LE 2017 Roger E. Pecoraro Award Lecture. Diabetes
amputations in diabetic patients are associated Care. 2018;41(3):391–7.
with higher in-hospital and 30-day mortality 8. Morbach S, Furchert H, Gröblinghoff U, Hoffmeier
[69]. H, Kersten K, Klauke GT, et al. Long-term prognosis
of diabetic foot patients and their limbs: amputation
Mortality risk following with LE amputation and death over the course of a decade. Diabetes Care.
increases with concurrent PAD and renal disease 2012;35(10):2021–7.
[70, 71]. One-year survival rate after LE amputa- 9. Armstrong DG, Boulton AJM, Bus SA. Diabetic
tion in patients with end-stage renal disease foot ulcers and their recurrence. N Engl J Med.
2017;376(24):2367–75.
(ESRD) on hemodialysis is estimated to approach 10. Armstrong DG, Wrobel J, Robbins JM. Guest
50% [72], which is notably lower than those of Editorial: are diabetes-related wounds and
patients who are hospitalized for heart failure or amputations worse than cancer? Int Wound J.
myocardial infarction. In comparison, diabetic 2007;4(4):286–7.
11. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global
limb salvage procedures, such as minor LE epidemiology of diabetic foot ulceration: a sys-
amputations, portend significantly lower mortal- tematic review and meta-analysis (†). Ann Med.
ity rates compared to major amputations. A meta- 2017;49(2):106–16.
analysis found the mortality rates after minor 12. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin
JA. Diabetic neuropathic foot ulcers: the association
amputation in diabetic patients to be 3.5% at 1 of wound size, wound duration, and wound grade on
month, 20% at 1 year, 28% at 3 years, 44.1% at 5 healing. Diabetes Care. 2002;25(10):1835–9.
years [59]. Therefore, whenever possible, limb 13. Singh N, Armstrong DG, Lipsky BA. Preventing
salvage should be attempted in diabetic patients foot ulcers in patients with diabetes. JAMA.
2005;293(2):217–28.
who present with foot ulcers to minimize mor- 14. Skrepnek GH, Mills JL Sr, Armstrong DG. A diabetic
bidity and mortality. emergency one million feet long: disparities and bur-
dens of illness among diabetic foot ulcer cases within
Financial Disclosure Statement The authors have no Emergency Departments in the United States, 2006-
financial disclosures, commercial associations, or any 2010. PLoS One. 2015;10(8):e0134914.
other conditions posing a conflict of interest to report. 15. Deshpande AD, Harris-Hayes M, Schootman
M. Epidemiology of diabetes and diabetes-related
complications. Phys Ther. 2008;88(11):1254–64.
16. Lavery LA, Armstrong DG, Wunderlich RP, Mohler
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Unlocking the Mystery
of Peripheral Neuropathy
6
in Diabetes
Andrew J. M. Boulton
Introduction (a) Why does DPN result in diabetic foot ulcer-

ation (DFU)?
Whereas there can be little doubt that peripheral This is not difficult to answer as it is not
neuropathy in diabetes (DPN) contributes to the neuropathy per se, but the results of neuropa-
many foot problems that require functional limb thy that contribute to foot ulceration. It was
salvage, I was somewhat intrigued by the title of Dr Paul Brand working in leprosy who
the chapter that I was asked to write. In a some- described neuropathy leading to “the loss of
what unconventional way, I will therefore con- the gift of pain” [1]. Indeed, it is neuropathy
sider why one might think that peripheral itself and not the underlying cause such as
neuropathy is indeed a mystery by posing a few diabetes or leprosy that puts the patients’
questions which I will briefly answer and then the limbs at risk of insensitive injury.
main text will contain the detail to support the (b) Why is the warm but insensitive foot at risk
answers that I have already given. of DFU?
I have already answered the first part of
this question, but the second part relates to
uestion: Why Should DPN
Q the diabetic patient who has no significant
Be a Mystery? peripheral arterial disease (PAD). DPN is
indeed a peripheral neuropathy but this
I am posing a few questions which will help involves both somatic and autonomic sys-
understand what I thought was somewhat of a tems. Autonomic neuropathy in the lower
rhetorical question! limb leads to release of sympathetic tone and
in the absence of PAD, there is increased
blood flow and functional arterio-venous
shunting that results in the neuropathic foot
being warm [2, 3].
(c) Why is neuropathy the main contributory
A. J. M. Boulton (*) factor to Charcot neuroarthropathy (CN)?
Division of Diabetes, Endocrinology and The answer is not dissimilar to that given
Gastroenterology, University of Manchester,
Manchester, UK above in that the patient with loss of the gift
of pain and disturbances in balance which are
Manchester Royal Infirmary, Manchester, UK
so common in DPN [4] is prone to recurrent
University of Miami, Miami, FL, USA minor injuries which because of the loss of

66 A. J. M. Boulton
the gift of pain go unnoticed. The autonomic has resulted in there being no generally
neuropathy, again as noted above, leads to acceptable pathogenetic treatment for the
increased blood flow including arterio-venous condition. Whereas there are a number of
shunting through bone and as noted in the proven symptomatic therapies for pain [9],
chapter on CN elsewhere in this text, recur- most drugs are actually treating the symp-
rent minor injuries which go unnoticed may toms but not the underlying cause: it must be
lead to sprains and indeed fractures which remembered that most of these drugs also
again remain unrecognized by the subject and have quite marked side effects. The so-called
this leads to recurrent fractures and new bone pathogenetic therapies may follow when we
formation resulting in marked deformity. have a clearer understanding of the patho-
(d) How can a patient with DPN have painful genesis of the condition.
symptoms but at the same time have insensi-
tivity on examination?
It was my mentor, Professor John D Ward, The Diabetic Neuropathies
with whom I was working with 40 years ago
in Sheffield, UK, that first described the The neuropathies are among the commonest
“painful painless foot” in diabetes [5]. This chronic complications of diabetes mellitus and
refers to the patient with severe uncomfort- can be a presenting feature of type 2 diabetes:
able neuropathic symptoms, often disturbing indeed, in the large United Kingdom Prospective
sleep, who is completely insensitive to sen- Diabetes Study, 13% of patients at the diagnosis
sory testing such as pin-prick and vibration of type 2 diabetes had neuropathy of sufficient
on examination. The explanation for this is severity to put them at risk of foot ulceration [2,
that there is a spectrum of symptomatology in 10]. The neuropathies of diabetes may present in
diabetic neuropathy: at one end of the spec- many different forms but the commonest is the
trum one finds patients with severe symptoms distal symmetrical polyneuropathy which is
and few signs, whereas at the other end of the referred to in this chapter as DPN. This is a sen-
spectrum patients who have no symptoms sorimotor neuropathy involving both sensory and
whatsoever but very much the at-risk foot motor fibers. Moreover, as noted above, the DPN
with complete loss of sensation on examina- involving the lower limbs also has an autonomic
tion. Thus, some patients with painful symp- component which leads, in the absence of PAD,
toms may have complete loss of sensation on to increased blood flow, but also to lack of sweat-
examination to pain, temperature, and vibra- ing resulting in dry skin in the peripheries [2]. As
tion. How can this be—that is, how can a up to 50% of patients with DPN may be asymp-
patient experience severe burning pain in the tomatic, neuropathy cannot be excluded without
feet and yet be completely insensate on a careful clinical examination of both lower
examination? Although DPN is a “dying- limbs.
back” phenomenon characterized by neural Much can be learned by considering the his-
degeneration, there are attempts at regenera- tory of any condition. It is often said that “noth-
tion that accompany degeneration: proximal ing is new in medicine—it is simply rediscovered.”
to the foot there may be small-fiber regenera- Interestingly therefore it was Dr RT Williamson,
tion and such fibers can act like a neuroma a physician at the Manchester Royal Infirmary
giving rise to spontaneous discharges that are where I currently work, who introduced physio-
interpreted as pain from where that nerve logical measurements such as measurement of
used to supply, i.e., the foot [6–8]. vibration in the lower limb, to the assessment of
(e) Why are there still no definitive therapies for neuropathy early in the twentieth Century [11].
DPN? Coincidentally, I was appointed as a Consultant
The lack of a complete understanding as Physician to the same hospital in 1986 and it was
to the pathogenesis of diabetic neuropathy my group that confirmed, in a prospective study,
6 Unlocking the Mystery of Peripheral Neuropathy in Diabetes 67
that loss of vibration sensation was the most reli- tory. These symptoms are often difficult to
able predictor of foot ulceration in diabetes [12]. describe because they are of a neuropathic nature
A full classification of the diabetic neuropa- rather than symptoms with which the patients
thies agreed by the American Diabetes will be familiar as might be caused, for example,
Association Position Statement on Neuropathy is by a bruise, a fall, or a burn. Pain may be
provided in Table 6.1 [9]. DPN is classified in described in many ways, but common symptom-
this table as a diffuse neuropathy and in relation atology includes burning pain, altered tempera-
to the diabetic foot is a mixed small and large- ture perception (freezing or boiling), electrical
fiber neuropathy also involving autonomic fibers. shock sensations, stabbing or shooting pain, and
For full details of the many other varieties of the many more. As shown in Table 6.2, these are a
diabetic neuropathies, the reader is referred to result of small myelinated nerve fiber disease.
several thorough reviews [2, 9, 13]. Whereas numbness and tingling have been rec-
ognized as symptoms caused by large myelin-
ated fibers for many years, more recently,
Diagnosis of DPN disturbances of balance such as unsteadiness
have been recognized as common [14]: patients
Up to 50% of all patients with DPN experience often put such symptomatology down to aging or
symptoms at some time during its natural his- arthritis, but careful examination should confirm
loss of proprioception.
The diagnosis of DPN remains a clinical one
Table 6.1 Classification of the diabetic neuropathies in day-to-day practice and no expensive equip-
Diabetic neuropathies ment is required to make this diagnosis [9].
(a) Diffuse neuropathy DPN Small-fiber function can be checked by assess-
• Primarily small-fiber neuropathy ing pin-prick sensation or the ability to differen-
• Primarily large-fiber neuropathy tiate between hot and cold rods. Large-fiber
• Mixed small- and large-fiber neuropathy (most
common)
function can be checked by assessing vibration
• Autonomic perception and proprioception or using a 10 g
• Cardiovascular monofilament [15]. Ankle reflexes are also use-
• Gastrointestinal ful in the clinical examination and absent
• Urogenital reflexes have been shown to be a predictor of
• Sudomotor dysfunction foot ulceration [2].
• Hypoglycemia unawareness
A simple composite score was developed for
• Abnormal pupillary function
(b) Mononeuropathy (mononeuritis multiplex) (atypical
a large UK diabetic neuropathy study as shown
forms) in Fig. 6.1 [2]. This comprises three sensory
• Isolated cranial or peripheral nerve signs: vibration, pin-prick, and temperature dif-
• Mononeuritis multiplex ferentiation together with the ankle reflex. Any
(c) Radiculopathy or polyradiculopathy (atypical normal sensation found during this examination
forms)
scores a zero, whereas absence of any sensations
• Radiculoplexus neuropathy (also known as diabetic
amyotrophy or proximal motor neuropathy) scores one for each leg. Reflexes are scored as
• Thoracic radiculopathy zero = normal, one = present on reinforcement,
Non-diabetic neuropathies common in diabetes two = absent. Thus, the total maximum score for
Pressure palsies the most severe neuropathy would be ten. This
Chronic inflammatory demyelinating polyneuropathy modified neuropathy disability score (NDS) has
Radiculoplexus neuropathy
been used in many studies and in the large North-
Acute painful small-fiber neuropathies (treatment
induced) West Diabetes Foot Care Study in the UK, for a
Adapted from Table 1 in Pop-Busui R, Boulton AJM,
study of 15,000 patients, a modified NDS score
Feldman EL et al. [9] with permission from American of ≥6 was a strong predictor of foot ulcer devel-
Diabetes Association opment [16].
68 A. J. M. Boulton
Table 6.2 Symptoms and signs of DPN europathy and the Pathway to Foot
N
Large myelinated Small myelinated Ulceration
nerve fibers nerve fibers
Function Pressure, balance Nociception,
As stated above, a DPN is a contributory factor to
protective
sensation foot ulceration in people with diabetes but it must
Symptomsa Numbness, Pain: burning, be remembered that the neuropathic foot will not
tingling, poor electric shocks, spontaneously ulcerate. It is a combination of neu-
balance stabbing ropathy (the loss of pain) and some form of exter-
Examination Ankle reflexes: Thermal (cold/hot)
nal injury that results in skin breakdown and
(clinically reduced/absent discrimination:
diagnostic)b Vibration reduced/absentb eventually ulceration. As Dr Paul Brand described,
perception: any peripheral neuropathy can put the patient at
reduced/absent risk of foot ulceration. His work was predomi-
10-g Pin-prick nantly in leprosy or Hansen’s disease in the mid-
monofilament: sensation: reduced/
reduced/absent absentb
twentieth Century. Trained as a surgeon, he left
Proprioception: London to work at the Christian Medical Center
reduced/absent (CMC) in Vellore, Tamil Nadu, South India where
Reproduced from Pop-Busui R, Boulton AJM, Feldman he was convinced that the horrific lesions described
EL et al. [9] with permission from American Diabetes in biblical times seen in people with leprosy were
Association not due to infection, but due to loss of sensation.
a
To document the presence of symptoms for diagnosis
b
Documented in symmetrical, distal to proximal pattern Leprosy is caused by the Mycobacterium Leprae
Neuropathy Disability Score (NDS)

Right Left
Vibration Perception
Threshold subject sitting, eyes
closed, legs
128 Hz tuning fork; apex of outstretched:
hallux; trial pair = vibrating, demonstrate on clavicle
non-vibrating (hit the wrong or dorsum of hand; in
end of the tuning fork); normal each case repeat 3 pairs
= can distinguish vibrating / not of trials (mix up stimulus
vibrating order within trial pair, in
Temperature Perception each case maintain
rest Tip-Therm rod on dorsum stimulus 2 seconds); in
of foot, trial pair = plastic end each case ask “do you
(“not cold”), metal end (“cold”); feel vibration / cold /
normal = can distinguish cold / sharp now or now?”;
not cold abnormal is at least 2 of
Pin-Prick 3 trials wrong or “cannot
apply Neurotip on proximal big tell”
toe just enough to deform skin;
trial pair = sharp end, blunt Normal = 0
end; normal = can distinguish Abnormal = 1
sharp / not sharp
Achilles Reflex
kneeling on a chair, upright Present = 0
holding back of chair; stretch Present with
tendon to ankle neutral first; reinforcement = 1
reinforcement – hook fingers Absent = 2
together and pull when asked
NDS Total out of 10
Fig. 6.1 The modified neuropathy disability score (nds)

bacillus and is primarily a granulomatous disease describe uncomfortable symptoms in the lower
of skin and peripheral nerves. As the leprosy bacil- limbs. In day-to-day clinical practice, the man-
lus prefers cold areas, it affects the skin and periph- agement normally falls mainly to the diabetes
eral nerves in the upper and peripheral nerves in physician (endocrinologist), the primary care
the upper and lower limbs. Despite being an infec- physician, and occasionally a neurologist or pain
tious disease, leprosy is not highly contagious but clinic. Most of those agents licensed for the man-
in biblical times, the horrific, trophic lesions of the agement of neuropathy pain simply treat the
hands and feet were thought to have formed as a symptoms rather than the underlying cause as
result of the leprosy infection, hence the establish- noted above. A realistic objective would be to
ment of “leprosy colonies.” When Brand arrived at achieve around a 50% reduction in the painful
the CMC, Vellore, he was appalled to see people symptoms. As DPN has a major impact on qual-
with extensive ulceration of the hands and feet due ity of life (QOL) [20], a secondary objective
to leprosy receiving no specific treatment. should be improving QOL and especially sleep
However, the medical staff there just reported to and mood. As studies suggest that whereas those
him that it was “a curse from God” as people went with painful symptoms tend to have predominant
to bed with intact skin and woke up with new anxiety, those with painless symptoms such as
lesions in the morning. He was told “there is noth- poor balance, unsteadiness, etc. are more prone
ing that can be done for these patients: it’s just lep- to depression [21].
rosy” [17] and that the injury to the feet of people There is strong evidence to implicate poor
with leprosy was caused by trauma to insensitive glycemic control as one of the most important
skin and not “a curse from God” was proven by factors in the etiology of DPN. Unfortunately,
Brand when it was observed that patients asleep at there is and never will be evidence from random-
night in huts often had their feet traumatized by ized controlled trials of tight glycemic control
vermin such as rats which could injure the foot that this is the case in the treatment of neuro-
without disturbing the patients because of com- pathic pain. However, there is the evidence that
plete sensory loss. increased blood glucose flux might contribute to
Similarly, even today in some countries, rat pain and therefore the general consensus is that
bites and other animal bites remain causes of foot good blood glucose control should be the first
ulceration in patients with severe peripheral neu- step in management [7, 9, 22].
ropathy [18].
A regular diabetic foot exam to identify those
with “at-risk neuropathic feet” is recommended Pharmacological Treatment
by the American Diabetes Association [19].
Simple tools such as those described above are Although many different agents have been
all that is needed to identify the high-risk foot. shown to provide symptomatic relief for neuro-
Patient self-care of the feet by regular inspection, pathic pain, none is without side effects. The
wearing sensible shoes are pivotal in the manage- first line recommended drugs for neuropathic
ment of the insensitive foot. The team approach pain in the ADA Position Statement come
involving diabetes specialist nurses, podiatrists, under two classes: firstly, anti-epileptics and
physician assistants, diabetologists, and many secondly, anti-depressants [9]. The algorithm
others remains the keystone in the prevention of developed for the ADA Position Statement is
foot ulceration in the twenty-first century. reproduced in Fig. 6.2. Indeed, most recent
guidelines on the pharmacological treatment of
painful diabetic neuropathy include these two
Treatment of DPN classes of drugs as alternatives to be used as
first line agents [9, 23, 24].
The majority of this section will refer to manage- Although opioid and opioid-like drugs have
ment of those patients with painful or difficult to been shown in several trials to be efficacious in
70 A. J. M. Boulton
Is pain due to DPN confirmed? No/Not sure
Refer
efer to
Ye
Y
Yes Neurology/Pain
Assess comorbidities, potential for AEs, Clinic
drug interactions, costs to select initial
therapy from the 3 choices below
Voltage gated α2-δ ligand Serotonin-norepinephrine

in-n Secondary amine - Tricyclic
(pregabalin, gabapentin) reuptake inhibitor Antidepressant (amitriptyline,
(duloxetine, venlafaxine) desipramine)
No clinically meaningful effect
a. Switch to another agent b. Try combining agents

s c. May add tramadol
from above from above if a and b fail
No clinically meaningful effect/ Refer to Pain Clinic

Not tolerated
Fig. 6.2 Algorithm for the management of patients with selecting agent of choice. (Reproduced from Pop-Busui
pain secondary to DPN. AE adverse effects. R, Boulton AJM, Feldman EL et al. [9] with permission
Pharmacokinetic profile, spectrum of AEs, drug interac- from American Diabetes Association)
tions, co-morbidities, and costs to be considered when
neuropathic pain, there is a high risk of addiction, have side effects and central side effects and
abuse, sedation, and other complications with occasional fluid retention are recognized to
any of these drugs including Tramadol and occur in people treated with Pregabalin [9]. It
Oxycodone. For these reasons, opioids are not is therefore recommended that one should
recommended in the treatment of painful DPN start at a low dose perhaps 75 mg daily and
before failure of other agents that do not have gradually increasing to a maximum of 300 mg
such side effects. It is highly recommended that bd. Drugs used for complex epilepsy includ-
patients who may require opioids should be ing Gabapentin and Pregabalin are both
referred to a specialized pain clinic. proven in several randomized controlled tri-
All patients with DPN whether with painful als (RCTs). It must be remembered, however,
symptoms or not require education on good foot that the mean dose required for Gabapentin in
self-care as well as regular visits to the podiatrist. RCTs was approximately 1.5–2 g daily in
divided doses such as 600 mg tid. However,
(a) Anti-epileptic agents as with all agents used in neuropathic pain,
Pregabalin, a drug used in complex partial one should start with a low dose and gradu-
epilepsy, is licensed for the treatment of neu- ally increase as required: moreover, it should
ropathic pain in diabetes in the USA, Europe, be noted that Gabapentin is not licensed for
and Canada. A number of randomized con- use in painful DPN by the FDA. As with all
trolled trials have confirmed the efficacy of agents, adverse events are common and more
this drug with 30–50% improvement in pain common in older patients [9].
[7, 9]. The usual dose range of Pregabalin is (b) Anti-depressants
150–600 mg daily, normally given on a b.i.d The most commonly used anti-depressant
regimen. As noted above, all these agents for neuropathic pain is the selective norepi-
nephrine and serotonin reuptake inhibitor, Conclusions

Duloxetine. Additionally, Amitriptyline may
be used although it is not FDA approved. As will be apparent, the diabetic neuropathies
This and other tricyclic anti-depressants have comprise broad spectrum of clinical conditions
been used for many years, but they have quite and only the commonest, DPN, is covered in any
marked side effects in up to 50% of patients detail in this review. It must be remembered that
including a dry mouth, blurred vision, drows- diabetic neuropathy cannot be diagnosed without
iness, and also a risk of falls. However, some a careful clinical examination as up to half of all
patients can tolerate low dose drugs such as patients may be asymptomatic. The only effec-
Amitriptyline 10–25 mg at night which can tive preventative approach to diabetic neuropathy
be very helpful in those who can tolerate the confirmed in the literature is tight glycemic con-
agent, and on occasions, the dose may be trol. All patients with diabetes require an annual
increased to 75 mg daily or more, given as a review for evidence of complications which are
single dose in the evening [9]. often silent until it is too late. The annual review
The selective norepinephrine and sero- should include a comprehensive diabetic foot
tonin reuptake inhibitor, Duloxetine, is exam [19] and those found to have neuropathy
licensed for use in neuropathic pain in diabe- require much more frequent review, preventative
tes and can be given at 60 or 120 mg daily. As foot care, and symptomatic treatment as required.
with Pregabalin, Duloxetine has been shown A reduction in neuropathic foot problems will
in several randomized controlled trials to be only be achieved if we remember that patients
efficacious in the relief of neuropathic pain. with insensitive feet have lost their warning sig-
Its side effects include somnolence, dizzi- nal—pain—that ordinarily brings the patients to
ness, and occasionally gastrointestinal their doctor. Thus, the care of the patient with
symptoms. sensory loss is a new challenge for which few of
(c) Other agents us have received any training. It might be diffi-
Although there is evidence to suggest that cult for us to understand, for example, that an
opioid and opioid-like agents may be helpful intelligent patient might buy a pair of shoes three
in the relief of neuropathic pain, there is sizes too small and then come to the clinic with
always a high risk of addiction and abuse extensive shoe-induced ulceration: the explana-
with such agents and their use cannot be rection, however, is that with reduced sensation, a
ommended unless agents listed above fail to very tight fit stimulates the remaining pressure
provide pain relief. In such cases, referral to nerve endings and is therefore perceived as a
a specialist clinic or pain clinic is recom- normal fit. Helping the patient to understand that
mended. Evidence has been shown for pain sensory loss puts them at great risk of unnoticed
relief with drugs such as controlled relief injury is vital in the management of all patients
Oxycodone and Tramadol as well as others with DPN.
[9, 24].
(d) Combination therapy
Combination therapy may occasionally be References
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and the reader is referred to recent literature JM. Diabetic somatic neuropathies: a technical
[9, 24]. A simple algorithm to the approach review. Diabetes Care. 2004;27:1458–86.
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The Science and Utility
of Offloading the Diabetic Foot
7
Caitlin S. Zarick, Kurtis D. Bertram,
and Thomas F. Milisits
I ntroduction to Offloading and Its generally used to describe decreasing pressure to

Utility a targeted area of the foot. Offloading is a crucial
component of the DFU treatment algorithm as it
Diabetes mellitus affects over 400 million peo- removes and redistributes forces to other areas of
ple around the world and over the next 25 years, the foot to prevent and/or treat ulceration [3].
it is estimated that more than 700 million people Understanding the etiology of the ulceration will
will be living with diabetes globally [1]. With help determine the best mechanism of offloading.
this drastic rise in the prevalence of the disease, One must take into account all deformities, con-
diabetic foot problems put an excessive burden tractures, prior amputations, and global appear-
on the healthcare system due to repeated hospi- ance of the foot when prescribing offloading
talizations, increased risk of amputation, and devices.
substantial healthcare costs. For people living It has been shown that as many as 50% of
with diabetes, the lifetime risk of developing a patients suffering from diabetes will lose sensa-
diabetic foot ulcer (DFU) is 25% and subse- tion in their feet secondary to peripheral neurop-
quently a 40% risk of lower extremity amputa- athy [4]. Neuropathy not only removes protective
tion [2]. Nearly 70% of amputations in the sensation but also leads to an imbalance of
United States are reported to be a result of diabe- intrinsic musculature leading to deformity. It is
tes and its consequences [2]. The harsh reality is the combination of deformity and loss of sensa-
that a large number of ulcerations that lead to tion that leads to tissue breakdown and ulti-
amputation can be prevented and treated with mately ulceration [5]. Understanding the
proper conservative and surgical offloading pathological forces and their potential conse-
techniques. quences will allow you to properly help choose
Offloading, an often underutilized tool in dia- the best offloading mechanism for your patients.
betic foot prevention and management, is a term Shear, frictional, compressive, and tensile forces
all play a part in the development of ulcerations
as well as the treatment (See Table 7.1). The goal
of offloading devices is to help counteract the
C. S. Zarick (*) · K. D. Bertram · T. F. Milisits forces at play.
MedStar Washington Hospital Center, MedStar
Washington, DC, USA
[email protected];
[email protected]

74 C. S. Zarick et al.
Table 7.1 Different forces that act on the diabetic foot Thorough radiographic and physical exami-
and contribute to ulceration [5]
nations are paramount in diabetic patients, par-
Type of force Definition ticularly in the uncontrolled diabetic. There are
Shear force When a material moves in one or certain areas of the physical exam that are cru-
more directions at the same time
Frictional force When a force moves along a material
cial for evaluation as it pertains to offloading.
while in direct contact with it
Compressive When a material is pressed together Key components of the examination in the dia-
force between two or more loads betic patient as it pertains to offloading:
Tensile force When a material is stretched by two –– Radiographic Evaluation: Radiographic anal-
or more opposing forces
ysis should be completed as it can give vital
information on areas of subluxation and bony
prominences. Weight-Bearing films are crucial
Biomechanics of the Diabetic Foot for an accurate assessment of bony
architecture.
The biomechanics of the diabetic foot are dif- –– Plantar Callus: Careful examination of the
ferent from that of a nondiabetic foot at both a plantar aspect of the foot for any callus for-
structural and functional level. On the struc- mation will help determine areas that require
tural level, there are changes to the soft tissue offloading. In a study by Potter et al., they
of the foot, particularly to the plantar aspect found that there was a 25% decrease in peak
(i.e., dryness) as well as loss of the plantar fat plantar pressure after callus removal.
pad. On a functional level, a disorganized pat- However, there was no significant difference
tern occurs within diabetic ligaments, capsules, between the two groups. Callus removal
and tendons leading to significant decrease in alone is not sufficient; the area must also be
elasticity and tensile strength. As a result of offloaded [9].
these changes, there is increased propensity for –– Range of Motion: One should assess the
joint instability, overall stiffness, and contrac- mobility of joints, whether hypermobile or
tures of the foot and ankle which leads to inef- immobile. This can give you predictors of
ficiencies in gait, lack of accommodation with potential future areas of pressure, Charcot
weight-bearing, and increased areas of local breakdown, and ulcer formation.
pressure [6]. –– Gait Analysis: A gait exam should always be
The classic example of this in the diabetic performed in order to understand the
patient is Charcot Neuroarthropathy which is mechanics of how a patient ambulates and
defined as a chronic destruction of the bones and can give clues to high pressure areas. If one
joint subluxations in patients with neuropathy [6– has access to a gait lab this would add even
8]. The main deforming force is the Achilles ten- further benefit to the exam [10]. This should
don which becomes contracted causing an equinus be done without shoe gear to assess aspects
deformity. During propulsion of a patient with of gait such as forefoot to rearfoot relation-
Charcot, there is an increased upward force of the ship, collapse of the midfoot, etc. Efficacy of
Achilles tendon, causing a break or subluxation of an offloading device can then be evaluated
different areas of the foot (most commonly the by comparing pedobarometric data before
midfoot). Additionally, this increased pull leads to and after application of an offloading
increased pressures on the forefoot. If these issues mechanism.
are not addressed in a timely manner with proper –– Contractures and deformities: The presence or
offloading, whether conservative or surgical, this absence of both ankle and foot deformities
can lead to devastating consequences on the must be evaluated. Some of the more common
patient’s function and quality of life. Increased pathologic deformities are equinus, ankle
plantar foot pressure can occur which leads to varus/valgus, rocker bottom deformity, pes
ulceration, infection, or even amputation. planus, pes cavus, digital contractures, and
7 The Science and Utility of Offloading the Diabetic Foot 75
bunions. It is of utmost importance to assess best in their own hands as well as what is readily
all possible underlying issues. available in practice. Compliance, or the ability
–– Prior amputation: Amputations lead to pre- of a patient to adhere to treatment, must also be
dictable mechanical imbalances. Prior ampu- considered.
tation can help the practitioner prophylactically
offload areas that are at high risk for ulcer-
ation. When a patient undergoes any kind of Felt Padding
amputation, whether it be a digit amputation
or a transmetatarsal amputation, there is a loss Felt padding is one of the oldest methods of
of tendinous attachments making the mechan- offloading and often overlooked in today’s prac-
ics of the foot less optimal. For example, ham- tice. It is extremely inexpensive and an easy way
mertoes often develop after a partial first ray to begin offloading immediately while waiting
amputation while equinus or even equinovarus for custom or permanent devices. The premise of
can develop after a midfoot amputation. the felt pad is to increase contact area around the
ulcer and redistribute pressure to other parts of
The importance of understanding the biome- the foot in order to optimize the ulcer’s healing
chanics in the diabetic patient is so that we can potential.
prevent and treat ulcerations with proper offload- In the author’s opinion, this is most effective
ing, whether it be from conservative or surgical for a smaller ulceration (i.e., size of a nickel) on
methods. the plantar forefoot, or medial/lateral aspects of
the foot. For this padding, you would use either ¼
or ½ inche felt, cut as an aperture pad (donut
onservative (“External”) Methods
C shape). It would get placed over top of the wound
of Offloading the Diabetic Foot and would ideally redistribute pressure away
from the ulceration.
Sound offloading principles are necessary in any This is a method that can be done right away
wound care plan, regardless of the etiology of the during the first office visit. It is also a device that
wound. The biomechanics are paramount to patients typically tolerate very well and compli-
choosing a device; however the practitioner can- ance will not be much of a concern. A downside
not forget other key variables such as age, weight, to felt pad offloading is that it very well may not
skin integrity, vascular status, neurological sta- offload enough pressure or could be placed inac-
tus, presence of infection, and purpose of the curately and cause increased pressure to other
device (i.e., prophylactic or treatment of an open areas. Additionally it could create an edge effect
wound) [11]. leading to a larger wound if not monitored closely
In an ideal world, a device that assists with [12]. This occurs when the healthy epidermis sur-
total non-weight-bearing would be used to rounding the wound breaks down due to increased
remove pressure from the plantar surface of the pressure from the pad. It is more likely to occur
foot. These include crutches, wheel chairs, or in completely insensate patients.
knee walkers. However, these are rarely practical
because of factors such as obesity, social bur-
dens, and debility [11]. Custom Accommodative Orthotics
There are several different ways that you can
conservatively offload the foot. There is often There are two different types of orthoses: func-
not a “one size fits all” method in choosing a tional and accommodative. In the diabetic popu-
device. Each patient will have unique factors lation, the authors prefer the use of the
about them that will sway you to one method accommodative orthotic because they are soft
over another. The choice also often comes down and aid in accommodating and offloading the
to provider preference and what they feel works foot (Fig. 7.1) [13]. There are several different
a b
c d
Fig. 7.1 Custom accommodative orthotics. (a) Plastazote top layer; (b) Side view of plastazote, EVA, and poron; (c–e)
Example of patient with hallux amputation fitting a custom accommodative orthotic with toe filler
materials that are used when creating a custom believe it provides the most offloading character-
accommodative orthotic; however in the diabetic istics. The base of the device should be the most
population, they must offload the foot and pre- dense and each layer above that, or towards the
vent further breakdown. foot, should be less dense, or a decreased durom-
At our institution, we use a layered device eter. Two durable and easy to work with materials
when designing an accommodative insert as we for the base are Ethylene vinyl acetate (EVA) and
Poron. For the top layer, plastazote is a great Diabetic shoes provide better motion control,
option because it is modifiable, comes in various prevent skin breakdown and callus formation,
densities, and is typically well tolerated by the and reduce high pressure areas of the foot. Due to
patients. the Therapeutic Shoe Bill passed by Congress in
Custom accommodative orthotics are typi- 1993, Medicare covers diabetic shoes and should
cally best utilized to prevent ulceration either always be in the back of the provider’s mind
from occurring or reoccurring, particularly after a when treating diabetics [16]. Our opinion is that
limb salvage surgery with reconstruction or any patient who has decreased sensation, a defor-
amputation. The premise behind custom orthot- mity, or history of an ulceration or amputation
ics is to control the biomechanics of the foot and should get a prescription for diabetic shoes.
to offload certain areas of the foot with different
modifications made to the device. They also help
to relieve strain on the tendons/muscles of the Custom Shoes
lower extremity as the biomechanics are con-
trolled. Several studies have examined the effec- Custom shoes are designed for patients who can-
tiveness of custom orthotics with the use of not get into an extra depth shoe because of a par-
F-Scan systems and found that these devices ticular deformity, prior amputation, or large foot
increase the contact area of the foot and decrease size. Patients will typically get a custom shoe
pressure [14]. The goal is to help prevent future after a large limb salvage attempt with recon-
ulcers from happening by offloading areas at risk struction to accommodate their deformity and
for ulceration. provide balance and stability. Custom shoes are
Another key point when it comes to custom fit to each specific patient and molded to a spe-
orthotics is that they should be checked for dura- cific foot and ankle shape and size (Fig. 7.2).
bility every 3–6 months. Once the device becomes
thin, they become less effective and are no longer
beneficial to the patient. While custom orthotics ontrolled Ankle Movement (CAM)
C
can be expensive, numerous insurance compa- Walker
nies do cover new prescriptions on a yearly basis
so it is crucial to check the device during each A controlled ankle movement or “CAM” walker
visit. (Fig. 7.3) is an adjustable and removable device
which is used for a variety of different clinical
Diabetic Shoes
Diabetic shoes should be made an option for

high-risk diabetic patients particularly if they
have components of neuropathy combined with
deformity. Patients with a history of an ulcer-
ation or amputation should also be prescribed
diabetic shoes with accommodative inserts.
Diabetic shoes are made with minimal stitching
to avoid irritation and typically come with extra
depth to accommodate custom orthotics for
added support and protection. Additionally, they
come with a large protective toe box to prevent
extra pressure of the digits as well as a multi-
density diabetic insole that prevents shearing Fig. 7.2 Custom shoe molded specifically to patient’s
forces [15]. foot and ankle shape, size, and deformity
Fig. 7.3 Controlled Ankle Movement (CAM) Walker. CAM walkers are dispensed in short or long form to accommo-
date specific deformities
circumstances. Indications for a CAM walker in the noncompliant patient. Some patients will
include plantar foot ulcers, Charcot neuroar- not adhere to your treatment regimen and take the
thropathy, trauma (such as ankle sprain or ankle walker off once they leave your office. In a recent
fracture), and postoperatively from elective sur- study, the authors found that patients using a
gery (such as a bunion correction or flatfoot/ removable cast walker only used it as prescribed
cavus reconstruction). There are also specific for 34% of their treatment duration [19]. In a
CAM walkers made for diabetic patients that patient that is noncompliant, a trick you can use
come with an accommodative inlay to help in the office is to use a layer of fiberglass cast
offload pressure from the plantar foot even fur- around the CAM walker to make it difficult for
ther. Some of the diabetic-specific CAM walkers the patient to take off while at home.
have softer outer shells to help prevent rubbing or The CAM walker is an excellent device to use
new wounds. for diabetic foot wounds, but the practitioner
Specifically when it comes to the diabetic must always examine the boot and investigate
foot, the CAM walker is particularly helpful in whether the patient is actually wearing it as
the patient with a forefoot ulceration. One study prescribed.
found that the CAM walker when compared to a
total contact cast had greater reduction in fore-
foot peak pressure, maximum force, and force- Total Contact Cast (TCC)
time integral [17, 18].
One of the main advantages of the CAM The Total Contact Cast or TCC (Fig. 7.4) is the
walker is the ease of wound inspection in a gold standard offloading device for diabetic foot
patient with this device due to the fact that it is ulcers. The TCC is made of fiberglass and can
removable. However, this is also a disadvantage incorporate different types of offloading pads
Fig. 7.4 Total Contact Cast (TTC); it is important to have malleoli and heel. Patients can weight bear in the TTC
the patient dorsiflex ankle and ensure that bony promi- while utilizing a special brace
nences are well padded, particularly medial and lateral
which offer a customized fit for each patient. The should be firmly held in neutral which will
cast encases the patient’s entire foot including the decrease the amount of plantarflexion with each
toes and leg. This allows for maximal offloading step and, as a result, decrease forefoot pressure
and is best suited for forefoot and midfoot ulcer- midstance and propulsion. With the decreased
ations. There are numerous high powered studies ankle motion comes a shortened stride length
in the literature supporting this claim [20, 21]. which results in less time on the ground and
One randomized controlled trial comparing a cast fewer ground reactive forces [21]. TCCs are also
shoe, removable cast walker (i.e., CAM boot), a method of “forced compliance” for patients
and TCC determined that the TCC healed 90% of because they are not easy to take off and also tend
wounds in half the amount of time compared to to be heavy for patients, which keeps them mini-
the other two groups. Additionally, the TCC mally weight-bearing. This should be considered
group took half the amount of steps as the other if deciding between a CAM boot and TCC for
two groups [20, 21]. treatment.
There are several advantages to a TCC. The Another great use of the TCC is with patients
first is decreased plantar pressure and weight with Charcot Neuroarthropathy. Patients in the
transfer to the tibia. It has been shown that active state of Charcot need proper offloading to
approximately 30% of plantar pressure from the minimize collapse and to help begin healing and
foot is removed when the patient is in a TCC. This consolidation. A TCC is an excellent tool for
is likely due to the conical shape of the tibia this and often used in diabetic patients to maxi-
which allows this cast to act as an external mize offloading during early phases of Charcot.
offloading device redistributing weight [21, 22]. One must be careful, however, to not place
The next advantage is the elimination of ankle patients in a TCC until acute swelling is also
joint motion. When properly applied, the ankle managed.
There are several contraindications to think 1. Apply a dressing to the wound prior to placing
about when you are deciding if you should use any cast padding. This can be a dry sterile
a TCC versus another offloading device. The dressing, medicated dressing, or synthetic graft
first is active infection. You always want to on the wound prior to putting on the TCC.
eradicate the infection prior to utilizing a 2. Place extra absorbant dressings for any
TCC. The reason is twofold: one is that the expected exudate.
patient will not be able to have daily dressing 3. Take extra care to make sure that the entire
changes done and second is that they will not be cast is in contact with the foot/leg because
able to tell if the infection is worsening or even the smallest amount of movement can
improving (i.e., increased drainage, redness, or lead to another pressure point leading to a new
malodor). The next is exposure of deep struc- ulceration.
tures such as tendons. This is a contraindication 4. Pad bony prominences extremely well and
because you will not be able to adequately keep any areas of increased pressure. Pads are
a close eye on the wound and may make the applied directly over the anterior tibial crest,
wound worse if the cast is not applied right. A medial and lateral malleoli, and the heel. The
heavily draining wound would also be chal- toes also get protected with felt padding.
lenging to place into a TCC for fear of this lead-
ing to an infection. A relative contraindication TCCs are typically changed weekly but can be
would be a patient with a large amount of swell- left on for 2 weeks at a time if there is no wound
ing or the ability to easily swell. If patients present at all or a small, minimally exudative
were to swell into the cast it could cause fric- wound. Educating the patients on the risks and
tion, blistering, or new wounds. benefits of the cast will assist with compliance.
There is a learning curve to applying these
casts. The author recommends that proper train-
ing or workshops on TCC application be harcot Restraint Orthotic Walker:
C
employed for anyone utilizing these in their “CROW” Boot
practice. TCCs are not without their own risks
if improperly applied. Below are some key The Charcot Restraint Orthotic Walker or CROW
points that the authors use when applying these (Fig. 7.5) is a long-term custom device that func-
casts: tions as a custom molded removable TCC for
Fig. 7.5 Charcot restraint orthotic walker: “CROW” Boot; custom walker typically used after total contact cast with a
rocker bottom insole to help alleviate pressure on the plantar foot and aide in gait
patients with Charcot Neuroarthropathy. It comes They are made either as fixed-ankle or non-
in two fiberglass or plastic pieces: one for the fixed ankle. One study showed that plantar
front of the foot/leg and one for the back. The pressures were significantly decreased in a
CROW is typically utilized after a TCC when fixed-ankle PTB brace [26]. For obvious rea-
swelling has decreased and the patient has proven sons the PTB can be another great option for
to be compliant with weight-bearing restrictions. continuously offloading pressure to the plantar
A recent study showed that 25.9% of patients diabetic foot.
transitioning from a TCC used a life-long CROW
as a way to prevent further Charcot breakdown
[23]. The walker consists of a fully enclosed cus- urgical (“Internal”) Methods
S
tom orthotic, typically with a rocker bottom insole of Offloading the Diabetic Foot
to help alleviate pressure on the plantar aspect of
the foot and to help support the ankle joint. Surgical intervention is indicated when the
patient is getting recurrent calluses or areas of
ulceration, despite other offloading measures.
Long-Term Bracing Options Armstrong and Frykberg revised a classifica-
tion system for diabetic foot surgery mainly
Arizona Brace based on the presence of an ulcer and acuity.
Class I surgeries were considered “elective”
The Arizona Brace is a custom-fabricated ankle and were performed to correct deformity in
foot orthosis which was originally designed for patients without neuropathy. Class II proce-
posterior tibial tendon dysfunction. However, dures were classified as “prophylactic” as they
this can be used to offload the diabetic foot as it were performed in patients with neuropathy to
stabilizes the ankle, subtalar, and midtarsal joints help reduce the risk of ulceration when no
and provides medial and lateral stability to the wound was present. Class III procedures were
foot [24]. In the authors hands, this device is most considered “curative” and were performed
effectively used postoperatively after a partial when ulcers were present in order to heal the
calcanectomy as the attachment of the Achilles is ulcer. An example of this would be to perform a
lost to give the patient more stabilization through tendoachilles lengthening procedure in order to
the gait cycle. It is also beneficial after Charcot cure a plantar forefoot ulceration. The final
reconstructive surgery. It increases ankle stability Class IV procedures were those considered
and can help provide support and offloading after “emergent” and performed when there was
ankle or tibiotalocalcaneal arthrodesis proce- presence of severe infection [28].
dures. It is also beneficial after midfoot Charcot
reconstruction to help stabilize the ankle and
potentially prevent breakdown or Charcot from Soft Tissue Procedures
occurring in the ankle joint as well.
Percutaneous Flexor Tenotomy
Flexible deformity of the digits can be treated
Patellar Tendon Bracing with a percutaneous flexor tenotomy (Fig. 7.6).
This will help alleviate pressure at the top or tip
The patellar tendon brace (PTB) was first of the digit to heal or prevent an ulceration.
described in the 1960s for the treatment of tib- This procedure can be done in the office with
ial fractures as it is said to offload the tibia, or without local anesthesia. The authors have
fibula, and bones of the foot by transferring found that in the presence of complete neuropa-
weight through lateral uprights [25, 26]. The thy local anesthesia is not needed. To get maxi-
PTB has been shown to have approximately a mal effect from the procedure, the provider
30% reduction in body weight to the foot [27]. should maximally dorsiflex the toe while the
Fig. 7.6 Example of flexor tenotomy being performed with an 18 gauge needle for distal toe wound with associated
hammertoe deformity
patient flexes the toe to cause a “bowstring” Tendoachilles Lengthening

effect of the flexor tendon. Utilizing a beaver Normal gait requires 10–15 degrees of ankle
blade or 18-gauge needle, puncture the skin mid- dorsiflexion which is determined by the flexi-
line at the base of the middle phalanx and care- bility of the gastroc-soleus complex. Below 10
fully move medial and lateral until you feel the degrees, there is a significant increase in plan-
tendon release. You will notice an immediate dif- tar pressure of the forefoot which poses a
ference in the motion of the toe. The puncture site problem for diabetics, particularly ones with a
can be dressed with a band aid and the patient is forefoot ulcer [29]. While degrees of dorsi-
weight-bearing as tolerated. In a patient who flexion is important the surgeon should con-
needs a partial first ray there should be a low sider an Achilles tendon lengthening anytime
threshold to prophylactically perform this proce- there is a forefoot ulceration. An additional
dure on the lesser digits. indication is when the biomechanics are
altered in a way that gives advantage to the tibial tendon transfer to the lateral aspect of the
Achilles, such as a transmetatarsal amputa- foot (typically the lateral cuneiform) through the
tion. The tendoachilles lengthening or TAL is interosseous membrane to create a more planti-
the surgical gold standard in these clinical sce- grade foot.
narios. In a study by Mueller et al., they looked
at 30 patients with forefoot ulcerations with
which a TAL was performed and all patients Bone Procedures
healed the ulceration [30]. The author’s pre-
ferred technique is the percutaneous triple odified Keller Resection Arthroplasty
M
hemisection as described by Hoke. The smaller for First MPJ Ulcers Under Hallux
incisions afford less complications in the The Keller arthroplasty is typically reserved for
comorbid patient. the elderly population with moderate to severe
osteoarthritis for the first metatarsophalangeal
joint and associated osteoporotic bone. However,
Tendon Transfers this procedure can be useful in the case of a
recurring plantar hallux ulceration. In a study by
Tendon transfers are utilized to improve motor Tamir et al., the authors looked at 28 keller
function when weakness and imbalance exist in arthroplasties with a plantar hallux wound. 78%
the diabetic foot, particularly after an amputa- of the ulcerations recovered in a mean of 3.1
tion of different parts of the foot. Key tendon weeks and had no recurrence at a mean follow-up
insertion sites are amputated and soft tissue of 26 months [31]. The procedure essentially acts
imbalance can lead to deforming forces on dif- to decompress the hallux and allow for more
ferent areas of the foot. extension of the metatarsophalangeal joint. This
In the authors opinion, there are key clinical acts to decrease the pressure associated with the
principles that are crucial when deciding to per- formation of the wound.
form a tendon transfer: (1) Tendon transfers
cannot overcome a fixed deformity; therefore, IS Invasive Floating Metatarsal
M
these are only of functional use in a flexible Osteotomy for Pressure Under
deformity, (2) the tendon being harvested Metatarsal Heads
should be a minimum strength grade of 4+ as There are several operations that can be utilized
the tendon loses one grade of strength follow- for plantar metatarsal head ulcerations such as
ing transfer, (3) the ideal tendon to transfer is the Weil osteotomy, plantar condylectomy, or
one that functions in the same phase of gait, dorsal closing wedge osteotomy. These are great
although this is not an absolute contraindica- procedures to offload the plantar aspect of the
tion of transplantation, (4) perhaps most impor- foot; however with these open procedures in the
tantly, muscle-tendon tension should be diabetic population, there is an increase in post-
adequately fixated to give optimal function operative complications such as wound dehis-
postoperatively. cence or infection [32].
Understanding agonist and antagonist actions This procedure is done by making a small
of the different muscles of the lower extremity is 3mm incision over the affected metatarsal. Next,
imperative when deciding when to do a tendon utilize a mosquito or curved hemostat for blunt
transfer. One of the most common muscle imbal- dissection down to bone. Using a Shannon burr,
ances in the foot is after amputation of the fifth make a perpendicular or short oblique osteotomy
ray and losing the peroneus brevis tendon attach- in the metatarsal to dorsally displace the metatar-
ment. The direct antagonist to the peroneus bre- sal head. In a study by Tamir et al., they looked at
vis is the posterior tibial tendon, which over time 20 cases of this osteotomy in patients with plan-
will lead to an equinovarus deformity of the foot. tar metatarsal head ulcerations. In 17 of the 20
One method to correct this is utilizing a posterior cases, the ulcer fully healed at 6 weeks. The
remaining 3 showed clinical improvement but As we stated earlier, total contact casts are
not full healing of the ulcer [32]. the gold standard for diabetic foot offloading.
As minimally invasive procedures are gaining The only pitfall to this cast is that the patient,
traction in foot and ankle surgery, this is an attrac- physician, or home nurse cannot examine a
tive procedure for numerous reasons. First, there wound regularly which can lead to advance-
is no hardware needed which is ideal in a patient ment of the ulcer, infection, or even new
with a wound. Additionally, there is a minimal ulcerations.
chance of wound complications and these patients The benefits of utilizing an external fixator
are able to be full weight-bearing immediately for offloading purposes is that you remove
post-op in a surgical shoe further decreasing absolutely all weight from the foot and elimi-
post-op recovery. nate all tension on the plantar aspect of the foot.
Additionally as stated above, wound care can
be done at any time and any skin graft or free
tility of External Fixation
U flap used can be protected from areas of
for Offloading pressure.
On the other hand, there are downsides to the
Surgical offloading via the use of external fixa- use of external fixation. First, the surgeon must
tion (Fig. 7.7) is a unique and valuable tool for be skilled and confident in applying these
any foot and ankle surgeon, particularly when frames. Perhaps the largest downside to external
conservative offloading methods fail due to fixation is the high possibility of pin tract infec-
excess drainage from the wound or patient com- tion which occurs at the skin-pin interface. One
pliance issues. It is used for the stabilization, systematic review reported that the cumulative
protection, and immobilization of the soft tissue pin tract infection rate throughout the literature
and osseous structures and is particularly help- was 27% [34] which every surgeon should be
ful with limb salvage plastic surgery techniques aware of and diligent wound care should be
[33]. Soft tissue reconstruction can easily be done daily.
disrupted postoperatively from weight-bearing In the author’s opinion the times to use an
or premature joint motion. The external fixator external fixation for offloading are: ulcerations
helps to avoid these complications as well as not responding to total contact cast treatment or
gives you access to wounds and/or free flaps. other typical methods of offloading, large plantar
Fig. 7.7 Circular external fixation device

Table 7.2 This table demonstrates different methods for offloading based on wound location
Location Common pathology Conservative Surgical
Hallux – Hallux limitus/rigidus – Diabetic shoe/ – Keller arthroplasty
insert
– Custom orthotics – Exostectomy
Digits – Mallet, claw, hammertoe – Diabetic shoe – Flexor tenotomy
– Arthroplasty
Forefoot – Distal fat pad displacement – Diabetic shoe/ – Tendoachilles lengthening
insert
– Transfer pressure from elongated or shorten – Felt metatarsal pad – Gastroc recession
ray
– Equinus – CAM walker – Tendon transfers
– Floating metatarsal head
osteotomy
Midfoot – Rigid flatfoot – Diabetic shoe/ – Exostectomy
insert
– Charcot neuroarthropathy – Total contact cast – External fixator
– CAM walker – Surgical reconstruction
– CROW boot – Tendon transfers
Hindfoot – Calcaneal gait – Diabetic shoe/ – External fixator
insert
– Charcot neuroarthropathy – Total contact cast – Achilles repair
– Pressure – CAM walker – Ankle fusion
– CROW boot – Tibio-Talo-Calcaneal arthrodesis
Listed are both conservative and surgical methods of offloading
ulcerations, ulcers in patients that have extreme ing and a patient continues to develop an ulcer-
difficulty being non-weight-bearing perhaps due ation, then a surgical offloading mechanism
to obesity, ulcerations that require skin grafting may be necessary. The treatment of diabetic foot
or flaps, and for reconstructive surgeries when ulcers begins with prevention and begins with
internal fixation is contraindicated. the basic knowledge and understanding of
offloading.
ffloading Options Categorized by

O
Wound Location References
Conservative and surgical offloading of the dia- 1. International Diabetes Federation. IDF diabetes atlas.
betic foot is paramount in both the treatment and 9th edn. 2019. p. 14–25.
the prevention of ulcerations. One must take into 2. Jodheea-Jutton A, Hindocha S, Bhaw-Luximon A.
Health economics of diabetic foot ulcer and recent
account many factors when selecting both short- trends to accelerate treatment. Foot. 2022;52:101909.
term and long-term offloading options. Each https://doi.org/10.1016/j.foot.2022.101909.
ulceration and each patient is unique and thus a 3. Blume P, Stephanie W. Updating the diabetic foot treat-
plan, whether conservative or surgical, must be ment algorithm: recommendations on treatment using
advanced medicine and therapies. 2017;30(2):29–35.
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see Table 7.2 for a summary of different methods ulcer prevention and healing. 2010;52(3):37–43.
of offloading both surgical and conservative 5. Baker N, Osman I. The principles and practicalities
based on wound location. of offloading diabetic foot ulcers. 2016;19(4):172–81.
6. Kim P. Biomechanics of the diabetic foot: consider-
Every diabetic patient should be evaluated ation in limb salvage. 2013;2(3):107–11.
periodically for proper offloading mechanisms. 7. Pham H, Armstrong DG, Harvey C, Harkless LB,
If conservative offloading devices are not work- Giurini JM, Veves A. Screening techniques to identify
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spective multicenter trial. 2000;23:606. March 2022.
8. Dardari D. An overview of Charcot’s neuroarthropa- 22. Messenger G, Masoetsa R, Hussain I. A narrative
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10. Veves A, Murray HJ, Young MJ, Boulton AJ. The 23. Griffiths DA, Kaminski MR. Duration of total con-
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Medical Management of the Limb
Salvage Inpatient
8
Marie M. Alternburg, Jennifer M. Haydek,
Sara Kiparizoska, Nina K. Weaver,
and Margot G. Wheeler
ection 1: Perioperative
S Estimate Risk
Management of Cardiac Risk
Factors and Disease It is crucial to begin any preoperative manage-
ment with an assessment of the patient’s cardiac
Noncardiac surgeries, including limb salvage risk as well as the risk inherent in the planned
procedures, are a robust part of a functioning surgery. This assessment can and should inform a
healthcare system, with 1 in every 30–40 adults range of clinical decisions regarding testing,
undertaking such procedures at some point in monitoring, and medical management leading up
their lives. In a large-scale WHO-funded inquiry, to the surgery as well as perioperatively.
among the 200 million adults worldwide who
undergo noncardiac surgery each year, more than Risk of Procedure
ten million will suffer from a major vascular The first step in any perioperative evaluation is to
event—myocardial infarction, cardiac arrest, car- risk stratify the procedure itself. The American
diac death—within 30 days from surgery [1]. guidelines consider noncardiac surgeries with
Effective, evidence-based perioperative cardiac <1% risk of major adverse cardiac event (MACE)
management can improve mortality, avoid subse- low risk, whereas high risk are procedures with
quent morbidities, decrease length of hospitaliza- higher rates of adverse events including vascular
tion, and minimize the cost burden on the (7.7%), thoracic (6.5%), transplant (6.2%), gen-
healthcare system. eral surgeries (3.9%) [2]. While most limb sal-
vage procedures fit in the low-risk category, more
complex surgeries such as flap procedures are
high-risk surgeries due to prolonged surgical
time.
M. M. Alternburg · J. M. Haydek · S. Kiparizoska · onditions That Confer Risk

C
N. K. Weaver · M. G. Wheeler (*) It has been established that pre-existing cardiac
Department of Internal Medicine, Medstar conditions like CAD, cardiac stents, CHF,
Georgetown University Hospital, arrhythmias including atrial fibrillation and val-
Washington, DC, USA
e-mail: [email protected]; vular pathologies including aortic stenosis can
[email protected]; increase the risk of perioperative morbidity and
[email protected]; mortality.
[email protected];
[email protected]

88 M. M. Alternburg et al.
Tools KG
E
The Revised Cardiac Risk Index (RCRI) is the most American guidelines recommend a preoperative
used risk assessment tool given its relative simplic- EKG when there is a history of coronary artery
ity, taking into account the risk of the surgery, a his- disease (CAD), arrhythmia, CVA, or structural
tory of ischemic heart disease, congestive heart cardiac disease and prior to a higher risk proce-
failure, cerebrovascular disease, preoperative insu- dure [8]. Multiple studies have found little benefit
lin dependence, and a preoperative creatinine to a preoperative EKG in low-risk surgeries, and
greater than 2 mg/dL. More recent prospective stud- while bundle blocks were associated with
ies suggest higher risk estimates for major adverse increased risk, no more so than when history
cardiac events than originally established; up to a identified risk [9–11].
sixfold increase in events vs. the rate predicted by
the RCRI. The NSQIP has been found to have supe- Transthoracic Echocardiography
rior ability to discriminate for adverse cardiac American guidelines do not support preoperative
events vs. the RCRI [3, 4], though these studies did transthoracic echocardiography (TTE) unless the
not routinely monitor perioperative troponins and patient has a history of moderate or severe valvu-
likely missed a significant number of cardiac events, lar disease without a TTE in past 12 months or in
which are often silent [5]. The major American and those with symptoms of severe valvular disease
Canadian guidelines recommend using the RCRI such as syncope, dyspnea, angina, dyspnea, or
over the NSQIP. Patients with 0 points on the RCRI edema [8]. Overall, routine TTE is not recom-
score have a 3.9% risk of MACE; 1 point confers a mended if there are no history of symptoms indi-
6.0% risk; 2 points confer a 10.1% risk; 3 or more cating active heart failure or structural disease.
points convey a 15% risk. These recommendations are based on studies that
have found an increased risk of perioperative car-
Functional Capacity diac events in patients with congestive heart fail-
The next crucial step in any preoperative evalua- ure and structural disease. Aortic stenosis with a
tion is to assess functional capacity. The inability gradient >40 mmHg, left ventricular hypertrophy,
to perform more than four metabolic equivalents and left ventricular systolic dysfunction associ-
(METS), which is equivalent to walking up two ated were associated with increased cardiac
flights of stairs or undertaking heavy housework events, including myocardial infarction, pulmo-
has been associated with double the perioperative nary edema, ventricular fibrillation or arrest, and
cardiac complications [6]. complete heart block [12]. A preoperative TTE w/
any degree of systolic dysfunction, moderate to
yocardial Injury After Noncardiac
M severe LVH, moderate to severe mitral regurgita-
Surgery (MINS) tion, or AS w/ gradient >20 mmHg was 80% sen-
The MINS protocol helps identify patients who sitive for perioperative cardiac events w/ negative
are at high risk for developing myocardial injury predictive value of 97% [12]. AS on preoperative
after noncardiac surgery. Patients >age 65 with TTE was associated with increased risk of periop-
known coronary artery disease should have tropo- erative death or MI (14% vs. 2% w/out aortic ste-
nin measurements on day 1, 2, and 3 after surgery. nosis) [13]. Left ventricular ejection fraction
An elevation in the troponin allows physicians to (LVEF) <30% was associated with greater risk of
identify MINS and start secondary measures [7]. perioperative death, MI, or heart failure decom-
pensation (53.5% vs. 26% w/ LVEF >30%) [14].
Preoperative Cardiac Testing Cardiac Stress Testing

The current American guidelines suggest preop-
Based upon the risk of the procedure being under- erative stress test only when a patient cannot
taken and the patient’s risk assessment, various pre- perform >4 METS and if the outcome would
operative diagnostic testing might be appropriate. change perioperative management [8].
8 Medical Management of the Limb Salvage Inpatient 89
These guidelines are based on studies associ- study of 955 patients found that while pre-op
ating poor functional capacity with worse periop- coronary CT can improve estimated risk, it can
erative outcomes. The inability to perform four also overestimate the risk by fivefold in patients
METS was associated with a twofold increase in who will not have these outcomes [22].
perioperative MACE [6]. In an assessment using
the Duke Activity Score Index, which is validated Cardiac Biomarkers
to access functional capacity, lower scores were N-terminal-pro-BNP (NT-ProBNP) is a poly-
associated with death or MI in 2% of patients peptide released by cardiac cells in response to
within 30 days of surgery [15]. In small, prospec- stretch. It is an area of active investigation to see
tive studies myocardial ischemia at low workload if serum NT-ProBNP levels might be associated
(<60% of maximum predicted heart rate) was with perioperative cardiac risk. The current
associated with increased event rates (23% risk AHA/ACC guidelines do not endorse preopera-
of death/MI vs. 5% in those without ischemia) tive BNP measurement as there has been no data
[16]. A negative dobutamine stress echo and no showing that this practice might reduce cardio-
wall motion abnormalities had excellent negative vascular risk [8]. The Canadian guidelines, how-
predictive value for perioperative MACE [17]. ever, recommend checking pro-bnp prior to
surgery for patients who have cardiovascular
Cardiac Catheterization/CTA disease and RCRI >1, or for anyone >65 years
The current American and Canadian guidelines old [5].
recommend invasive angiography only if a pre-
ceding stress test indicates myocardial ischemia
and when results would change perioperative Optimizing Medical Therapies
care. A randomized controlled study assigning Preoperatively
510 patients with CAD about to have vascular
surgery to either revascularization or conserva- Beta-Blocker
tive management found that revascularization did Beta-blockers are known to decrease myocardial
not significantly impact long-term outcomes, wall stretch, prolong coronary artery diastolic
though the study was not adequately powered to filling time, and reduce myocardial oxygen sup-
assess differences in short-term outcomes [18]. ply and demand mismatch. As such, they were
There is no current guideline for coronary CT previously prescribed perioperatively with aban-
scans [19]. It is an area of active inquiry whether don, including starting new beta-blockers on the
noninvasive preoperative coronary CT scans day of surgery. Current ACC/AHA guidelines
might help predict perioperative MACE and support continuing previously prescribed beta-
potentially inform management. In a study of 239 blockers and starting them for patients with
patient getting pre-op CT coronary angiography, appropriate BB indications if >7 days prior to
a higher RCRI, a high CACS (113), the presence surgery, but do not support initiating beta-
of significant coronary artery stenosis (diameter blockers in the immediate pre-op period [19],
stenosis 50%), and multivessel coronary artery which is in line with European guidelines. In a
disease were significantly associated with post- retrospective cohort analysis of 136,745 patients
operative cardiovascular events. CTCA was more exposed to beta-blockers on the day of or follow-
sensitive than RCRI alone in patients with RCRI ing surgery, perioperative beta-blocker exposure
<2. This suggests CTCA might be a good option was associated with lower rates of 30-day all-
for patients who cannot tolerate exercise or cause mortality in patients with 2 or more Revised
chemical stress test [20]. A 2019 meta-analysis Cardiac Risk Index factors [23].
found incremental risk of MACE with CAD by A 2014 metanalysis including 16 RCTs
coronary CT and that multivessel CAD on coro- showed that while beta-blockers were associated
nary CT conferred eightfold increased risk of with a trend toward reduced all-cause mortality
perioperative MACE [21]. A prospective cohort rate in the DECREASE trials (RR: 0.42; 95% CI:
0.15–1.22), they were associated with increased and initiating them at least 2 weeks in advance
all-cause mortality rate in other trials (RR: 1.30; for patients with indications not currently on
95% CI: 1.03–1.64). Additionally, this study statin therapy [28]. Canadian guidelines sup-
found that while perioperative beta-blockers port continuing but not initiating statin therapy
started within 1 day or less before noncardiac preoperatively. ACC/AHA guidelines support
surgery prevents nonfatal MI, these patients had initiating statin therapy prior to a vascular sur-
increased risks of stroke, death, hypotension, and gery in patients with indications for lipid lower-
bradycardia. As such, putting aside the ing therapy. While there have been observational
DECREASE studies, there are insufficient data studies, there are no major RCT data to support
on beta blockade started 2 or more days prior to this. In practice, many limb salvage patients
surgery [24]. have pre-existing coronary artery and periph-
An international, multicenter RCT of 8351 eral vascular disease and are already on a mod-
patients with cardiovascular disease or at risk for erate to high dose statin. If not, the internist
cardiac disease randomized to receive 100 mg should consider the addition of a statin during
metoprolol succinate on day of surgery and then the hospitalization.
continued for 30 days found that fewer patients in
the metoprolol group than in the placebo group Ace-I/Arb
had a myocardial infarction. However, there were Angiotensin converting enzyme inhibitors and
more deaths in the metoprolol group than in the angiotensin II receptor blockers have a neuro-
placebo group, as well as more strokes [25]. hormonal effect by reducing activation of the
In a 2010 prospective study of 940 vascular renin-angiotensin-aldosterone axis, resulting in
surgery patients given beta-blockers 0–1, 1–4, downstream vasodilation and decreased circu-
and 4 weeks before surgery, beta-blocker treat- lating blood volume. They are part of the back-
ment initiated >1 week before surgery is associ- bone of heart failure with reduced ejection
ated with lower preoperative heart rate and fraction treatment. Canadian guidelines suggest
improved outcome, compared with treatment ini- stopping ACE-I/ARBs 24 h prior to surgery and
tiated <1 week preoperatively [26]. restarting on postoperative day 2 [5]; European
guidelines suggest a temporary hiatus if they are
Aspirin prescribed for blood pressure control but con-
Aspirin is an irreversible cox-1 inhibitor and as tinuing them if prescribed for heart failure with
such reduces the aggregation of platelets and is decreased left ventricular systolic function [28];
associated with increased bleeding risks. The American guidelines suggest that continuing
current American guidelines recommend to hold Ace/Arb medications “is reasonable” in all
aspirin prior to noncardiac surgery unless the cases and suggests restarting them as soon as
ischemic risks outweigh the chances of bleeding possible if they are held [8]. Debate about best
[19]. However, more recent data supports con- practices remains as there is yet to be a well-
tinuing aspirin in patients who have had a history designed RCT comparing administration vs.
of PCI [27]. In practice, many of the limb salvage holding of these medications.
patients do have a history of PCI or lower extrem- The recommendations are based upon pro-
ity stenting and aspirin is continued throughout spective and observational studies. A prospective
the perioperative period. randomized trial analyzing hemodynamics dur-
ing anesthesia induction showed an increased
Statin/Lipid-Lowering incidence of severe hypotension during induc-
Statin therapy might have a role in minimizing tion for people who continued their chronic ARB
perioperative cardiac risk, as they have been on day of surgery [29]. An international prospec-
found to have anti-inflammatory and stabilizing tive cohort study of 14,687 patients found that
effects on cardiac lesions more generally. when compared to patients who continued their
European guidelines support continuing statins angiotensin-converting enzyme inhibitors/angio-
tensin II receptor blockers, the 1245 (26%) ing glucose management, medication manage-
angiotensin-converting enzyme inhibitor/angio- ment, insulin initiation and titration, and
tensin II receptor blocker users who withheld discharge planning—is crucial for many hospi-
their angiotensin-converting enzyme inhibitors/ talized limb salvage patients.
angiotensin II receptor blockers in the 24 h A diabetic patient’s glucose should be checked
before surgery were less likely to suffer the pri- regularly while admitted and kept within a goal
mary composite outcome of all-cause death, range, avoiding both hypoglycemia and
stroke, or myocardial injury and intraoperative hyperglycemia.
hypotension [30].
Hypoglycemia
Hypoglycemia, defined by the American Diabetes
Summary of Cardiovascular Association (ADA) and the Endocrine Society as
Assessment glucose <70 mg/dL, is a serious adverse event
that can complicate antidiabetic therapy in the
The preoperative history and physical examina- hospital [33]. In many cases, hypoglycemia is a
tion are used to assess the patient’s cardiovascu- side effect of the antidiabetic therapy itself.
lar risk factors and medication management. A Overtreatment with insulin or the continuation of
risk assessment utilizing the RCRI is performed an insulin secretagogue like a sulfonylurea can
in order to quantify the patient’s risk of cardiac result in hypoglycemia, particularly when a
complications. Next, consideration of further car- patient is hospitalized and might be suffering
diac testing is made and only pursued if the from a severe illness or not eating their normal
results will affect the patient’s management. A diet. Many patients recognize the symptoms of
careful review of medications is performed prior hypoglycemia, but hospitalized patients may
to surgical intervention. The internists’ role is to have impaired awareness and be unable to detect
perform a risk assessment, communicate that risk these symptoms [34]. Hypoglycemia triggers the
to the patient and surgical team, and to guide fur- autonomic nervous system, producing symptoms
ther testing and treatment for known or suspected including tremulousness, anxiety, diaphoresis,
heart disease. A clear analysis of the patient’s risk and palpitations. Hypoglycemia also deprives
and management options is essential in surgical neurons of glucose, producing fatigue, weakness,
planning. and confusion. When severe or prolonged, acute
hypoglycemia can cause seizures, neuronal dam-
age, or even death [35]. Even after symptom res-
Section 2: Diabetes Management olution, episodes of hypoglycemia have been
associated with long-term increased morbidity
Glucose Management and mortality.
Inpatient care for limb salvage patients often Hyperglycemia

requires diabetes management. Diabetes mellitus Hyperglycemia presents a more visible and
puts patients at greater risk for atherosclerotic common conundrum for the inpatient provider.
disease, including peripheral arterial disease Many patients, diabetic or not, experience
(PAD). A disproportionate share of diabetic hyperglycemia while hospitalized due to gluco-
patients has PAD, and 20–30% of patients with corticoid use or acute illness. Hyperglycemia
PAD have diabetes [31]. Diabetic neuropathy, a has been associated with increased morbidity
complication of long-standing diabetes, and PAD and mortality during hospitalizations [36]. In
put patients at increased risk for limb salvage surgical patients specifically, preoperative
procedures, as patients with both PAD and diabe- hyperglycemia has been linked in some studies
tes are five times as likely to need amputation to elevated infection rates and worse overall
[32]. Therefore, inpatient diabetes care—includ- outcomes [37, 38].
oal Glucose Range

G not yet have safety data supporting use for hospi-
Providers should aim to keep a diabetic patient’s talized patients [39]. Oral and injectable medica-
glucose between 140 and 180 mg/dL, in accor- tions also tend to act slowly, limiting easy
dance with the 2020 ADA Standards of Care and titration. Particularly for patients scheduled for
Endocrine Society guidelines [39]. Titrating ther- surgery, the Endocrine Society recommends dis-
apy to this goal generally protects against hyper- continuing oral and non-insulin injectable anti-
and hypoglycemia. A patient who is eating should diabetic agents and typically transitioning to
have their blood glucose checked at bedside fast- insulin [44].
ing in the morning and before every meal. A
patient who is NPO or on continuous tube feeds Insulin
should have blood glucose checked every 4–6 h. In most cases, insulin should be the primary ther-
The optimal range of 140–180 mg/dL has apy used to manage hyperglycemia during a hos-
been studied in perioperative patients. A Cochrane pital stay [44]. If a patient is not already on
review of perioperative glycemic control in dia- insulin, they should be started when they have a
betic patients noted that lower targets were asso- persistent glucose >180 mg/dL. Insulin dosing
ciated with no improved outcomes but with more should be calculated using the patient’s weight
episodes of hypoglycemia [40]. A subsequent and diet. If a patient is NPO or has poor oral
meta-analysis of perioperative outcomes noted intake, insulin should be provided as a basal dose
that a liberal glucose target of >200 mg/dL with a correctional sliding scale. A patient on
resulted in higher mortality and stroke than a tar- continuous tube feeds or TPN should receive
get of <200 mg/dL. However, a very strict glu- subcutaneous rapid-acting insulin every 4–6 h. A
cose goal of <140 mg/dL showed no additional patient eating a normal diet should receive basal
benefits but higher rates of hypoglycemia [41]. insulin, prandial insulin, and a mealtime correc-
The 2009 NICE-SUGAR trial demonstrated tional sliding scale [44]. Figure 8.1 shows stan-
the risk of strict glucose control in critically ill dard dosing of insulin in patients with diabetes
patients. Those patients maintained at a blood and hyperglycemia depending on type and
glucose of <108 mg/dL had a significantly higher amount of intake [43].
mortality rate than those maintained at <180 mg/ Some clinicians may be concerned about
dL. Patients receiving tighter control also had causing hypoglycemia when starting a patient on
more episodes of hypoglycemia and no better a weight-based insulin regimen. A retrospective
outcomes in length of stay or mechanical ventila-
tion [42]. Per the Endocrine Society guidelines, a
Diabetes with glucose > 140 mg/dL (7.7 mmol/L)
patient’s antidiabetic therapy should be reevalu-
ated and potentially lessened if a patient’s glu-
cose falls below 100 mg/dL. Nothing by mouth Adequate
Uncertain oral intake oral intake
Poor oral intake
Antidiabetic Medications Basal insulin Basal-bolusb

• Start at 0.2–0.25 U/kg/daya Total daily dose:
Non-insulin Medications • Correction doses with 0.4–0.5 U/kg/day
rapid-acting insulin • 1/2 basal, 1/2 bolus
Many patients will be taking oral or injectable before meals • Adjust as needed
antidiabetic medications when admitted to the • Adjust basal as needed
hospital. In general, these antidiabetic agents aReduce total daily dose to 0.15 U/kg in patients ≥
should be withheld on admission [43]. An admit- age 70 or with serum creatinine ≥ 2.0 mg/dL.
bIn patients already on basal-bolus at home,
ted patient may develop acute abnormalities,
decrease insulin dose by 25%.
such as kidney injury or critical illness, which are
contraindications to use of these medications. Fig. 8.1 Insulin dosing in a patient with diabetes and
Some medications, like SGLT-2 inhibitors, do hyperglycemia depending on type and amount of intake
study found that hypoglycemia was relatively 100% of their previous insulin dose the night
uncommon at weight-based doses below 0.6 before surgery had higher rates of hypoglyce-
units/kg. Above that threshold, hypoglycemia mia than patients who received 60–87% of their
became much more common [45]. previous dose. The patients receiving the
A patient should not be started on sliding reduced dose of insulin were more likely to be
scale insulin alone [39]. Sliding scale insulin within the goal range of 100–180 mg/dL during
is not a physiologic therapy. When used in this the operation [39]. From a review in
way, insulin treats hyperglycemia that has Anesthesiology on perioperative hyperglycemia,
already occurred, so the body has already been Tables 8.1 and 8.2 recommend the following
exposed to the elevated glucose. By contrast, insulin regimens on the day before and day of
basal-bolus insulin, in which a basal rate of surgery [38].
insulin is delivered along with prandial boluses The review recommends that patients with
to address postprandial glucose spikes, pre- type 1 diabetes receive 80% of their usual basal
vents hyperglycemia in the first place [46]. dose the evening before surgery and 80% again
Sliding scale insulin has been associated with the morning of. In diabetic patients receiving
worse glycemic control overall. One study of morning doses of insulin, the NPH should be
hospitalized patients found that patients reduced to 50% of the usual dose and longer act-
treated with sliding scale insulin had a mean ing insulins reduced to 60–80%. Prandial insulin
glucose level 20 mg/dL higher than a similar should be held at the time the patient becomes
group on basal-bolus insulin [46]. The ran- NPO [38].
domized, controlled RABBIT 2 trial also
noted a significant improvement in glycemic
control in inpatients treated with basal-bolus Preparation for Discharge
insulin. These patients had a daily mean glu-
cose level 27 mg/dL lower than those treated Education
with sliding scale insulin [47]. A patient nearing discharge should be prepared
for continued diabetes management at home. The
erioperative Insulin Management
P ADA recommends reviewing the patient’s outpa-
A patient’s insulin regimen needs adjustment tient diabetes provider, the patient’s understand-
prior to surgery. All oral antidiabetic medica- ing of their diagnosis, how to monitor glucose
tions should be held in the perioperative period. levels, recognition and plan of action for hyper-
The ADA recommends giving basal insulin at glycemia and hypoglycemia, a healthy nutrition
60–80% of the full dose the night before the plan or referral to diabetes dietician, and the
operation. In a 2017 study, patients who received patient’s antidiabetic medications [39]. A recent
Table 8.1 Standard recommendations for day before surgery insulin regimens
Day before surgery insulin regimens based on oral intake status
Glargine or NPH or 70/30 Lispro, aspart,
detemir insulin glulisine, regular Non-insulin injectables
Day before surgery AM PM AM PM AM PM
insulin regimens dose dose dose dose dose dose AM dose PM dose
Normal diet until Usual 80% of 80% of 80% of Usual Usual Usual dose Usual dose
midnight (includes those dose usual usual usual dose dose
permitted clear liquids dose dose dose
until 2 h prior to surgery)
Bowel prep (and/or clear Usual 80% of 80% of 80% of Usual Usual Hold when Hold when
liquids only 12–24 h prior dose usual usual usual dose dose starting clear starting clear
to surgery) dose dose dose liquid diet/ liquid diet/
bowel prep bowel prep
Table 8.2 Standard recommendations for day of surgery medications for comorbid conditions. Many limb
insulin regimens
salvage patients with diabetes also have PAD, a
Day of surgery insulin regimens form of atherosclerotic disease. For secondary
Lispro, prevention, diabetic patients of all ages with ath-
aspart, Non-
Glargine or NPH or 70/30 glulisine, insulin erosclerotic disease should be started on a high-
detemir insulin regular injectables intensity statin and aspirin 81 mg daily and
80% of usual 50% of usual Hold Hold should be considered for an ACE inhibitor or
dose if dosea if BG angiotensin receptor blocker (ARB) medication
patient uses 120 mg/dL
twice daily Hold for BG
[50]. A diabetic patient aged 40–70 even without
basal therapy <120 mg/dL atherosclerotic disease should be started on a
BG blood glucose medium-intensity statin for primary prevention.
a
6.6 mmol/L Diabetic patients over 50 without atherosclerotic
disease but with other risk factors likely benefit
review of inpatient diabetes education notes that from a high-intensity statin [50].
although most diabetes education occurs in the
outpatient setting, hospitalization is an ideal time oal Hemoglobin A1c Ranges
G
to provide this education. There is growing evi- Providers should also review goal hemoglobin
dence for the benefit of inpatient diabetes educa- A1c ranges with patients. There is no consensus
tion, particularly on reducing readmission rates guideline for goal hemoglobin A1c, so the dis-
and improving health outcomes [48]. cussion should be individualized and take into
account patient preference, patient characteristics
ome Medication Management
H and comorbidities, and pre-existing complica-
While a patient is admitted, a hemoglobin A1c tions of diabetes. The ADA 2020 Glycemic
should be obtained if none is identified within the Control guideline states that a goal hemoglobin
last 3 months. Based on this value, the Endocrine A1c of <7% is appropriate for many patients to
Society suggests an algorithm for discharge medi- prevent microvascular and macrovascular com-
cation management that the ADA subsequently plications. However, for patients with a history of
found to be useful. If the patient’s hemoglobin A1c severe hypoglycemia, limited life expectancy,
is <7%, there should be no change made to the advanced macrovascular or microvascular com-
home diabetes regimen. If the patient has a hemo- plications, extensive comorbidities, or long-
globin A1c of 7–9%, the patient has suboptimal standing diabetes, a goal of <8% may be more
control. At discharge, the patient should be consid- reasonable [33]. Many limb salvage patients
ered for intensified oral medication or basal insulin. already have advanced macrovascular and micro-
If the hemoglobin A1c is >9%, the patient’s diabe- vascular complications in the forms of PAD and
tes is poorly controlled. These patients should be diabetic neuropathy, likely making the <8% goal
considered for a basal-bolus insulin regimen. This more appropriate. Similarly, American College
discharge algorithm was found to be safe and effi- of Physician guideline suggests a goal hemoglo-
cacious in a prospective trial. The study started bin A1c of 7–8% for most patients [51]. Providers
patients with a hemoglobin A1c of 7–9% on home should discuss these factors with each patient to
glargine at 50% of the hospital dose and patients set a reasonable, individualized goal.
with hemoglobin >9% on glargine or basal-bolus at
80% of their hospital dose. The patient should oth- Follow-Up
erwise be restarted on their pre-admission oral anti- Appropriate outpatient follow-up is for diabetic
diabetic medications at discharge [49]. patients. The ADA recommends follow-up with
a primary care physician, diabetes educator, or
revention of Atherosclerotic Disease
P endocrinologist within 1 month of discharge for
A diabetic patient’s admission presents an ideal all patients. If the patient’s medications were
time to ensure that they are on all recommended adjusted while inpatient or on discharge, the
ADA recommends follow-up within 1–2 weeks lable state, and the presence of active malignancy.
[39]. Coordination of care does not end with Patients with a recent DVT/PE within 3 months or
hospital discharge; the internist should ensure who have a known severe thrombophilia includ-
that the discharge summary includes any medi- ing antiphospholipid syndrome or deficiency of
cation changes communicated to the outpatient protein S, C or antithrombin1 [53] are at highest
physician. risk of recurrent thrombosis. Moderate risk
patients include those who have had a VTE
3–12 months ago, recurrent VTE, active cancer or
ection 3: Anticoagulation
S presence of non-severe risk factors for thrombo-
and Antiplatelet Management philia including heterozygous factor V Leiden or
prothrombin gene mutation1. Patients with a
Background DVT/PE greater than 12 months prior to surgery
have a low risk of thromboembolic events.
Many patients requiring limb salvage surgery Thrombotic risk with atrial fibrillation accounts
will be chronically on anticoagulation or anti- for the largest proportion of patients on anticoag-
platelet agents. Managing these medications ulation. Disruption of systemic anticoagulation
perioperatively is a challenging task as interrup- increases the risk of a cardioembolic stroke. These
tion increases the risk of thromboembolic events patients represent a diverse group which can be
and continuation through a procedure increases further risk stratified based on the prevalence of
the risk of bleeding. Interruption in anticoagula- risk factors including age, sex, hypertension, dia-
tion for invasive procedures confers a risk of an betes, prior CVA, congestive heart failure, and
adverse event from a VTE or cardioembolic other vascular disease. These variables can be
cerebrovascular accident (CVA). The RE-LY used to calculate a CHA2DS2-VASc score. The
trial (Randomized Evaluation of Long-Term score is proportional to stroke risk with a score of
Anticoagulant Therapy) showed that of 4591 0–3 indicating a low risk for stroke. A score of
people who underwent a procedure there was a 4–6 indicating a moderate risk, and a score of 7–9
1.2% risk of cardioembolic events defined as indicating a high risk for cardioembolic stroke. A
CVA, cardiovascular death, and pulmonary CVA or transient ischemic attack (TIA) within the
embolism (PE) [52]. Care of the surgical patient past 3 months or having rheumatic valvular heart
on chronic anticoagulation presents risks both of disease also makes the patient at high risk for a
thrombosis and bleeding. A methodical assess- thromboembolic event [54].
ment of the patient-specific thrombosis risk and Thrombotic risk also needs to be assessed for
the surgery-specific bleeding risk is essential in patients with mechanical prosthetic heart valves.
the care of these patients. We will focus on These patients can be further risk stratified based
patients who are anticoagulated for a history of on which valve has the prosthesis and the pres-
venous thromboembolism (VTE), atrial fibrilla- ence of additional medical comorbidities. Low-
tion, and prosthetic heart valves and outline risk patients include those with bileaflet aortic
decision-making in the surgical setting. valve prosthesis without atrial fibrillation or addi-
tional risk factors for CVA. Moderate risk patients
are those with bileaflet aortic valve prosthesis
Thrombotic Risk plus one or more comorbidities including atrial
fibrillation, prior CVA or TIA, diabetes, hyper-
The first step in decision-making involves an esti- tension, congestive heart failure, or age greater
mation of the patient’s thrombotic risk. than 75 years. Patients who are at highest risk for
Thrombotic risk in a patient with a history of a thromboembolic event include anyone with a
deep venous thrombosis and/or pulmonary embo- CVA/TIA in the past 6 months, any mitral valve
lism is affected by the timeline of thrombotic prosthesis, and presence of a caged-ball or tilting
events, the presence of an underlying hypercoagu- disc aortic valve prosthesis [54].
Bleeding Risk din can be reversed. Oral or IV vitamin K

(2.5–5 mg) can be effective in 1–2 days. If the
The second step in decision-making about anti- surgery is emergent, fresh frozen plasma (FFP) or
coagulant therapy involves a review of the four factor prothrombin complex concentrate
surgery-specific bleeding risk. (4F-PCC) can be given.
Having assessed our patients’ risk of thrombo- Since VKA antagonists must be held for days
sis, next we turn our attention to the risk of surgi- prior to surgery, patients at high risk of thrombo-
cal bleeding. Bleeding risk is determined by the sis will require the interval use of short acting
type of procedure being performed. By defini- anticoagulants such as low molecular weight
tion, procedures that have a 2-day major bleeding heparin or unfractionated IV heparin. This prac-
risk of 2–4% are high-risk bleeding procedures; tice is call “bridging anticoagulation.” Bridging
procedures with a bleeding risk of 0–2% are low- reduces the amount of time a patient is not anti-
risk bleeding procedures [54]. Limb salvage sur- coagulated and thereby reduces thrombotic and
gery is typically a low risk of bleeding procedure cardioembolic events. Bridging is primarily used
and therefore discussion here will be limited to for long-acting anticoagulants such as coumadin.
low-risk procedures. Bridging anticoagulation also increases the risk
Now that we have assessed the patient-specific of surgical bleeding. In patients who are at a high
thrombotic risk and the surgery-specific bleeding risk for a cardioembolic event (recent dvt/pe,
risk, the decision on whether to disrupt anticoag- atrial fibrillation with a high CHADs2Vasc score,
ulation can be made. For procedures with a very and high-risk mechanical heart valves), bridging
low risk of bleeding, anticoagulation can often be with an unfractionated heparin drip or LMWH is
continued throughout the perioperative period. indicated. Patients with low risk of thrombosis do
This would apply only to simple and superficial not require bridging. Bridging is achieved by
debridement. Limb salvage surgery is often dosing LMWH (enoxaparin 1 mg/kg every 12 h
urgent and may be complex; therefore, interrup- or dalteparin 100 units/kg every 12 h) or starting
tion of anticoagulation is usually necessary. If an unfractionated heparin drip either 3 days prior
anticoagulation is held for a procedure, it should to surgery (2 days after stopping coumadin) or
be stopped for a time that is sufficient for the anti- when INR is no longer in the therapeutic range
coagulation effects to resolve. I will review the [55]. Discontinue LMWH 24 h prior to the proce-
common anticoagulants including vitamin K dure. Discontinue an unfractionated heparin drip
antagonists, unfractionated heparin, low molecu- 4–5 h prior to the procedure. After the last
lar weight heparin (LMWH), direct thrombin and planned procedure, Warfarin may be resumed
direct Xa inhibitors and antiplatelet agents. that day, and LMWH or an unfractionated hepa-
rin drip is typically started 24–48 h after the pro-
cedure assuming adequate hemostasis. The short
nticoagulants
A acting heparinoids and coumadin are overlapped
and both continued until the INR is in a therapeu-
arfarin
W tic range for at least 24 h [55]. At that point the
Warfarin is a vitamin K antagonist that inhibits heparin or LMWH can be stopped as the patient
factors II, VII, IX, and X. It is monitored using is therapeutic on their warfarin.
prothrombin time (PT) and international normal-
ized ratio (INR). Warfarin should be discontinued Direct Thrombin and Direct Xa
5 days prior to surgery for a goal INR of less than Inhibitors
1.51 [55]. Check INR on the day prior to surgery The direct Xa inhibitors include apixaban and
and if the INR is greater than 1.5, oral vitamin K rivaroxaban and the direct thrombin inhibitors
can be given (1–2 mg). Coumadin should be include dabigatran. These medications are also
restarted 12–24 h after the last planned procedure known as the DOACs. The timing of discontinuing
[55]. If the procedure is urgent/emergent, couma- these medications was studied in the perioperative
anticoagulation use for surgery evaluation PCI regardless of the stent type. If a bare metal
(PAUSE) trial. This study standardized the time in stent was placed, then DAPT may be discontinued
which DOACs that were being taken for atrial as soon as 30 days after PCI. If a drug-eluting stent
fibrillation were held. It showed the rates of major was placed, DAPT should be continued for
bleeding as less than 2% and ischemic stroke as 6 months after PCI, but if the surgery is urgent dis-
less than 0.5%. Based on this data, for low to mod- continuation may be considered after 3 months
erate risk procedures, DOACs should be stopped [59]. When DAPT is interrupted, aspirin should be
1 day prior to a procedure and resumed 1 day after held 5–7 days prior to the procedure. Clopidogrel
surgery [56]. One exception is that dabigatran should be held 5 days prior to the procedure.
should be held 2 days prior to the procedure if the Prasugrel should be discontinued 7 days prior to
creatinine clearance is 30–505,6. Reversal of these surgery. Ticagrelor should be discontinued
agents is not typically necessary but is available. 3–5 days prior. DAPT can be restarted when there
Dabigatran can be reversed by idarucizumab. is no longer a risk for major bleeding.
Apixaban and rivaroxaban can be reversed by In practice, many of the limb salvage patients
andexanet alfa. Because of the much shorter half- have strong indications for antiplatelet therapies.
life, DOACs do NOT require bridging anticoagu- Care coordination with the surgical team is criti-
lation with heparin/or LMWH. You simply stop cal in decision-making. Often, DAPT can be con-
the agent 1–2 days prior to surgery and resume tinued if surgical bleeding is controlled. Where
postoperatively once adequate hemostasis is possible, we recommend at least continuing aspi-
obtained. We are more conservative in resuming rin in the high-risk patients with a history of car-
NOACs and DOACs postoperatively, and in gen- diac or peripheral arterial stenting.
eral prefer waiting 48–72 h after surgery.
Antiplatelet Agents Venous Thromboembolism (VTE)

Antiplatelet agents include aspirin, clopidogrel, Prophylaxis
prasugrel, and ticagrelor. Aspirin irreversibly
inhibits platelet cyclooxygenase. Clopidogrel, DVT/PE is a common postoperative problem and
prasugrel, and ticagrelor are platelet P2Y12 one of the most preventable types of hospital mor-
receptor blockers. Aspirin can be used as a mono- bidity/mortality [60]. Limb salvage surgery is
therapy or in combination with one of the P2Y12 typically a lower risk procedure for major bleed-
receptor blockers which is referred to as dual ing. LMWH can therefore be started 12 h prior to
antiplatelet therapy (DAPT). surgery and resumed 2–12 h after a procedure. The
Aspirin monotherapy is used for both primary most commonly used agents include enoxaparin
and secondary prevention of cardiovascular 40 mg every 24 h and dalteparin 5000 units every
events including myocardial infarction (MI) and 24 h [61]. An alternative is fondaparinux, which is
CVA. The POISE-2 trial suggests that discontin- started 6–8 h postoperatively and dosed at 2.5 mg
uing aspirin for noncardiac surgery reduces every 24 h [62]. In patients with advanced kidney
bleeding without increasing cardiovascular disease, subcutaneous unfractionated heparin at
events. Aspirin should be held 5–7 days prior to 5000 q8 h is recommended. VTE prophylaxis
surgery and restarted when there is no longer a should be continued until the patient becomes
risk for major bleeding [57]. ambulatory or until hospital discharge.
One of the primary indications for DAPT is fol-
lowing a percutaneous intervention (PCI). These
patients are at an increased risk for MI or stent Summary of Anticoagulation
thrombosis, and premature cessation of DAPT is
the strongest risk factor for these complications Management of anticoagulation in the surgical
[58]. Per the 2016 ACC/AHA guidelines, surgery setting is one of the most high-risk areas of medi-
would ideally be delayed until 6 months following cal decision-making. Resuming anticoagulation
after surgery requires careful coordination with vage treatment. The limb salvage patients have an
the surgical team. In general, full anticoagulation increased rate of underlying chronic kidney dis-
is usually permitted 48 h after surgery. This time- ease which further increases their risk for AKI. A
line can be accelerated to 24 h post-procedure in thorough evaluation to determine the etiology of
low-risk bleeding situations or extended to 72 h the decline in kidney function involves an assess-
or longer if significant surgical bleeding is ment of the patient’s volume status, a review of
encountered. Other factors that will delay the potentially reno-toxic medications and evalua-
resumption of full anticoagulation include neuro- tion to rule out obstruction.
axial anesthesia with a lumbar epidural catheter Pre-renal AKI can be triggered by volume
and a history of postoperative bleeding. In set- depletion or hypotension. Limb salvage patients
tings where there is not full confidence that anti- are at increased risk of volume depletion due to
coagulation will be tolerated, we recommend NPO status for multiple days due to staged proce-
beginning a heparin drip as it can be most rapidly dures. Poor oral intake is common in the postop-
stopped and/or reversed. If the heparin drip is tol- erative setting due to postoperative nausea and
erated, then the patient can be transitioned back vomiting (PONV), sedation due to narcotic anal-
to their outpatient regimen. The reason for the gesia and delirium. Hypotension is another
longer wait period for the DOACs is that they are known precipitator of pre-renal AKI. Hypotension
not readily reversible. With the complicated man- occurs preoperatively in patients with severe sep-
agement decisions and potential life-threatening sis, intraoperatively due to anesthetic response or
possibilities of DVT/PE, stroke, and postopera- surgical blood loss, and postoperatively due to
tive bleeding, regular communication between the effects of opioid analgesia.
the surgical and medical teams is essential. Intrinsic injury to the kidney occurs from
direct nephrotoxicity from medications and con-
trast agents. Common culprits include intrave-
ection 4: Postoperative
S nous antibiotic, intravenous contrast, and
Complications NSAIDs. Contrast induced nephropathy is much
less common now that lower osmolality contrast
Postoperative complications are common in the agents are utilized [63]. Renal injury from con-
hospitalized patient and require prompt medical trast is possible in patients with an estimated GFR
evaluation and treatment. The limb salvage less than 30 and in patients with a recent AKI
patients are at higher risk of complications due to [64]. Likewise, directed angiography to assess for
their underlying age and comorbidities including peripheral vascular disease now can involve
diabetes, vascular disease, chronic kidney disease. smaller amounts of contrast. Antibiotic associated
Medical complications increase length of stay, nephropathy is also common. Careful monitoring
morbidity, and mortality. We will focus on the rec- of dosing and drug levels for vancomycin is rec-
ognition and treatment of acute kidney injury, ommended to help reduce the incidence of
delirium, and postoperative gastrointestinal com- toxicity.
plications. Development of complications can Urinary tract obstruction also occurs in the sur-
affect a patient’s readiness for the operating room gical patient. It can be precipitated by urinary
and also for safe hospital discharge. The internist retention due to spinal/epidural anesthesia, postop-
must work in careful coordination with the surgi- erative ileus, and medications. Mechanical obstruc-
cal team as delay in surgery may be required. tion more commonly occurs in male patients with
underlying BPH. A simple bladder scan to check
post void residual will detect both of these obstruc-
Acute Kidney Injury tive causes of AKI. A renal US is needed to rule out
the less common etiologies of obstruction such as
Acute kidney injury (AKI) is a common compli- ureteral obstruction due to anatomic problems,
cation in surgical patients undergoing limb sal- nephrolithiasis, malignant processes.
Delirium where possible [65]. Current recommendations

do not support the use of anti-psychotic medica-
Delirium is common in the hospitalized patient, tions [67].
affecting up to 50% of hospitalized patients and
may be preventable in as much as 30–40% of
cases [65]. The development of delirium is asso- Postoperative GI Complications
ciated with increased length of stay, increased
risk of discharge to a nursing facility, and Common gastrointestinal complications that will
increased risk of death. Risk factors for delirium be addressed include postoperative nausea and
include dementia or cognitive impairment, func- vomiting (PONV), opioid induced constipation
tional impairment, vision impairment, history of (OIC), postoperative ileus (POI), and antibiotic
alcohol abuse, age >70, comorbidity burden, associated diarrhea. The internist should be pre-
polypharmacy, psychoactive medication use, pared to institute preventive therapies, recognize
physical restraints, and anormal laboratory val- complications, and implement appropriate treat-
ues [65]. ment options.
Initial evaluation of delirium should include
ascertaining baseline mental status cognitive ostoperative Nausea and Vomiting
P
function utilizing information obtained from the Postoperative nausea and vomiting (PONV) is a
patient, family, and other caregivers. It is impor- term used to describe a patient’s nausea and vom-
tant to determine the patient’s pre-morbid cogni- iting in the immediate 24 h post-procedure. If not
tive status so that subtle changes will be noticed managed properly, PONV can lead to prolonged
and identified early. The initial exam should be hospitalizations, patient dissatisfaction, and even
focused to screen out acute physiologic problems severe medical complications like aspiration and
such as hypoxemia, hypoventilation, hypoglyce- wound dehiscence. A strategic approach for treat-
mia, acute cardiac decompensation. Next steps ment of PONV includes identifying high-risk
include medication review, assessment of meta- patients, using prophylactic antiemetics, and
bolic derangements, ruling out intercurrent or understanding the different treatment options.
intreated infection, checking an EKG to evaluate Table 8.3 is a simplified risk calculator that can
for silent ischemia, with consideration of neuro- be sued to decide if prophylactic PONV treat-
imaging reserved for cases where the exam is ment is appropriate.
focal, head trauma suspected, or a complete eval- While medical treatment options for PONV
uation has failed to yield a suspected etiology. can differ based on hospital formularies and a
While often multifactorial in etiology, identifica- patient’s underlying disease, there are several
tion, and removal of inciting factors along with other strategies that can be universally applied.
careful application of delirium protocols can help PONV can be reduced when using combination
to minimize the consequences of delirium. antiemetics from different classes, using local-
Simple non-medical interventions such as ized instead of generalized anesthesia if possible,
keeping shades up/lights on during daytime, fre- ensuring patient hydration, and providing ade-
quent reorientation, therapeutic activities, main-
taining hydration and nutrition, and providing
vision and hearing aids such as is described in Table 8.3 Simplified risk calculator by Apfel [68] that
can be used to decide if prophylactic PONV treatment is
the Hospital Elder Life Program (HELP) and appropriate
help with prevention [66]. Minimization of psy-
Risk factors (1 point Prevalence of PONV
choactive medications such as narcotic analge- each) Points (%)
sics, muscle relaxants, benzodiazepines will Female 0–1 10–20
help the patient to clear their delirium. The addi- Non smoker 2–3 40–60
tion of antihistamines, sedative hypnotics, and History of PONV 4 80
anti-
psychotic medications should be avoided Post operative opioids
Table 8.4 List of commonly used antiemetics and their side effects. For maximum efficacy, a rescue treatment should
include an antiemetic from a different class than the ones that were used for prophylaxis unless significant time has
passed
Drug class Example Side effects
Serotonin 5-hydroxytryptamine Ondansetron QTc prolongation
type 3 (5-HT3) receptor
antagonists
Glucocorticoids Dexamethasone Slow onset, can interfere with cell counts and glucose
metabolism
Anticholinergic Scopolamine Slow onset, dry mouth, blurry vision, confusion or
agitation in older adults, acute angle closure glaucoma
Antidopaminergic Droperidol Sedation, cardiac arrythmias and sudden cardiac deaths
Antihistamine Diphenhydramine, Sedation, dry mouth, dizziness, urinary retention
promethazine
quate pain control. Common antiemetics and

their side effects are listed in Table 8.4.
pioid Induced Constipation

O
Opioid induced constipation (OIC) is a common
manifestation of chronic or acute opioid use. To
diagnose OIC, we use the Rome IV criteria which
include new or worsening constipation symptoms
when opioids are initiated or increased. Prevention
is the recommended treatment strategy for OIC
and can include an osmotic laxative like polyeth-
ylene glycol or a stimulant laxative like senna.
Additional modifications to consider are proper
hydration, increased mobility, and adequate
dietary fiber intake. It is reasonable to up titrate Fig. 8.2 Megacolon measuring 16.3 cm on plain abdomi-
the frequencies of current management or con- nal radiograph (author’s own image)
sider adding another agent for those patients who
develop OIC despite a preventative regimen. If a lactose intolerant patients as it may cause abdom-
patient is refractory to increase of the current inal discomfort [70].
management, if ileus and obstruction have been
ruled out, it is important to consider impaction as Postoperative Ileus
the source of the constipation. Mineral oil enemas Postoperative ileus (POI) is a physiologic process
and soap water enemas are useful and safe. that is usually benign and typically resolves by
Peripherally acting mu-opioid receptor antago- postoperative day 3. The proposed physiology of
nists (PAMORAs) should be reserved for refrac- POI is multimodal and includes gastrointestinal
tory OIC in the absence of bowel obstruction. dysmotility secondary to bowel inflammation,
Ultimately, we suggest following the regimen inhibitory neural reflexes, and neurohormonal
that is most effective and best tolerated by the peptides. Logically, the risk of POI is higher with
patient. However, there are two important consid- intraabdominal surgeries and perioperative opioid
erations worth mentioning when choosing a use. Common clinical symptoms of POI include
bowel regiment including fleet enemas and lactu- nausea and vomiting, inability to tolerate an oral
lose. Fleet enemas should be avoided in patients diet, absence of flatus, abdominal distention, and
with renal failure as they contain high amounts of radiologic confirmation without an alternative
phosphate [69]. Lactulose should not be used in mechanical cause. Figure 8.2 shows an impres-
sive abdominal radiograph of a megacolon mea- If there is a low clinical suspicion for C. Diff.
suring 16.3 cm. colitis or other infectious diarrheal sources, most
Initiation of treatment for prolonged POI antibiotic associated diarrhea can be supportively
(greater than 3 postoperative days) is focused on managed with proper hydration, antidiarrheal
supportive care. Interventions such as manage- agents, and consideration of the risk vs. benefit of
ment of pain with avoidance of opioid agents, removing the suspected antibiotic.
bowel rest and decompression if indicated, elec-
trolyte replacement, and nutritional support are
common ways to shorten the course of POI. While Summary of Complications
fluid replacement is also an important factor of
supportive therapy, it is important to mention that The internist follows each patient daily during
studies have shown that overly aggressive fluid the hospital stay in order to detect and treat com-
resuscitation in the perioperative setting could plications that may arise. Early recognition of
lead to edema in the gastrointestinal tract and kidney injury, delirium, and gastrointestinal
may actually lead to postoperative ileus [71]. The problems will aide in the treatment and recovery
use of prokinetic agents remains controversial as of the limb salvage inpatient.
studies have shown limited utility.
ntibiotics Associated Diarrhea

A onclusion: Medical Management
C
The first step in evaluating the cause of a patient’s of the Limb Salvage Inpatient
diarrhea is to look over the patient’s existing
bowel regimen and eliminate any offending Limb salvage inpatients are medically complex
agents as the possible cause of symptoms. Next, and at substantial risk of complications.
the most concerning diagnosis in a patient with Preparation for surgery involves coordination
antibiotics associated diarrhea is C. difficile coli- between the internal medicine specialist and the
tis and must be properly investigated. surgical team. Careful review of cardiac status
Although any recent antibiotic use can predis- and risk factors is essential to quantify the periop-
pose patients to C. Diff. infection, the most erative cardiac risk. This evaluation also p rovides
common offending agents are fluoroquinolones, the opportunity to review a patient’s cardiac medi-
clindamycin, cephalosporins, and penicillins [72]. cation management and to optimize it prior to sur-
In addition to antibiotic use, suspicion for C. dif- gery. Diabetes is present in the vast majority of
ficile colitis should arise if the patient has any of the limb salvage inpatients. The internist reviews
the following: advanced age, recent hospitaliza- current diabetic medications and control and con-
tion, >3 loose stools per day, unexplained leukocy- verts oral medications to insulin. These treatment
tosis, and abdominal pain. Once there is a clinical decisions must be coordinated daily with the sur-
suspicion, the patient should be placed on contact gical team as the patient will frequently be NPO
precautions and tested for C. Diff. via a stool test. for procedures. Anticoagulation management is
If clinical suspicion and testing is positive, ini- critically important in surgical patients due to
tial treatment for uncomplicated C. Diff. without competing risks of thrombosis and bleeding. The
evidence of toxic megacolon includes oral vanco- internist works with the surgical team to assess
mycin or oral fidaxomicin. For recurrent epi- the need for and safety of anticoagulants around
sodes, a prolonged course of vancomycin with a the time of surgery. Lastly, the internist works to
taper is an option. For fulminant episodes that prevent and identify medical complications.
include toxic megacolon and hemodynamic Surgical success is aided by careful control of
instability, IV metronidazole and oral vancomy- medical comorbidities. The importance of close
cin are both recommended along with additional coordination between the medical and surgical
considerations for rectal vancomycin and fecal teams cannot be overemphasized. We have found
microbiota transplant. the best way to achieve this coordination with
daily multidisciplinary rounds in which each 9. Noordzij PG, Boersma E, Bax JJ, Feringa HH,
Schreiner F, Schouten O, Kertai MD, Klein J, van Urk
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Evaluation and Examination
of the Diabetic Foot
9
Michael Edmonds, Rajesh Kesavan, and Arun Bal
Introduction 1. The neuropathic foot

2. The ischaemic foot
There have been several consensus documents
depicting best practice recommendations for It is important to differentiate the neuropathic
clinical evaluation of the diabetic foot [1–3]. In foot from the ischaemic foot as management of
this chapter, we describe a simple practical each differs in many respects. Usually there will
approach to the evaluation and examination of be little doubt as to which category the foot
the diabetic foot which informs the practitioner should be placed in. However, if the examiner has
how to carry out a comprehensive assessment. any doubt, then the foot should be regarded as
From this, a diagnostic classification and staging ischaemic, because if an ischaemic foot is
of the foot can be made which will enable the wrongly classified as neuropathic, there may be
correct treatment to be performed. resulting failure to do further tests to identify
The diabetic foot can be classified into two ischaemia and adapt the care plan accordingly.
main clinical groups: This may lead to preventable catastrophe and loss
of the foot.
The neuropathic foot may be further stratified
into two clinical scenarios.
M. Edmonds (*)
King’s College Hospital, London, UK
1. Foot with neuropathic ulceration (Fig. 9.1)
Diabetic Foot Medicine, King’s College, London, UK
2. Charcot foot, which may be secondarily com-
plicated by ulceration and infection (Fig. 9.2)
R. Kesavan
Dr. RK Diabetic Foot and Podiatry Institute and
Rakesh Jhunjhunwala Amputation Prevention Centre, The ischaemic foot may be stratified into three
Chennai, India clinical scenarios:
SRM Institute of Science and Technology,
Chennai, India 1. Neuroischaemic foot characterised by mild or
A. Bal moderate ischaemia and neuropathy and often
Raheja Fortis Hospital, Mumbai, India complicated by ulcer (Fig. 9.3)
Amrita Institute of Medical Sciences, Kochi, India 2. Severely ischaemic foot otherwise known as
the critically ischaemic foot (Fig. 9.4)
Diabetic Foot Society of India, Mumbai, India
3. Acutely ischaemic foot (Fig. 9.5)
International Association of Diabetic Foot Surgeons,
Frederiksberg, Denmark

108 M. Edmonds et al.
Fig. 9.3 Neuroischaemic ulcer on medial aspect of first

toe
Fig. 9.1 Neuropathic ulcer
Fig. 9.4 Necrosis of toes in critically ischaemic foot
Fig. 9.2 Charcot foot with ulcer over lateral malleolus
Fig. 9.5 Necrosis and mottling of the foot secondary to

acute ischaemia
9 Evaluation and Examination of the Diabetic Foot 109
Fig. 9.6 Simple Staging System showing natural history of the five scenarios of the diabetic foot
With reference to the ischaemic scenario, the sion of each scenario from the normal foot through
Global Vascular Guidelines have recently pro- the stages to necrosis. In particular, it emphasises
posed the term Chronic Limb Threatening the development of the ulcer as a pivotal stage in
Ischaemia to include a broad group of patients the natural history of the diabetic foot demanding
with varying degrees of ischaemia that can often urgent and aggressive management.
delay wound healing and increase amputation The Simple Staging System is thus based on
risk [4]. This will include both the neuroisch- clinical presentation and clinical assessment and
aemic and the critically ischaemic scenarios. allows all practitioners, whether experienced in
Each of the above five main clinical scenarios diabetic foot care or not, to make an initial assess-
(two neuropathic and three ischaemic) are char- ment of the diabetic foot and establish at what stage
acterised by having specific stages in their natural the foot may be in its natural history. The stage then
history. These stages have been described in a determines treatment. The aim is to keep all dia-
Simple Staging System [5] (Fig. 9.6). betic feet at as low a stage as possible [5].
The stages are
Simple Staging System 1. Normal foot

2. High-risk foot
The Simple Staging System covers the entire 3. Foot with tissue damage (ulceration, Charcot
spectrum of diabetic foot disease. It describes five foot, or ischaemic tissue)
stages in the natural history of each of the five 4. Threatened foot
clinical scenarios. It also traces the rapid progres- 5. Necrotic foot
Classifications of the Diabetic Foot resenting Complaint (Be Aware That

P
Some Patients May Be Asymptomatic
There are various classifications of the diabetic Due to Neuropathy)
foot which are suited to different circumstances,
such as characterising populations, designing The presenting complaint is usually concerning
clinical trials and assessing comparative effec- one or more of the following features:
tiveness of treatments. Classifications such as the
Wagner, the University of Texas and SINBAD Skin breakdown
are established classifications of ulcers [6–8]. In Discharge
a person with diabetes and a foot ulcer, the Swelling
SINBAD system has been used for communica- Colour change
tion among health professionals to convey the Pain
characteristics of the ulcer, and to allow compari-
sons between institutions on the outcomes of For skin breakdown, discharge, swelling and
people with a diabetic foot ulcer in regional/ colour change or any other specific presenting
national/international audits [9, 10]. complaints, the following questions may be
In the Lower Extremity Threatened Limb helpful:
Classification System of the Society for Vascular
Surgery, perfusion of the foot is considered in the • Where is the problem?
context of wound characteristics and infection. It • When did it start?
stratifies amputation risk according to wound • How did it start?
extent, the degree of ischaemia, and severity of
foot infection and thus is known as WIfI [11]. It Were there any injuries, burns, rat bites
provides accurate and early risk stratification for (Figs. 9.7 and 9.8), ant bites (Figs. 9.9 and 9.10),
patients with threatened lower limbs. It aids clini-
cal management and predicts risk of amputation at
1 year and the need for limb revascularization. It
has been correlated with the probability of limb
salvage and wound healing following revascular-
ization [12].
In order to classify and stage the diabetic foot,
according to the Simple Staging System, a com-
prehensive assessment, consisting of full history
and examination and bedside (or chair side)
investigations, should be carried out.
History
The history can be divided into the following

sections:
–– Presenting complaint
–– Past foot history
–– Diabetic history
–– Past medical history
–– Family history
–– Drug history Fig. 9.7 Rat bites over the third and fifth toes
Assessment of Pain
It is important for personnel who work in a diabetic

foot clinic or limb salvage clinic to understand the
various causes of pain in the diabetic lower limb.
Pain may be a lone specific complaint or it may
accompany the other problems. It may arise locally
or be diffuse. Local sources may come from bone,
joint or soft tissue including skin and subcutaneous
tissue. Generalised burning pain in both feet sug-
gests a diagnosis of painful neuropathy. Diffuse
localised pain in a single foot at rest suggests isch-
Fig. 9.8 Rat bite with partial amputation of the tip of the
left third toe aemia, classically known as rest pain which is
relieved by dependency such as achieved by hang-
ing the foot over the side of the bed. However, pain
in the mild or moderately ischaemic foot should
not always be blamed on reduced arterial perfu-
sion. It may be caused by infection. In the neuro-
pathic or ischaemic foot, severe infection can still
cause pain, particularly throbbing pain. Pain around
an ulcer also suggests infection or ischaemia.
Neuropathy and ischaemia may co-exist in the
foot, and it is important to understand the presen-
tation of pain in neuropathy and also in isch-
aemia. It should be noted that, in general,
peripheral neuropathy in diabetes is usually NOT
Fig. 9.9 Ants attracted to the neuropathic foot painful and secondly when painful neuropathy
does occur, it is not usually associated with tissue
loss. Thus caution must be exercised in attribut-
ing pain to neuropathy when it is more likely due
to infection or ischaemia.
Pain may be unilateral or bilateral and of neu-
ropathic or ischaemic origin. Pain may also be
caused by focal pathology such as infection. The
following sections will discuss first the assess-
ment of bilateral and then unilateral pain of neu-
ropathic origin and secondly bilateral and then
unilateral pain of ischaemic origin.
ilateral Neuropathic Pain

B
Fig. 9.10 Excoriations due to ant bites over the dorsum Bilateral symmetrical neuropathic pain is usually
of the left lateral forefoot due to painful neuropathy. It is important to ask
three questions to aid in the diagnosis of painful
neuropathy.
application of native medicines or chemicals,
self-surgery, massage, treatment from unauthor- What is the nature of the pain?
ised personnel or damage caused by footwear When is the pain worse?
[13]. Where is the pain?
What Is the Nature of the Pain? Where Is the Pain?

Pain may be spontaneous or be brought on by a The distribution of pain is usually in both feet
specific stimulus. Spontaneous pain may com- extending into the lower legs in a stocking distri-
prise one or several of the following: bution. Often there is poor localisation and it is
usually diffuse. Pain does not generally extend
• Sharp, shooting, stabbing or burning pain above the knees but one limb may be slightly
• Paraesthesiae (‘pins and needles’) worse than the other. In severe cases, pain does
• Unpleasant tingling (dysaesthesiae) extend above the knees and it may also be felt in
• Deep muscular aching pain the hands and arms and also on the skull.
• Restless legs However, unilateral lower pain with no pain at all
• Cramps on the contralateral limb does not suggest a clas-
• Sensation of cold sical painful neuropathy. It may be due to a focal
• Sensation of tightness (as if a constricting ischaemic neuropathy or compression of a nerve
band is around the foot) plexus or root by a prolapsed intervertebral disc.
• Heaviness
General Symptoms
Patients may complain of walking on marbles. Relentless, burning pain and contact discomfort
The pain may be continuous, varying in intensity make patients extremely miserable. Patients in
or intermittent and episodic and of short duration, severe pain cannot sleep and can become pro-
like electric shocks. Itching may also be a symp- foundly disturbed, confused and depressed. Pain
tom of painful neuropathy. Pain can vary accord- interferes with the activities of daily living and
ing to the evolution of the disease. The pain often the quality of life is reduced. There is a negative
has an acute early phase which lasts a few months impact on sleep, ability to work, mood, recre-
followed by a gradual reduction in pain over the ational activity, mobility and enjoyment of life
subsequent year. [14, 15].
Patients with painful neuropathy may charac- Patients with painful neuropathy may also
teristically have pain which may be described in present with the following syndromes.
medical terms as allodynia, hyperalgesia or
hyperpathia. Diabetic Neuropathic Cachexia
Allodynia is defined as the patient feeling The syndrome of diabetic neuropathic cachexia
painful sensations from stimuli which are not is characterised by profound weight loss and
usually painful to normal individuals such as pain severe pain [16]. The weight loss can be up to
evoked by contact with bedclothes. 60% of the normal weight and can be so great
Hyperalgesia refers to increased sensation to that patients often appear cachectic. The weight
stimuli which are normally painful. loss is not related to diabetic control. The emo-
Hyperpathia is a greatly exaggerated painful tional disturbances are severe and depression,
sensation to a stimulus after cessation of the stim- anorexia and often erectile dysfunction may be
ulus especially a repetitive stimulus. present. Depression is an inherent part of the syn-
drome rather than related to the pain.
When Is the Pain Worse? The sensory loss is mild or absent. There is
Painful neuropathy is worse in bed at night, and usually no motor weakness but ankle jerks may
when the feet and legs are in contact with clothes, be absent. The initial incorrect diagnosis may be
including bedclothes. Pain intensity is altered by metastatic carcinoma or carcinomatous neuropa-
emotion and fatigue. The pain may vary in rela- thy. Usually there is spontaneous resolution with
tion to the temporal evolution of the condition, weight completely restored and the painful neu-
being especially painful in the initial stages. ropathic symptoms resolved.
Acute Painful Neuropathy of Rapid pression point. Sensory symptoms are sharp
Glycaemic Control burning pain associated with paraesthesiae.
This is often known as insulin neuritis but the Allodynia may also be present. Complex regional
condition is associated with rapid improvement pain syndromes which often present with unilat-
of glycaemic control whether it results from insu- eral neuropathic pain must be considered in the
lin therapy, oral hypoglycaemic agents or diet differential diagnosis.
alone. Symptoms are burning pain and
paresthesiae worsening at night. Sensory loss
ocal Nerves Affected in the Leg
F
may be minimal or absent. There is usually reso- • Lateral cutaneous nerve of thigh
lution of symptoms within about 1 year. • Common peroneal nerve
• Posterior tibial nerve
Acute Reversible Neuropathy • Femoral nerve
This has an acute onset and is characterised by • Saphenous nerve
distal pain and weakness associated with very
high blood glucose levels and often ketosis. Lateral Cutaneous Femoral Nerve of Thigh-
There is a sensory neuropathy but usually com- Meralgia Paraesthetica
plete recovery ensues after improvement in dia- This is entrapment of the lateral cutaneous femo-
betic control. ral nerve of thigh as it exits the pelvis. It is com-
pressed or stretched as it passes through the
Painful Neuropathy of Impaired Glucose lateral end of the inguinal ligament next to the
Tolerance anterior superior iliac spine. It causes burning,
Prediabetic states are associated with neuropathy tingling, itching and numbness over the antero-
that typically is predominantly sensory and pain- lateral surface of thigh which demonstrates con-
ful [17]. It is often known as ‘impaired glucose tact sensitivity. Similar symptoms may be caused
tolerance neuropathy’ and may represent the by a prolapsed disc which is compressing the
earliest stage of diabetic neuropathy. Patients Lumbar 3 nerve root. The causes are surgical
with impaired glucose tolerance usually have interventions to that area, as well as a tight belt or
small fibre neuropathy, whereas those with diabe- corset and weight gain underneath inguinal
tes more often have neuropathy involving both ligament.
small and large fibres.
Posterior Tibial Nerve: Tarsal Tunnel
nilateral Neuropathic Pain
U Syndrome
Neurological symptoms and signs limited to one This is an entrapment neuropathy which develops
leg are indicative of a focal neuropathy. Focal from compression of the posterior tibial nerve or
neuropathy may be due to ischaemic damage to its associated branches as the nerve passes below
the nerve from diabetes itself or due to a compres- the flexor retinaculum at ankle level or more dis-
sion of the nerve or nerve root by external factors tally [18]. There is tingling and burning pain in
in an entrapment neuropathy. Focal neuropathies the sole and toes which is worse at night. There is
due to ischaemic damage with resulting subse- also cramping of the intrinsic muscles of the
quent infarction have an acute onset but they heal plantar region. Weakness of the small muscles of
spontaneously in 6–8 weeks. They must be distin- the foot includes abductor hallucis but not exten-
guished from entrapment syndromes which start sor digitorum brevis which is supplied by deep
slow and progress and persist without treatment. peroneal nerve. Dysaesthesia, paraesthesia and
Pain is a prominent symptom of focal neurop- contact sensitivity are present in the distribution
athies. It is present at rest and worse at night. Pain of medial and plantar nerves on the sole of the
can be felt both proximal and distal to the com- foot.
Common Peroneal Nerve Saphenous Nerve

The nerve is compressed around the head of the The saphenous nerve is compressed as it pierces
fibula. External compression can be caused by the roof of the subsartorial fascia in the lower
squatting, leg crossing or a tight plaster cast in third of the thigh. The nerve is commonly dam-
circumstances of diminished consciousness. The aged during the stripping of the long saphenous
common peroneal nerve splits into two branches: vein. There is pain in thigh and lower leg on
the superficial branch supplies the skin of lateral walking.
side of lower leg and the lateral calf muscles that
evert the foot and the deep peroneal branch, Lumbar Spinal Stenosis
which supplies the toe and ankle dorsiflexors This is a common cause of leg pain and results
and an area of skin on dorsum between first and from the narrowing of the spinal canal or neural
second toes. The nerve can further be com- foramina leading to root ischaemia and neuro-
pressed as it splits and passes through the origin genic claudication. Stenosis of the spinal canal is
of the peroneus longus muscle 1 inch inferior to most often caused by loss of disc space, osteo-
the fibular neck. phytes and a hypertrophic ligamentum flavum.
Injury to the common peroneal nerve leads to Lumbar stenosis can be caused by other patholo-
a painless foot drop with weakness of tibialis gies that decrease the space of the spinal canal,
anterior and the evertors and also numbness over including tumours and infection.
the dorsal aspect of the ankle and foot There may There is gradual onset of unilateral or bilat-
be pain over the lateral aspect of the shin and the eral leg pain (with or without back pain), numb-
dorsum of the foot. The sensory impairment over ness, and weakness which develop after the
the lateral leg and dorsum of the foot must be dis- patient walks a certain distance. Painful sensa-
tinguished from an Lumbar 5 nerve root lesion. tions shoot down the legs with continued walk-
ing and diminish with resting. Standing and
Femoral Nerve bending backwards can exacerbate the symp-
The femoral nerve arises from Lumbar 2,3,4 roots toms because bending forward increases the
which pass through the psoas muscle and beneath space in the spinal canal and vertebral foramen,
the inguinal ligament to supply the anterior thigh while bending backward decreases the space.
muscles. It may be compressed by a psoas abscess, The pain is usually decreased by sitting, lean-
retroperitoneal haematoma, particularly in ing forward, putting the foot on a raised cush-
patients on anticoagulants, or by a pelvic tumour. ion or stool. Walking uphill may be easier than
A femoral nerve lesion produces weakness of downhill. The patient may have leg fatigue, and
knee extensors of the quadriceps group, with mus- numbness or paraesthesiae of the leg.
cle wasting, a depressed or absent knee jerk and If not treated, there can be increasing weak-
sensory loss in anterior thigh and medial part of ness and dysfunction of the bladder and bowel
knee. Diabetic amyotrophy and upper lumbar leading to a cauda equina syndrome. This results
radiculopathy (Lumbar 2,3,4) can present in a in lower back pain, severe bilateral pain radiating
similar way to entrapment of the femoral nerve. down the legs, weakness of legs and feet, reten-
Diabetic amyotrophy is a focal neuropathy tion of urine, bowel dysfunction and impotence
of the lumbosacral radiculoplexus and presents with sensory deficits and reduced or absent
with severe pain in the proximal lower limb, reflexes in the legs. The cauda equina syndrome
usually involving the thigh, sensory loss, sig- is a surgical emergency.
nificant weight loss and weakness of thigh
muscles. The knee reflex is also absent. There Complex Regional Pain Syndrome
is usually a spontaneous resolution of diabetic Another cause of unilateral neuropathic pain is
amyotrophy by 1 year with return of the knee complex regional pain syndrome (CRPS), pre-
reflex. It is important to differentiate between viously called Reflex Sympathetic Dystrophy
diabetic amyotrophy and root compression. (RSD). It is a chronic, painful and progressive
neurological condition that affects the skin, Venous hypertension of the legs
muscles, joints and bones [19, 20]. The syn- Polymyalgia rheumatica
drome usually develops in an injured limb but Polymyositis
often there is only a minor injury or no precipi- Restless legs syndrome
tating event at all. Typically, there is burning
pain, excessive sweating, swelling and sensitiv- nilateral Ischaemic Pain
U
ity to touch. The presentation of swollen hot Pain in the lower limb due to ischaemia is
foot may be mistaken for an acute Charcot neu- known as rest pain and by this stage the isch-
roarthropathy. Although CRPS does demon- aemia is severe and has been previously termed
strate sensory loss, it is characterised by severe critical ischaemia. Rest pain is usually a con-
neuropathic pain compared with the Charcot stant pain, occurring in the toes and the fore-
foot which is relatively painless [19]. Both con- foot, often worse at night. It is exacerbated after
ditions demonstrate areas of bone marrow lying down because of the loss of gravity-
oedema on MRI although in CRPS, it is diffuse, assisted flow and is relieved by sitting or stand-
patchy and fluctuating. Pain may begin in one ing. Rest pain is eased by hanging the leg down
area or limb and then spread to other limbs. In outside the bed.
some cases, symptoms of RSD/CRPS diminish Although atherosclerosis is usually pres-
for a period and then reappear with a new ent in both limbs, marked deterioration of the
injury. occlusive disease leading to critical ischaemia
often occurs in one leg at any one time leading
Bilateral ischaemic pain. to the classical presentation of rest pain pre-
Ischaemic pain rarely develops in both legs dominantly in one leg. This is commonly due to
simultaneously but can occur in the following a thrombosis on top of existing atherosclerosis.
circumstances. It can lead to the pink painful foot or in cases
of sudden complete occlusion a pale mottled
1. Saddle embolus in the lower aorta. foot. Claudication of the calf is another sign
Patients with acute embolic occlusion of of ischaemia but may be absent in people with
the aortic bifurcation appear marble white or diabetes because of the very distal site of ath-
mottled to the waist. They may also present erosclerosis in the tibial vessels of the diabetic
with paraplegia due to ischaemia of the cauda leg as well as the presence of neuropathy. Thus
equina, which can be irreversible. Immediate diabetic patients do not usually go through the
bilateral embolectomy restores lower limb classical natural history in peripheral vascular
perfusion. disease of claudication, then rest pain and then
2. Acute aortic dissection extending into the tissue loss.
iliac arteries can lead to acute lower extremity
ischaemia which can accompany the predomi- ifferentiation of Neuropathic Pain
D
nant symptom of chest pain. from Ischaemic Pain
3. Rupture of an abdominal aortic aneurysm Most patients with painful neuropathy have pal-
may also lead to acute lower limb ischaemic pable dorsalis pedis and posterior tibial pulses,
pain. Nevertheless, severe pain in the back or thus ruling out significant ischaemia. However,
abdomen is the dominant symptom. when both these pulses are absent, it is necessary
4. Leriche syndrome is claudication of the glu- to assess how much pain is due to neuropathy and
teal muscles due to severe disease at the aortic how much may be due to ischaemia. One helpful
bifurcation. clinical point is that ischaemic rest pain initially
presents unilaterally although background
ther Causes of Bilateral Leg Pain
O peripheral vascular disease may be present in
Osteoarthritis of hips, knees and feet both legs, whereas painful neuropathy is usually
Rheumatoid arthritis bilateral.
The rest of the history is devoted to gathering Past Medical History

important relevant information about the patient
to aid diagnosis and management. • Serious illness
• Accidents
• Injuries
Past Foot History • Hospital admissions
• Operations
• Previous ulcers and treatment
• Previous surgery to the lower limb
• Amputations Major/Minor Drug History
–– Peripheral angioplasties
–– Peripheral arterial bypass –– Present medication
–– Known allergies
Diabetes History
Family History
• Type of diabetes
• Duration of diabetes –– Diabetes
• Treatment of diabetes: –– Other serious illness
–– Insulin –– Cause of death of near relatives
–– Oral hypoglycaemics
–– Diet
Psychosocial History
Complications of diabetes
Retinopathy • Occupation
• Background • Number of cigarettes smoked per day
• Proliferative –– Number of cigarettes previously smoked
• Previous laser therapy per day and for number of years
• Vitrectomy • Number of units of alcohol per day
• Cataract • Recreational drugs
Nephropathy • Psychiatric illness
• Proteinuria • Home circumstances:
• Renal replacement therapy: • Type of accommodation
–– Continuous ambulatory peritoneal dialysis • Lives alone
(CAPD)
–– Haemodialysis
–– Renal transplant Examination
Cardiovascular
• Angina This comprises three parts:
• Heart failure
• Myocardial infarction • Simple inspection
• Coronary artery angioplasty • Palpation
• Coronary artery bypass • Special assessments that can be carried out at
Cerebrovascular the bedside/chairside
• Transient ischaemic attack
• Stroke
In practice, these are often integrated into a

comprehensive examination with the aim to look
for and assess particular diagnostic features that
will enable the practitioner to accurately classify
and stage the feet [20, 21]). Examination of the feet
should be carried out in a systematic fashion: first
the right and then the left, including dorsum, sole,
medial border, lateral border, back of the heel, mal-
leoli and interdigital areas. It is useful to compare
the feet particularly when assessing colour and
temperature. The examination should particularly
focus on the following aspects of the foot.
Skin and Skin Breakdown
kin
S
In the initial inspection, the general features of
the skin including colour and temperature should
be examined. The skin under the metatarsal heads
should be specifically assessed, looking for any
redness as sign of inflammation, particularly in
the neuropathic foot in which the skin is dry and
fissured. Prominent dilated veins secondary to
autonomic neuropathy may be visible. Signs of
pruritus may indicate dryness (Fig. 9.11). Hair
Fig. 9.11 Scratch marks due to itching secondary to dry-
loss can be a sign of ischaemia or neuropathy. ness of skin complicated by cellulitis
Colour of the Skin of Foot

It is important to observe the colour of the foot
including the toes. Colour changes may be local-
ised or diffuse. Common colour changes are red,
blue, pale (white) or black. In dark skins, the red
colour may present as a tawny (orange-brown)
hue (Fig. 9.12).
Causes of the red foot/toe

• Cellulitis
• Critical ischaemia, especially on dependency
(dependent rubor—may be dusky red
(Fig. 9.13)
• Charcot foot
• Gout
• Burn or scald Fig. 9.12 Cellulitis of right foot, with tawny (orange-
• Chilblain brown) hue on the dorsum of the foot and ulcer on dorsum
• Dermatitis/eczema of right great toe with infection of the extensor hallucis
longus tendon
• Blood blister
• Shoe dye
• Application of Henna Black
• Tumour (melanoma)
Temperature of the Skin Foot

Skin temperature is compared between both feet
with the back of the examining hand. The tem-
perature gradient is checked by gently moving
the back of the hand from the pretibial region of
the leg towards the dorsum of the foot and then to
the toes while keeping in contact with the
patient’s skin. An asymmetric gradient may indi-
cate either unilateral ischaemia on the colder side
or unilateral inflammatory response such as
Charcot’s osteoarthropathy or infection on the
warmer side.
It is helpful to follow up the clinical assess-
ment of skin temperature by measuring skin tem-
perature using a digital skin thermometer. An
infrared thermometer is ideal and skin tempera-
tures can be compared between similar areas on
each foot. This is particularly helpful in the man-
Fig. 9.13 Red discolouration of the dependent critically
ischaemic foot agement of the Charcot foot. Warm areas or hot
spots indicate inflammation which may be due to
infection, fracture, Charcot’s osteoarthropathy or
Causes of the blue foot/toe soft tissue trauma. Unilateral temperature increase
• Peripheral arterial disease in the foot especially in the absence of ulceration
• Severe infection is best presumed to be Charcot’s osteoarthropathy
• Cardiac failure until proved otherwise. In the neuroischaemic
• Chronic pulmonary disease foot, coexisting autonomic neuropathy may keep
• Venous insufficiency (often with brownish the foot relatively warm, although an ice-cold foot
pigmentation due to haemosiderosis) is indicative of acute ischaemia.
Causes of the pale foot/toe Causes of the hot foot [22]

• Critical ischaemia, especially on elevation. • Cellulitis
• Acute ischaemia, the foot is pale, often with –– Charcot foot
purplish mottling. –– Gout
• Venous insufficiency
Causes of the black foot/toe • Deep vein thrombosis
• Wet necrosis
• Dry necrosis Causes of the cold foot
• Severe chronic ischaemia • Chronic ischaemia
• Acute ischaemia • Acute ischaemia
• Emboli • Low output cardiac failure
• Bruise • Deep vein thrombosis
Skin Breakdown
An active search should be made for breaks in the
skin or wounds over the entire surface of the foot
and ankle, not forgetting the areas between the
toes and at the back of the heel. Toes should be
gently held apart for inspection (Fig. 9.14). This
may reveal web space fungus infection.
• Abrasions, bullae and fissures also represent

breakdown of the skin. Bullae are often the
first sign of skin breakdown in the ischaemic
foot. They are also a feature of fungal skin Fig. 9.14 Toes gently stretched apart to reveal interdigi-
infections (tinea pedis), as is web space mac- tal ulcer
eration. Bullae at pressure points may indicate
an impending ulcer.
• Dry skin around the heel will form deep fis-
sures (Fig. 9.15) unless an emollient is applied
regularly.
• In assessing any wound, it is important to note
the size, edge, shape, nature of the base of
ulcer, any slough, discharge, exposure of
bones and tendons and the characteristics of
the surrounding tissue.
• As well as skin lesions specific to the diabetic
foot, it is important to recognise inflammatory
skin disease such as psoriasis, eczema and
dermatitis, which may complicate the diabetic
foot and leg.
Fig. 9.15 Dry fissured heel in neuroischaemic foot
Infection
beneath the surrounding skin and tracking of fluid
When skin breakdown develops, it may act as a underneath callus. Deep infection may spread from
portal of entry for infection which develops in 50% the site of skin breakdown along tendons and their
of ulcers. A close examination for signs of infection sheaths (Fig. 9.12). This may not be obvious.
should be made. These include purulent discharge In the presence of infection, it is important to
from the lesion and cellulitis as indicated by ery- look for signs suggestive of necrotising fasciitis
thema, swelling and warmth of the toe or foot including purpuric rash and blistering. Palpation
although in the presence of neuropathy, these clas- may reveal crepitus as a fine crackling sensation
sical signs of infection may be diminished. Signs of indicating gas in the tissues.
infection may also be limited in the presence of Osteomyelitis may be suspected by an exposed
ischaemia as the inflammatory response to infec- or visible bone at the base of the ulcer or the appear-
tion needs increased blood supply. ance of the ‘sausage toe’ as a red fusiform swelling
Thus, it is important to look for subtle signs of (Fig. 9.16). It is often associated with an ulcer on
infection including increased friability of granula- the dorsum of the toe which probes to bone.
tion tissue, wound odour, wound breakdown and The probe-to-bone involves inserting a sterile
delayed healing. There may be tracking of the ulcer metal probe into the suspected ulceration. A
A small handheld Doppler can be used to con-

firm the presence of pulses and to assess the vas-
cular supply and with a sphygmomanometer, it
can be utilised to measure the brachial systolic
pressure and ankle systolic pressure. The ankle
brachial pressure index (ABI), which is the ratio
of ankle systolic pressure to brachial systolic
pressure, can then be calculated. In normal sub-
jects, the ABI is usually >0.9 but in the presence
of ischaemia is <0.9. Thus, absence of pulses and
an ABI of <0.9 confirms ischaemia. Conversely,
the presence of pulses and an ABI of >1 essen-
tially rules out ischaemia in the leg but not in the
foot in which arterial disease may be located in
diabetes. Furthermore, the calf arteries in diabetes
typically show diffuse medial calcification which
renders the vessel incompressible and can limit
the utility of assessing the ABI. If arteries are cal-
cified, the ABI may be artifactually raised but the
test is still important as long as one understands
its interpretation. Thus, if the ABI is 0.5, then it is
low, and indicates severe ischaemia, whether the
foot arteries are calcified or not. Indeed, if it is
calcified, the true ABI may be lower. Furthermore,
Fig. 9.16 Sausage-shaped discoloured toe suggesting
absence of foot pulses would be an indication to
osteomyelitis
investigate popliteal and femoral arteries.
Further information about the circulation can
‘click’ (solid or gritty end point) indicates a posi- be obtained from assessing the Doppler wave-
tive finding. Osteomyelitis is unlikely after a form which normally is pulsatile with a positive
negative test in the outpatient or low-risk loca- forward flow in systole followed by a short
tion. However, it is likely after a positive test in a reverse flow and a further forward flow in dias-
high-risk or inpatient situation [23, 24]. tole. In the presence of arterial narrowing, the
waveform shows a reduced forward flow and is
described as damped and monophasic.
Ischaemia It is now accepted that ischaemia may occur
very peripherally in the foot arteries and may not
On inspection the foot has thin atrophic shiny be detected by ABI. Thus it is advisable to mea-
skin without hair. There is atrophy of the subcu- sure either the transcutaneous oxygen pressure
taneous tissue. Ulcers may be present on the mar- on the dorsum of the foot or the toe pressures.
gin of the foot and the toes and there may be Recent studies suggest that toe pressure is more
patches of necrosis. sensitive than ankle pressure in the diagnosis of
The most important manoeuvre to detect isch- limb threatening ischaemia and is more predic-
aemia is the palpation of foot pulses. tive of amputation risk [25, 26].
As adjunctive tests, it is possible to perform
• The dorsalis pedis pulse is felt lateral to the the capillary filling time (also known as the
extensor hallucis longus tendon on the dorsum blanch test). In the capillary refill test, pressure is
of the foot. applied to the pulp of the toe until the digit loses
• The posterior tibial pulse is felt below and colour. On release of pressure, the refill time
behind the medial malleolus. should be less than 3 secs if the patient has good
cardiac output and digital perfusion. A capillary suddenly decreases. Acute ischaemia is a clinical
refill time of more than 5 secs is abnormal and emergency with severe morbidity and mortality.
suggests poor peripheral perfusion. If ischaemia is not treated within 6 hours, then
From the history, examination and investiga- mottling becomes fixed, leading to blistering and
tions it is possible to assess the severity of the then digital necrosis.
ischaemia. However, the ischaemic foot covers a
wide spectrum ranging from the neuroischaemic
foot with mild or moderate ischaemia to the criti- Necrosis
cally ischaemic foot and the acute ischaemic
foot. It is important to recognise these two par- Areas of necrosis or gangrene can be identified
ticular presentations, those of critical ischaemia by the presence of black or brown devitalized tis-
and acute ischaemia. sue. Such tissue may be wet (usually related to
infection) or dry. Wet necrosis is usually second-
ritically Ischaemic Foot
C ary to a septic vasculitis accompanying severe
The colour of the skin is bright pink or a dusky soft tissue infection and ulceration and is the
red. The foot is cool and the pulses absent. In the commonest cause of necrosis in the diabetic foot.
foot with such severe ischaemia, Buerger’s test is In the neuropathic foot, necrosis is usually wet
positive. This is performed by elevating the leg and is caused by infection complicating a digital,
with the patient supine and within 30 secs it metatarsal or heel ulcer, and leading to a septic
becomes pale. The foot is then allowed to hang vasculitis of the digital and small arteries of the
over the side of the couch and the dependent limb foot (Fig. 9.17). Wet necrosis is also prominent in
becomes red due to the chronic dilatation of the the infected neuroischaemic foot and has a simi-
microcirculation distal to the arterial occlusion lar pathology of septic vasculitis. However, in the
(Fig. 9.12) A positive Buerger’s sign is indicative neuroischaemic foot, reduced arterial perfusion
of severe ischaemia which needs urgent vascular to the foot resulting from occlusive disease of the
investigations. Another sign of critical ischaemia leg and foot arteries is also an important predis-
is the leg being held in the knee flexed position. posing factor.
Dry necrosis is hard, blackened, mummified
Acute Ischaemia tissue and there is usually a clean demarcation
Acute ischaemia results from a sudden occlusion line between necrosis and viable tissue. It may be
of a major artery, usually popliteal or superficial
femoral. Classically there are five features of
acute limb ischaemia (5 P’s):
1. Pain
2. Pulselessness
3. Pallor
4. Paresthesiaes
5. Paralysis
Signs are:
• Pallor of the foot

• White or blueish nail beds
• Blueish-grey discolouration with mottling or
‘bruised’ appearance (Fig. 9.5)
If a hand is run down the leg, a ‘cut-off’ point Fig. 9.17 Wet necrosis of right third toe secondary to a
will be found where the temperature of the skin septic vasculitis of the digital arteries
difficult to diagnose in the patient with a dark Hammer Toe

skin. Dry necrosis can be seen usually in three A hammer toe is a flexible or rigid deformity in
situations, in the ischaemic foot namely in criti- which there is buckling of the toe with extension
cal ischaemia (Fig. 9.4), in acute ischaemia and at the metatarsal-phalangeal joint, flexion of the
in emboli to the toes. proximal interphalangeal joint and extension of
the distal interphalangeal joint. In people with
diabetic neuropathy, hammer toes are commonly
eformity (Including Limited Joint
D caused by weakness of the small intrinsic mus-
Mobility) cles (interossei and lumbricals) of the foot
(Fig. 9.18). This deformity results in increased
Deformity often leads to bony prominences, pressure over the metatarsal head, over the prom-
which are associated with high mechanical pres- inent interphalangeal joint and at the tip of the
sures on the overlying skin. This results in ulcer- toe. There is a risk of the toe rubbing against the
ation, particularly in the absence of protective uppers of the shoe.
pain sensation and when the shoes are unsuitable.
When assessing deformity it is important to Claw Toes
assess whether it is fixed or mobile. Claw toes are similar to hammer toes, but with
more buckling. There is hyperextension at the
Common deformities include: metatarsal-phalangeal joint and flexion defor-
• Pes cavus
• Trigger toe
• Hammer toes
• Claw toes
• Hallux valgus
• Fibrofatty padding depletion (FFPD)
• Charcot foot
• Deformities related to previous trauma and
surgery
Pes Cavus
Normally the dorsum of the foot is domed due to
the medial longitudinal arch, which extends
between the first metatarsal head and the calca-
neus. When it is abnormally high, the deformity
is called pes cavus and results in a reduction of
the area of the foot in contact with the ground
during walking and an abnormal distribution of
pressure. This leads to excessive callus formation
under the metatarsal heads. This deformity is a
sign of a motor neuropathy but may be idiopathic.
It is often associated with clawing of the lesser
toes or a trigger first toe.
Trigger Toe
A trigger toe is a flexion or contraction at the
interphalangeal joint of the hallux leading to Fig. 9.18 Typical neuropathic foot demonstrating ham-
increased vertical pressure on the first metatarsal mer toes, wasting of lumbricals, xerosis and crowding of
head. toes
mity at the proximal and distal interphalangeal ropathy, the fibrofatty padding may be dis-
joints. This results in callus formation and ulcer- placed forward or destroyed by infection or
ation of the apex and dorsal aspect of the inter- ulceration reducing the foot’s capacity to absorb
phalangeal joints. Although claw toes may be pressure.
associated with neuropathy, they are often unre-
lated, especially when the clawing is unilateral Charcot Foot
and associated with trauma or surgery of the fore- Bone and joint damage in the tarso-metatarsal
foot. Claw toes may rarely result from acute rup- joints and mid-tarsal joints leads to two classical
ture of the plantar fascia. deformities: the rocker bottom deformity, in
which there is displacement and subluxation/
Hallux Valgus dislocation of the tarsus downwards, and the
Hallux valgus is a deformity of the first medial convexity (Fig. 9.20) which results from
metatarsal-phalangeal joint with lateral deviation displacement of the talonavicular joint or from
of the hallux and a medial prominence on the tarsometatarsal dislocation. Both are often asso-
margin of the foot. This site is particularly vul- ciated with a bony prominence which is very
nerable in the neuroischaemic foot and frequently prone to ulceration. When the ankle and subtalar
breaks down under pressure from a tight shoe. joints are involved, instability of the hindfoot
can result.
ibrofatty Padding Depletion (FFPD)
F
There is reduction of the thickness of the fibro- eformities Related to Previous
D
fatty padding over the metatarsal heads Trauma and Surgery
(Fig. 9.19). Normal feet contain cushions of Deformities of the hip and fractures of the tibia or
fibrofatty padding over the metatarsal heads fibula lead to shortening of the leg and abnormal
which absorb plantar pressures. In diabetic neu- gait, which predisposes to foot ulceration. Ray
Fig. 9.20 Medial convexity deformity of Charcot foot

Fig. 9.19 Distal migration of plantar metatarsal fat pad,
callus and prominent metatarsal heads
amputations remove the toe together with part of soft. Callus can also occur in the mild or moder-
the metatarsal. They are usually very successful ately ischaemic foot, when it is glazed in nature.
but disturb the biomechanics of the foot leading In contrast to callus, corns are discrete areas, usu-
to high pressure under the adjacent metatarsal ally not more than 1 cm in diameter and can
heads. After amputation of a toe, deformities are extend to a depth of several millimetres. Neither
often seen in adjoining toes. should be allowed to become excessive as this
can be a forerunner of ulceration (usually in the
imited Joint Mobility (Including
L presence of neuropathy). Haemorrhage within
Hallux Rigidus) callus is an important precursor of ulceration
Limited joint mobility can affect the feet as well (Figs. 9.21 and 9.22).
as the hands. The range of motion is diminished
at the subtalar and first metatarsophalangeal
joints. Limited mobility at the subtalar joint leads
to reduced dorsiflexion of the ankle and also
plantar flexion of the foot resulting in increased
plantar pressures on the foot.
Limited joint mobility of the first metatarsal-
phalangeal joint, so-called hallux rigidus, results
in loss of dorsiflexion of this joint and excessive
forces on the plantar surface of the first toe. This
leads to overloading of the plantar aspect of the
forefoot in the toe off phase of the gait cycle,
causing callus formation and ulceration. It is
often seen in barefooted and sandal-wearing
populations. Furthermore an unbending toe is
exposed to repeated traumas.
Fig. 9.21 Callus with underlying haemorrhage on medial

Callus and Corns side of left first toe
Callus is a thickened area of epidermis which

develops at sites of pressure, shear and friction. It
should not be allowed to become excessive as
callus is a common precursor of ulceration in the
presence of neuropathy. Callus is caused by high
pressures and is suggestive of unsuitable foot-
wear or unprotected walking and its most com-
mon site is under the metatarsal-phalangeal
joints, commonly the first metatarsal-phalangeal
joint. Interdigital callus is due to crowding of the
toes and friction and injury due to adjoining toe-
nail. Callus is a classical feature of the neuro-
pathic foot, forming diffuse plaques. It can be
proliferative and hard with a peculiar smell which
attracts insects [13]. When proliferation is exces-
sive it may look like a malignant growth. If the Fig. 9.22 Callus under second metatarsal head with
neuropathic foot gets wet or infected, it becomes underlying haemorrhage
Oedema Nails
Oedema of the tissues of the foot is a major factor It is important to inspect the nails closely as
predisposing to ulceration, and often exacerbates the nail bed and periungual tissues may become
a tight fit inside poorly fitting shoes. It also the site of ulceration. The following should be
impedes healing of established ulcers. Oedema assessed:
already suspected on inspection can be confirmed
by gentle digital pressure applied for a few sec- • Structure of the nails
onds. Oedema may be unilateral or bilateral. • Colour of the nail bed
• Abnormalities under the nail
Unilateral Oedema • Signs of nail infections
This is usually associated with local pathology in
the foot or leg. Structure of the Nails
Causes are: Thickened nails is a common feature in the gen-
eral population. If the shoe presses on the nail, it
• Infection, when it is usually associated with may cause bleeding under the nail. Eventually
erythema and skin breakdown this may lead to ulceration.
• Charcot foot (a unilateral hot, red, swollen Nails in the neuropathic foot may be hard and
foot is often the first sign and the oedema can brittle. The nails in an ischaemic foot may also be
extend to the knee) brittle but ivory in appearance [13]. Alternatively,
• Gout, which may also present as a hot, red, nails may become atrophic in patients with neu-
swollen foot ropathy and ischaemia.
• Trauma, sprain or fracture An ingrowing toenail (onychocryptosis) arises
• Deep vein thrombosis when the nail plate is excessively wide and thin,
• Venous insufficiency or develops a convex deformity, putting pressure
• Lymphoedema caused by lymphatic obstruc- on the tissues at the nail edge. Callus builds up in
tion secondary to malignancy response to pressure and inflammation.
• Venous obstruction by a pelvic mass, malig- Eventually, usually after incorrect nail cutting or
nancy or ovarian cyst trauma, the nail penetrates the flesh.
• Localised collection of blood or pus which
may present as a fluctuant swelling olour of the Nail Bed
C
Red, brown or black discolouration of the nails
Bilateral Oedema may indicate subungual haematoma. The cause
This is usually secondary to: may be acute trauma or chronic trauma such as
pressure from ill-fitting shoes.
• Cardiac failure In acute ischaemia, the nail beds are very pale.
• Hypoalbuminaemia
• Renal failure bnormalities Under the Nail
A
• Venous insufficiency (sometimes unilateral) Discharge of fluid from beneath or around the
• Inferior vena caval obstruction nail, and any maceration or softness of the nail
• Lymphoedema plate, may indicate the presence of a subungual
• Neuropathic oedema ulcer or infection.
Neuropathic oedema secondary to diabetic Nail Infections

neuropathy is rare and is related to increased arte- Fungal infection of the nail usually invades the
rial blood flow and arteriovenous shunting. It nail plate dorsally causing onycholysis. The hal-
often responds to the drug, ephedrine. lux is the most common nail affected. Infection
starts in one corner and over a period of years it will affect the patient’s gait. If a painful mono-
spreads to involve the entire toenail and may neuropathy is suspected from the history, a more
affect other nails. detailed neurological examination is indicated to
Paronychia is associated with a nail that has a detect a femoral neuropathy or a diabetic amyot-
convex nail bed with tendency to incurve in the cor- rophy and to rule out compressive lesions of
ners. Recurring pressure in the insensitive foot can nerve roots supplying the lower limb.
cause repetitive microtrauma in the nail groove,
causing the nail to act as a foreign body, creating a Autonomic Neuropathy
foreign body inflammatory response with second- The classical signs of autonomic neuropathy are:
ary inflammation and localised infection.
• Dry skin with fissuring secondary to decreased
sweating (Figs. 9.11 and 9.15). (The sweating
Neuropathy loss normally occurs in a stocking distribu-
tion, which can extend up to the knee.)
Peripheral neuropathy is the most common com- • Distended veins over the dorsum of the foot
plication of diabetes affecting 50% of all diabetic and ankle, secondary to arteriovenous
patients. Although neuropathy may present with shunting.
tingling and a feeling of numbness, it is asymp-
tomatic in the majority of patients and neuropa- Sensory Neuropathy
thy will only be detected by clinical examination. Sensory neuropathy can be simply detected by:
An important indication of neuropathy will be a
patient who has no pain even when significant • Clinical examination
foot lesions are present. Painless ulceration is • Monofilaments examination
definite evidence of a peripheral neuropathy. In • Neurothesiometry
practice, any patient who walks on a foot with
ulceration or heavy plantar callus without dis- Clinical Examination
comfort has significant neuropathy. A simple clinical examination detecting sensa-
Peripheral neuropathy can involve sensory, tion to light touch using a cotton wisp and vibra-
motor and autonomic nerves. Simple inspection tion using a 128-Hz tuning fork may suffice,
will usually reveal signs of motor and autonomic comparing a proximal site with a distal site to
neuropathy of the feet but sensory neuropathy confirm a symmetrical stocking-like distribution
must be detected by a simple sensory assessment. of the neuropathy. It is preferable to avoid the use
of ‘pin-prick’ to detect sensory loss.
Motor Neuropathy Initially, vibratory sensation should be
The classical sign of a motor neuropathy is a high assessed over the tip of the great toe. An abnor-
medial longitudinal arch, leading to prominent mal response is determined when the patient can
metatarsal heads and pressure points over the no longer feel the vibratory sensation but the
plantar forefoot. In severe cases, pressure points examiner still perceives it. Absence of ankle
also develop over the apices and dorsal interpha- reflex even after reinforcement confirms a
langeal joints of associated claw toes. However, peripheral neuropathy. Small fibre function may
claw toe is a common deformity and may not be evaluated using quantitative sensory tests of
always be related to a motor neuropathy. It may thermal and pain perception [27] or by measur-
be caused by wearing unsuitable shoes or trauma ing the axon reflex-mediated Laser Doppler
or may be congenital. Imager flare response (LDIflare) [28].
Complicated assessment of motor power in The Ipswich Touch Test (IpTT) is an alterna-
the lower limb is not usually necessary, but it is tive neurologic test that requires only the physi-
advisable to assess dorsiflexion of the foot to cian’s index finger. During the IpTT, the physician
detect a foot drop secondary to a common pero- instructs the patient to close his or her eyes while
neal nerve palsy, which is usually unilateral and the physician lightly rests his or her finger on
each of the patient’s first, third, and fifth toes for threshold (VPT) is a measure of large fibre func-
1–2 secs. Patients are instructed to respond with a tion that can be semi-quantified by the use of the
‘yes’ when they feel the physician’s touch. In a neurothesiometer (Fig. 9.23). The stylus of the
head-to-head trial, diagnostic results of the IpTT instrument is placed over the pulp of the hallux.
directly paralleled those of the monofilament in The amplitude of vibration is increased until the
detecting Loss of Protective Sensation (LOPS); patient can detect the vibration. The mean of
IpTT was also equally sensitive and specific [29]. three readings is taken over the hallux. The vibra-
tion threshold increases with age and thus should
Monofilaments Examination be corrected for age. Standards for normal sub-
It is important to detect patients who have suffi- jects, their satisfactory reproducibility and rela-
cient neuropathy to render them susceptible to tionship to age have been described. However, a
foot ulceration. This can be carried out using a VPT >25 V is regarded as abnormal and has been
monofilament which, when applied perpendicu- shown to be highly predictive of subsequent foot
lar to the foot, buckles at a given force of 10g ulceration.
[30]. Ability to feel that level of pressure pro- Determination of an abnormal VPT is impor-
vides protective sensation against foot ulceration. tant for two reasons. First, it identifies patients
It is helpful first to demonstrate the technique on with large fibre dysfunction who are susceptible
the patient’s forearm. to foot ulceration and second, it identifies a pop-
The number of sites used varies according to ulation with increased cardiovascular risk.
different protocols. Sites examined include the A small number of patients have a small-fibre
plantar aspects of the first toe, the first, third and neuropathy with impaired pain and temperature
fifth metatarsal heads, the plantar surface of the perception but with intact touch and vibration.
heel and the dorsum of the foot. The filament They are prone to ulceration and thermal trau-
should not be applied at any site until callus has mas but test normal with filaments, and a clinical
been removed. If the patient cannot feel the fila- assessment of light touch and vibration is nor-
ment at any of the tested areas, then protective pain mal. As yet, there is no simple inexpensive
sensation is lost, indicating susceptibility to foot method of detecting and quantifying small fibre
ulceration [31]. The 10g monofilament may neuropathy. However, a simple temperature
become inaccurate after use on numerous occa- assessment of cold sensation can be made by
sions and should be replaced regularly. There are placing a cold tuning fork on the patient’s foot
differences in the performance of commercially and leg.
available 10g monofilaments. Monofilaments were
tested using a calibrated load cell. Each monofila-
ment was subjected to ten mechanical bucklings.
The monofilaments were mounted vertically and
were compressed in the vertical plane by 10 mm
while the load cell detected the maximal buckling
force. Longevity testing was performed on the
monofilaments by subjecting them to continuous
compression until the buckling force was less than
9g. Longevity and recovery testing suggested that
each monofilament would be reliable on 10 con-
secutive patients before needing a recovery time of
24 hours before further usage [32].
Neurothesiometry
Quantitative sensory testing can be used to evalu-
ate vibration perception threshold as well as ther- Fig. 9.23 Neurothesiometer measuring vibration percep-
mal sensory thresholds. Vibration perception tion threshold
Examination of Painful Neuropathy • Is there wear across whole of tread suggesting

pes cavus?
On examination, there may be few objective neu- • Do the insoles show excessive wear and tear?
rological deficits and the feet and legs may be • Are there exudates/blood stains?
normal, although some patients may show a
stocking distribution of loss of sensation of pain xamination of Patient’s Socks
E
and temperature. Autonomic dysfunction is not • Are the socks large enough?
prominent. Vibratory sensation can be mildly • Are the seams too prominent?
reduced at the toes. Motor strength, tendon • Is there a tight band at the top?
reflexes, and proprioception, however, may be • Are the socks in good repair—no holes or
preserved because they are functions of large lumpy darns?
nerve fibres. There may be an increased sensation • Are the socks made of absorbent material?
to a normal stimulus such as light touch confirm- • Are the socks very thick, taking up too much
ing allodynia. space in the shoe?
• Are the socks nonelastic and impede lym-
phatic and venous drainage causing oedema of
Gait feet?
There may be high stamping gait due to loss of

proprioception [13]. General Examination
Patients with distal symmetrical neuropathy
may walk with a wide gait. • As part of the diabetic foot assessment and
In the presence of foot drop, the foot scrapes indeed the diabetic assessment, all patients
along the floor or there is a high stamping gait. should have a physical examination including
the following systems:
• Cardiovascular
Footwear Assessment • Respiratory
• Abdomen
It is important to examine both shoes and socks. • Eyes:
• Visual acuity
xamination of Patient’s Footwear
E • Fundi (A patient lacking necessary visual acu-
The following enquiries should be made: ity to give himself a daily foot examination is
a patient at risk, and his family or caregiver
• Is the shoe long enough? should help him.)
• Is the toe box broad and deep enough?
• Are the heels too low?
• Does the shoe fasten with a lace or strap (slip- Classification and Staging
ons are unsuitable for everyday wear). of the Diabetic Foot
• If using a velcro strap, is it too tight or loose?
• Is the sole thick enough to provide protection Evaluation and examination of the foot will facil-
from puncture wounds? itate classification and staging. As previously dis-
• Is the shoe lining worn, with rough areas that cussed, the neuropathic foot may be stratified
may prove irritating and warrant into two clinical groups: the foot with neuro-
replacement? pathic ulceration and the Charcot foot, which
• Are there foreign bodies within the shoes? may be secondarily complicated by ulceration
• Is there excessive wear under hallux suggest- and infection. The ischaemic foot may be strati-
ing a hallux rigidus? fied into three clinical groups: the neuroisch-
aemic foot characterised by mild or moderate predominantly infection together with mild or
ischaemia and neuropathy and often complicated moderate ischaemia. In the critically ischaemic
by ulcer, the severely ischaemic foot otherwise foot and the acutely ischaemic foot, severe isch-
known as the critically ischaemic foot and the aemia is the threat, driving the foot towards
acutely ischaemic foot (Fig. 9.6). necrosis.
Stage 5
Staging Necrosis has supervened. In the neuropathic foot,
infection is usually the cause. In the ischaemic
Stage 1 foot, infection is still the most common reason
At this stage, the patient does not have the risk for tissue destruction although ischaemia contrib-
factors of neuropathy, ischaemia, deformity, cal- utes. In some cases, ischaemia alone can lead to
lus and swelling rendering him vulnerable to foot necrosis of a previously intact foot. The foot in
ulcers. The normal foot is characterised by no Stage 5 is at risk of becoming unsalvageable with
symptoms, including no pain, and examination is overwhelming necrosis, or has intractable pain or
normal. gross instability and there is a risk a major
amputation.
Stage 2
The patient has developed one or more of the risk
factors for foot ulceration including neuropathy, Conclusion
ischaemia, deformity, callus and oedema and the
foot may be divided into the neuropathic foot and We have described a practical approach to the
the ischaemic foot. evaluation and examination of the diabetic foot.
Using this approach, the practitioner should be
Stage 3 able to carry out a comprehensive assessment to
The neuropathic and the ischaemic foot have allow an accurate diagnostic classification and
developed tissue damage mainly skin breakdown. staging of the foot. This should enable the correct
This is usually an ulcer, but because some minor treatment to be carried out.
injuries such as blisters, splits of skin or grazes
have a propensity to become ulcers, they are
included in Stage 3. Ulceration is usually on the References
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Frailty and Mobility Degeneration
in Diabetes and Diabetic Foot
10
Ulceration
Bijan Najafi and Gu Eon Kang
Aging, Diabetes, and Frailty of cardiovascular disease and strokes two- to

threefold and further reduces the life expectan-
More than 700 million people were aged 65 years cies and quality of life of the affected individuals
or over worldwide in 2019, according to a report [6]. Studies also demonstrated diabetes acceler-
by the United Nations, and the number of people ates the aging process such as cognitive decline
aged 65 years or over will increase to 1.5 billion and functional decline at a younger age compared
by 2050 [1]. One serious concern regarding the to those without diabetes [7, 8], which raises con-
rapid increase in aging population is growing cerns about the onset of frailty in older adults
challenges in the clinical management of chronic with diabetes.
health conditions such as diabetes in the popula- Frailty is a geriatric syndrome, defined as
tion [2]. For example, in 2017, 123 million peo- increase in vulnerability in older adults to poor
ple aged 65 years or over had diabetes worldwide, resolution of homeostasis after stressful events
and the number will be doubled by 2045 [3]. [9] (Fig. 10.1). Although a gradual decline in
Diabetes is a group of metabolic disorders that cognitive function and physical function is nor-
occurs due to deficits in insulin secretion, insulin mal with aging, frailty significantly speeds up the
action, or both [4]. The World Health Organization decline and starts to fail the homeostatic reserve
estimated 1.5 million people died directly from mechanism [11]. Frailty is also considered a
diabetes in 2019 [5]. Diabetes heightens the risk measure of resilience, and increases adverse
health outcomes such as falls, pressure ulcers,
and disability even after a small insult such as a
minor surgical procedure and a minor infection,
B. Najafi (*) and results in dramatic decrease in health state
Interdisciplinary Consortium on Advanced Motion
Performance (iCAMP), Division of Vascular Surgery [10, 12, 13].
and Endovascular Therapy, Michael E. DeBakey In this chapter, we will review current knowl-
Department of Surgery, Baylor College of Medicine, edge of the pathway to develop frailty in diabe-
Houston, TX, USA tes. We will also summarize strategies on how to
screen frailty and its impact on adverse outcomes
G. E. Kang in people with diabetes and will discuss potential
Neuromuscular and Musculoskeletal Biomechanics
Laboratory, Department of Bioengineering, Erik treatments to improve health outcomes among
Jonsson School of Engineering and Computer frail older adults.
Science, University of Texas at Dallas,
Richardson, TX, USA

134 B. Najafi and G. E. Kang
Fig. 10.1 Frailty is a

measure of resilient or
measures of inability to
cope with acute stressors
like surgery or an acute
illness such as flu or a
fall. (This figure is built
based on the Figure
from [10])
Pathways of Frailty in Diabetes Arteriosclerosis may be another pathway to

frailty in diabetic individuals. Diabetes acceler-
The two “storms” of aging and diabetes are ates arteriosclerosis [18]. For example, studies
associated with a greater risk of developing showed peripheral arteriosclerosis, peripheral
frailty [14]. In people with diabetes, the preva- chronic ischemia with impaired oxygen supply
lence of frailty significantly increases by nearly caused by arteriosclerosis can cause muscle atro-
50% (the prevalence of frailty of 5–10% in non- phy and muscle loss and weakness [19].
diabetic individuals) [15]. Although the true Several studies also identified chronic inflam-
pathways from diabetes to frailty are still mation and increased oxidative stress may be
unclear, one commonly considered pathway is other causes of frailty in diabetes. Chronic
insulin resistance [16] (Fig. 10.2). Insulin resis- inflammation induces anabolic resistance in mus-
tance might result in muscle loss (i.e., sarcope- cle, which leads to sarcopenia because of reduced
nia) particularly in people with type 2 diabetes production of growth factors and necessary sig-
by reducing stimulation of protein synthesis naling for muscle recovery [20]. Similarly,
and mitochondrial function and increasing pro- increased oxidative stress in diabetes can lead to
tein degradation [17]. muscle atrophy and sarcopenia by reducing mito-
chondrial function [21].
10 Frailty and Mobility Degeneration in Diabetes and Diabetic Foot Ulceration 135
Fig. 10.2 Diabetes, frailty, and cognitive dysfunction are cular factors, physical inactivity, and malnutrition are
closely related to the mechanisms of aging. It is estimated important risk factors for frailty in older adults with diabe-
that between 10% and 25% of older adults with diabetes tes. Having one of these clinical syndromes can signifi-
are frail. Insulin resistance, chronic inflammation, oxida- cantly increase the risk for another one and will
tive stress, and mitochondrial dysfunction may be com- significantly impose a substantial personal and public
mon mechanisms shared by diabetes, frailty, and cognitive health burden
impairment. Hyperglycemia, hypoglycemia, obesity, vas-
railty and Biomechanics of Lower

F resistance against shear stress, becomes flattened,
Extremities thinner, dehydrated, and loss of elasticity with
aging [22]. This in turn could reduce skin reli-
Frailty and aging could alter the biomechanics of ance against pressure and shear and thus early
lower extremities, which in turn may increase the skin breakdown with a lower magnitude of pres-
risk of diabetic foot ulcer (DFU) among older sure and shear forces. In addition to the changes
individuals with diabetes. Figure 10.3 is a sum- in the skin noted above, there are also changes in
mary illustration of age-related factors affecting the tissue properties interfacing with the plantar
lower extremity biomechanics reported in a sys- surface of the foot causing higher tissue stiffness
tematic review by Neville and colleagues [22]. In due to aging that in turn could be one of the fac-
summary, aging has been shown to alter the bio- tors for the high prevalence of foot problems (e.g.
mechanical properties of the skin and plantar soft foot pain and foot deformity) in frail older adults
tissue of the foot. These soft tissues, which as reported by Muchna and colleagues [24].
anchor the plantar skin to the underlying bony Furthermore, the increase in soft tissue stiffness
architecture of the foot, serve as a protection to could be postulated to contribute to the decrease
the underlying neurovascular structures, provide in tactile sensation and limit sensory feedback
resistance against frictional shear force, and [25]. Over time this change can reduce the load-
attenuate the pressure and force during collision bearing capacity of the plantar soft tissues, which
impact [23]. Because of aging, the dermo- might result in reduced shock absorption as well
epidermal junction of the skin, which provides as slower recovery after compression [26]. This
Fig. 10.3 The impact of frailty on lower extremity biomechanics and its association with increased risk of DFU
can increase plantar pressure [27] leading to foot sure and shear, thus increasing likelihood of DFU
pain and foot deformity [28]. A systematic review in response to a lower magnitude of pressure and
by Wrobel and Najafi [25] demonstrated that the shear force compared to non-frail and younger
changes in the properties of soft tissues led to populations [22, 24, 25].
impaired gait function and adaptation to uneven
or irregular surfaces, which may result in falls
and increased risk of DFU. In addition, Najafi obility Degeneration in Diabetes
M
and colleagues linked poor plantar sensory feed- and Diabetic Foot Ulceration
back with poor balance [29].
The impact of aging is not limited to soft tis- Frailty and sarcopenia result in a severe reduction
sue and skin properties. Neville and colleagues in functional mobility in people with diabetes
reported age-related changes in the musculoskel- [31], which can further speed up the progression
etal properties occurring at specific joints in the of frailty [32]. A common manifestation of
foot and ankle negatively impact balance and gait frailty-related mobility degeneration is impaired
in older adults [22]. Furthermore, loss of muscle gait performance [25]. For example, Petrofsky
mass particularly in type II muscle fibers affects and colleagues found that people with diabetes
the lower limb strength and results in a decline in walk slower and take shorter and wider steps than
force and power production, slower muscle people without diabetes [33]. However, interest-
responses, and the reduction in ability developing ingly, in terms of walking activity under natural
rapid muscle activation and power [30]. These circumstances, often measured by daily step
lower extremity biomechanical changes in the counts, studies have reported mixed results.
aging population are anticipated to be magnified Tudor-Locke and Bassett reported that daily step
because of frailty, which in turn may increase the counts for people with diabetes (approximately
likelihood of joint deformities and joint rigidity, 6660 steps per day) are not necessarily lower
leading to alerted gait, inability to absorb colli- than those for healthy adults (between 6000 and
sion shock during walking, higher likelihood of 7000 steps per day) [34, 35]. However, Morrato
developing callus and lower resilience to pres- and colleagues reported that approximately 40%
of people with diabetes are engaged in a mini- participants. According to these criteria, 49 indi-
mum of 30 min of moderate exercise (3 days/ viduals were classified as non-frail, 92 as pre-
week), but approximately 60% of healthy people frail, and 20 as frail. The gait parameters
are engaged in the same amount of moderate associated with propulsion characteristics includ-
exercise [36]. ing propulsion duration and propulsion accelera-
In people with DFU, in general, mobility tion had the largest effect size (Cohen’s
impairment worsens compared to those without d = 1.28–1.95) to distinguish between frail and
diabetes and those with diabetes but without foot non-frail individuals. More specifically, their
ulceration. For example, Yavuzer and colleagues results suggest that frail individuals have an ear-
reported slower gait speed and cadence in people lier heel-off phase leading to longer propulsion
with diabetic peripheral neuropathy compared to duration on average by 58% and less efficient
people with diabetes but without peripheral propulsion (lower propulsion acceleration) on
neuropathy and normal controls [37]. Najafi and average by 45% compared to non-frail
colleagues demonstrated that 4 weeks’ immobili- individuals.
zation of the foot after treatment for DFU caused The early heel-off phase in frail individuals
a reduction of daily walking duration by an aver- could be explained by muscle loss from sarcope-
age of 44% and a reduction of the total number of nia or fat infiltration and loss of muscle quality
steps by an average of 23% [38]. A similar obser- and force production capacity in older adults. In
vation was reported by Fernando and colleagues: a conference paper, Najafi and colleagues
the average daily step counts were reduced from reported that treating people with DFU using
7762 ± 3590 steps for people with diabetic irremovable offloading for a duration of longer
peripheral neuropathy (DPN) to 3729 ± 2042 than 4 weeks could lead to reduced propulsion
steps for people with DFU treated by irremovable performance with similar characteristics reported
offloading devices [39]. This reduction in the in Rahemi and colleagues [44]. Additionally,
level of activity could be due to muscle wasting they found, compared to plantar pressure with an
caused by irremovable offloading, as suggested age-matched non-frail individual, peak plantar
by de Oliveira and Moore [40]. Interestingly, the pressure was 109% higher in people with DFU
level of activity observed in people treated by treated with irremovable offloading probably
irremovable offloading devices was similar to because of inefficient propulsion, joint rigidity,
activity levels in a frail population as observed in and reduced area of contact. Thus, irremovable
another study performed by Schwenk and col- offloading could enhance wound healing out-
leagues [41]. They reported average daily steps in comes. It may have long-term consequences such
non-frail, pre-frail, and frail older adults (age as muscle wasting, poor gait, and physical activ-
65 years or older) were 6030 ± 3075, 3869 ± 1996, ity reduction, which in turn could increase risk of
and 3869 ± 1996 steps, respectively. This may recurrence of ulcers, increase the risk of falling,
suggest that the treatment of DFU by irremovable and frailty. This speculation however needs to be
offloading may lead to frailty, particularly among confirmed by future studies.
older patients.
Frailty could significantly impact gait perfor-
mance, which in turn may increase the risk of Screening Frailty
DFU in people with diabetes. Rahemi and col-
leagues analyzed gait performance of 161 older Frailty is a multidimensional construct including
adults (age 65 years and older) using wearable clinical manifestation of cognitive decline or
sensors to explore gait parameters among frail functional decline or both, also referred to as
and non-frail participants [42]. They used the “cognitive frailty” [45]. Although frailty is not
frailty phenotype criteria developed by Fried and routinely screened in primary care settings, due
colleagues [43] to determine the frailty status of to the impact of frailty on clinical outcomes, it is
Frailty Phenotypes and Frailty Index
One approach that is widely used is the frailty

phenotype proposed by Fried and colleagues
[9]. The frailty phenotype primarily measures
functional decline and consists of five criteria of
weight loss, weakness (i.e., weak grip strength),
exhaustion, slowness (i.e., slow gait speed), and
reduced physical activity and classifies people
into three categories of robust (those who meet
0 criteria), pre-frail (those who meet 1 or 2 cri-
teria), and frail (those who meet 3 or more crite-
ria). Numerous studies demonstrated frailty
Fig. 10.4 Although more than 20 different methods for assess using the frailty phenotypes is a strong
frailty assessment have been suggested in literature, two predictor of mortality in a population with spe-
of the most popular methods are frailty phenotype and cific health condition such as cardiovascular
frailty index. The frailty phenotype, proposed by Fried
and colleagues, assesses five physical components: unin-
disease and a community-dwelling population
tentional weight loss, slowness, weakness, exhaustion, [46, 47].
and low physical activity. The frailty index, proposed by However, administration of frailty using the
Rockwood and colleagues, considers health deficits frailty phenotype can be challenging in patients
(symptoms, signs, disabilities, diseases, etc.). The frailty
index is represented as a ratio between the number of pre-
with limited mobility, or bed-bound patients in
sented deficits and the number of considered deficits. the hospital setting. An example is a person with
Also, there are several digital health-based technologies peripheral arterial disease, often with rest pain,
that facilitate objective screening of frailty foot ulcers, foot gangrene, or previous limb
amputations; these issues may make usual assess-
becoming more critical to properly screen frailty ments of frailty impractical or invalid [48].
in the primary care setting to early identify when Moreover, assessing slowness could be invalid or
a person starts being frail. Until now, there is no inaccurate in those with concurrent parental IV
consensus made on how to best measure frailty, therapies, fractures, presence of wounds, need of
but there are several widely used approaches and walking assistance, or on ventilator support. An
some recently emerging approaches. Although additional challenge in the hospital setting is
more than 20 different methods for frailty assess- allocating space for distance-specific testing. In
ment have been suggested in literature, two of the the absence of complete phenotype assessment,
most popular methods are frailty phenotype and interpretation of frailty results can be narrow, and
frailty index described in the following. the predictive power might be reduced [49, 50].
Additionally, recently the use of digital technol- For example, Rockwood et al. [51] showed
ogy facilitates monitoring frailty and its severity patients who were missing performance-based
based on quick and simple assessment of motor measures had a risk of mortality 3 times higher
performance (Fig. 10.4). over the span of 5 years than those who were not.
Furthermore, evaluation of frailty using frailty and colleagues developed a single wearable sen-
phenotype requires trained personnel to conduct sor worn on the wrist and successfully assessed
the assessment, especially when evaluating some of the frailty phenotypes (e.g., slowness,
patients with cognitive impairment, limiting their weakness, and exhaustion) as well as other move-
ability to respond to the questionnaires (e.g., ment characteristics that are associated with
inactivity, weight loss, and exhaustion of frailty (e.g., rigidity) from a 20-s elbow flexion–
questionnaires). extension movement (i.e., frailty meter) [56–58].
Another popular approach is the frailty index Wearable technology is also used to measure
proposed by Rockwood and colleagues [52]. The gait and balance performance under supervised
frailty index measures deficits in physical perfor- (e.g., lab setting) and unsupervised conditions
mance, health state, and self- and familial history (e.g., home setting), which is another way of
of diseases including cognitive impairment and is screening frailty. Kang and colleagues examined
based on cumulative deficits in overall state (total characteristics of gait initiation in older adults
70 items). The frailty index is calculated as a with DPN in comparison with non-diabetic older
fraction of the number of existing deficits (e.g., adults and successfully differentiate the gait ini-
seven deficits out of 70 items = 0.1), which results tiation phase between the two groups [59]. Kang
in a continuous scale between 0 (“no deficit”) and and colleagues also examined the combining
1 (“deficits in all 70 items”). Studies demon- effects of cognitive and functional status on gait
strated the frailty is a strong predictor of mortal- and balance performance during single-task gait
ity across clinical conditions [53]. However, and dual-task gait in older adults with DPN using
since it consists of a high number of general signs wearable sensors and successfully demonstrated
or symptoms, it mainly serves as a “red flag” for cognitive decline exacerbates the risk of physical
potential problems but cannot be used to deter- injury [60].
mine immediate effect of preventive or therapeu- More recently, with increasing needs of tele-
tic interventions since it is not sensitive to change medicine in the era of COVID-19, image analysis
over short time intervals [54]. of human motion is being developed to identify
frailty status of older adults during the telemedi-
cine service. Zahiri and colleagues used the 20-s
Emerging Technologies elbow flexion–extension movement and devel-
oped an image analysis system to measure frailty
The development of wearable technology state of older adults and successfully identified
enhances screening frailty in both clinical and slowness, weakness, and exhaustion as well as
research settings [55]. For example, Toosizadeh rigidity [61] (Fig. 10.5).
a b
c d
Fig. 10.5 (a–e) Recent advances in artificial intelligence cessing algorithm and a machine learning model, the
and image processing allow a new generation of frailty frailty index and each phenotype are measured from this
meter over telemedicine. Above is a solution proposed by 20-s test. This method could open an opportunity to
Zahiri et al. in which frailty and its key phenotypes includ- remotely assess frailty over telemedicine. (This figure is
ing weakness, slowness, exhaustion, and flexibility could recreated using one of the figures reported in Zahiri et al.
be measured by a 20-s repetitive elbow flexion–extension study [60])
test in front of a camera. Using a deep-learning image pro-
The Impact of Frailty in Diabetes
Once an individual starts being frail, it further

exacerbates aging process, further deteriorates
diabetes itself, and develops diabetic complica-
tions, which eventually results in significant
reduction in functional abilities, independency,
and mortality [62, 63]. To this end, although the
association between frailty and diabetes is not
fully understood, some studies have reported the
Fig. 10.6 Screening of frailty could be useful to evaluate
impact of frailty state on adverse health outcomes
risk of surgical intervention like revascularization for our
in diabetes and DFU. Examples of the adverse patients, it could also help to better determine biomechan-
health outcomes include the development of bio- ical risk factors associated with diabetic foot ulcer; it may
mechanical risk factors, occurrence of postopera- be also helpful for predicting chronic and hard to health
wounds
tive complications, and delayed wound healing,
which will be discussed in the next paragraph
(Fig. 10.6).
Takeji and colleagues investigated the impact
of frailty on clinical outcomes (all-cause mortal-
ity and major amputation after 2 years) of patients
with critical limb ischemia who underwent either
endovascular therapy or bypass surgery [64]. In
their study, frailty was assessed using the frailty
index [52]. They found the frailty index was inde-
pendently correlated with all-cause mortality and
major amputation after 2 years. O’Donovan and Fig. 10.7 Najafi and colleagues demonstrated that using
colleagues compared psychosocial wellbeing and a sensor-based frailty meter based on a 20-s elbow repeti-
morality among four groups of people (diabetes tive flexion–extension test is a practical test to quickly
and frail, diabetes and non-frail, frail and non- determine physical frailty in a hospital setting and predict
adverse events in people with critical limb-threatening
diabetic, and non-diabetic and non-frail) [65]. ischemia after lower extremity revascularization [13]
They found the lowest quality of life for the dia-
betic and frail group followed by the diabetic and
non-frail group, the frail and non-diabetic group, using a single wearable sensor can predict 30-day
and the non-diabetic and non-frail group. They major adverse events (i.e., myocardial infarction,
also found similar mortality rate at 2 year between stroke, all-cause mortality) in people with critical
the diabetic and frail group, and the frail and non- limb-threatening ischemia after lower extremity
diabetic group (approximately 15%), which was revascularization [13] (Fig. 10.7). They found the
significantly higher than the diabetic and non- frailty state was able to distinguish the occur-
frail group (7.3%) and the non-diabetic and non- rence of 30-day major adverse events. Kang and
frail group (2.7%). Bąk and colleagues Najafi used a single wearable sensor to measure
investigated the impact of frailty on quality of life biomechanical characteristics during normal
and depression in older adults with type 2 diabe- daily activities [67]. They found lower level of
tes [66]. They found frail older adults with type 2 activity, which is also considered as a domain of
diabetes have significantly higher depression and frailty, was a strong predictor of the risk of all
lower quality of life compared to robust older among older adults with diabetic foot. In another
adults with type 2 diabetes. Najafi and colleagues study, Van Epps and colleagues found that frailty
investigated if preoperative frailty state measured is a strong predictor and a better predictor than
age for inflammation and thrombosis in older tial solution is mechanical stimulation. For exam-
adults [68]. Although their study was not neces- ple, Kang and colleagues tested the effect of
sarily on people with diabetes, it provides enough home-based mechanical stimulation applied to
implications on potential impact of frailty in the plantar side of the feet on gait, balance and
diabetes. plantar numbness in people with diabetic foot
[75]. They found that daily use of the home-based
mechanical stimulation for 4 weeks is effective
otential Solutions to Improve
P improving gait speed, balance control, and plan-
Outcomes Among Frail and Pre-frail tar numbness.
Diabetic Patients Several studies investigated the effect of exer-
cise on frailty or a domain of frailty in diabetes.
Then, this question arises: What can we do to pre- Geirsdottir and colleagues investigated the effect
vent (or reverse) frailty or to improve health out- of a 12-week resistance exercise intervention on
comes in frail or pre-frail diabetic patients? muscle strength and physical function in older
Although frailty has been traditionally considered adults with prediabetes and type 2 diabetes [76].
non-treatable and non-reversible, in 2013, in a They found that the exercise intervention signifi-
consensus conference, it was agreed that frailty cantly improved muscle strength and physical
state may be reversed with exercise and nutritional function. Some recent studies combined the exer-
solutions [69]. Furthermore, some studies reported cise intervention with an interactive computer
possible reverse of frailty in older adults [70, 71]. game, the so-called exergame (Fig. 10.8). Zhou
In this section, we summarize previous methods and colleagues investigated the effect of an intra-
that researcher has used to improve frailty or a dialytic exergame program on psychological dis-
domain of frailty in people with diabetes or dia- tress in people who undergo hemodialysis [77].
betic complications, or those at risk of diabetes. They found the exergame program is effective in
Armstrong and colleagues examined the effect improving psychological distress. Rahemi and
of electrical stimulation on pain level in people colleagues evaluated the exergame program in
with diabetic foot [72]. They reported the improving femoral venous parameters in healthy
electrical stimulation significantly improved pain individuals [78]. They found the exergame pro-
level after 4 weeks. Najafi and colleagues used gram significantly increased the femoral vein
plantar electrical stimulation and investigated its mean flow volume and mean velocity and showed
effect on postural balance and plantar numbness its potential in preventing deep venous thrombo-
in people with diabetic foot [73]. They found that sis. Grewal and colleagues investigated the effect
daily use of electrical stimulation for 6 weeks of exergame on balance control in people with
significantly improved both postural balance and diabetic foot [79]. They reported people with dia-
plantar numbness. Zulbaran-Rojas and col- betic foot had significant improvement in balance
leagues investigated the effect of electrical stimu- control after the exergame. Despite these studies,
lation on wound healing in people with type 2 we were not able to identify a study that proposed
diabetes with chronic non-healing wounds [74]. a potential solution that will reverse comprehen-
They reported that daily use of electrical stimula- sive domains of frailty in people with diabetic
tion for 4 weeks significantly reduced wound foot. As such, future research is recommended on
area (22% reduction on average). Another poten- this aspect.
Fig. 10.8 Zhou and colleagues have suggested the use of motilities such as those with plantar ulcer, which in turn
low intensity and gamified non-weight bearing foot and may enhance perfusion to lower extremities while reduce
ankle exercise as intradialytic exercise program [62]. lower extremity joint rigidity
These exercises could be tailored for people with limited
2. Fazeli PK, Lee H, Steinhauser ML. Aging is a power-

Conclusion ful risk factor for type 2 diabetes mellitus independent
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frailty may be reversed by exercise or other glucose concentration, and risk of vascular disease: a
collaborative meta-analysis of 102 prospective stud-
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Anesthesia for the DLS Patient:
Minimizing Risk and Maximizing
11
Safety
Kasra Razmjou and Andy Liao
Preoperative Optimization lar disease (CVD), obesity, hyperlipidemia, renal

disease, elderly age (60+ years of age), chronic
In an effort to accommodate an aging population lung disease, and history of smoking [2, 3]. These
with chronic diseases, the American Society of disease processes all negatively impact the car-
Anesthesiologists (ASA) developed the periop- diovascular system and should be medically opti-
erative surgical home [1]. The PSH aims to optimized in preparation for anesthesia.
mize patient care through the process of surgery In 2014, the American College of Cardiology
and recovery, beginning in the preoperative stage. (ACC) and American Heart Association (AHA)
During this period, the anesthesiology service developed guidelines for perioperative cardiovas-
will collaborate with the surgeon and primary cular evaluation for the management of patients
care physician to evaluate the patient’s history, undergoing noncardiac surgery [4]. These guide-
comorbidities, and goals of surgery. They will lines provide a stepwise algorithm stratifying the
also make recommendations on additional testing risk of patients with potential cardiovascular con-
and medical management in preparation for sur- ditions. The first step assesses the urgency of sur-
gery. At this point, the patient’s team is focused gery for patients with risk factors or a history of
on optimizing the patient for successful surgery CAD [5]. Risk factors for CAD were first intro-
and postoperative recovery. The DLS patient will duced by the Framingham Heart Study [6], but
likely require multiple surgeries and hospitaliza- now can be taken from the ACC/AHA
tions; thus the PSH model is ideal in maintaining Atherosclerotic Cardiovascular Disease
anesthesiology’s continual presence in the (ASCVD) risk calculator [7]. This tool considers
patient’s care. age, low-density lipoprotein (LDL), total choles-
DLS patients tend to have several medical terol, blood pressure, diabetes, and smoker sta-
comorbidities including hypertension, coronary tus. These risk factors and the urgency of surgery
artery disease (CAD), arrhythmia, cerebrovascu- should be evaluated in a discussion between the
surgeon and anesthesiologist. If surgery can be
delayed, the ideal plan of action involves treating
K. Razmjou (*)
Regional Anesthesia and Acute Pain Medicine, the underlying cardiovascular issues prior to sur-
MedStar Medical Group Anesthesiology, gery. Unfortunately, in the DLS population criti-
Baltimore, MD, USA cal limb ischemia and sepsis are common causes
e-mail: [email protected] of urgent and emergent surgical interventions [8].
A. Liao The second step evaluates the patient for acute
North American Partners in Anesthesia, coronary syndrome (ACS), which requires
Melville, NY, USA

148 K. Razmjou and A. Liao
referral to the cardiology service for evaluation not be physically feasible for DLS patients, leav-
and management. The third step proceeds if the ing pharmacologic stress testing as the best alter-
surgery is deemed non-emergent; the patient does native. If the stress test results are abnormal, the
not have ACS, but the patient has risk factors for ACC/AHA guidelines recommend considering
CAD. At this point, the anesthesiology service coronary angiography and revascularization.
will assess the patient’s risk for major adverse In the DLS population, glucose control is
cardiovascular events (MACE) defined as total especially important in medically optimizing
death, myocardial infarction (MI), stroke, hospi- patients for surgery and recovery. Hospital sys-
talization due to heart failure (HF), and ACS tems may have their own guidelines for appropri-
requiring revascularization via percutaneous cor- ate preoperative serum glucose, and the definition
onary intervention (PCI) or coronary artery of glucose control may vary across groups. Based
bypass graft (CABG). This risk can be evaluated on the widely cited NICE-SUGAR study, serum
by the American College of Surgeons National glucose is ideally kept in the 140–180 mg/dL
Surgical Quality Improvement Program (NSQIP) range [10]. Although this is based on patients in
or the Revised Cardiac Risk Index (RCRI). the intensive care unit, this can be translated to
Although there has not been a clear consensus on the realm of anesthesia where surgical stress,
which calculator is superior [9], the RCRI is eas- medically induced comas, and potentially signifi-
ier to remember and simpler to use with only six cant fluid shifts can occur. Glucose control is
risk factors. The RCRI risk factors include the important for proper wound healing and avoid-
type of surgery, ischemic heart disease, conges- ance of hypoglycemic or hyperglycemic coma
tive heart failure (CHF), CVD, insulin depen- [11]. Preoperative glucose control will allow for
dence, and preoperative creatinine greater than more optimal control in the intraoperative and
2 mg/dL. These risk factors are each assigned one postoperative settings.
point, cumulatively translating into the risk of
MACE. A score of two points indicates a 10%
risk of MACE and suggests further evaluation Intraoperative Risk Mitigation
and testing may be necessary.
The common comorbidities of the DLS popu- Surgical interventions will inevitably require the
lation will likely fulfill several risk factors for specialty care of anesthesiologists, especially
MACE and necessitate further cardiovascular within the DLS patient population. This group
evaluation. In patients with elevated risk for typically has several comorbidities affecting the
MACE, the next step evaluates functional capac- cardiovascular system and requires many anes-
ity through the Duke Activity Status Index thetic considerations to maximize patient safety.
(DASI). This series of self-reported activities Nil per os (NPO) guidelines were developed
correlate with functional status or assesses meta- by the ASA in an effort to prevent aspiration risk
bolic equivalents (METs), which can be objec- associated with sedation and anesthesia [12].
tively tested through cardiopulmonary exercise The data was based on gastric pH and volumes
testing. The ACC/AHA guidelines indicate that relative to the time of fasting, resulting in the
moderate functional capacity or about 4 METs recommendation of at least 8 h of fasting prior to
(and a DASI score of 10) is the minimum require- surgery. However, these guidelines assume nor-
ment for proceeding to surgery. This can be esti- mal gastric motility. In the DLS population, dia-
mated with the ability to walk up two flights of betic gastroparesis is a possibility and delayed
stairs without chest pain or shortness of breath. gastric emptying should be considered when
Most DLS patients will not be able to answer this assessing NPO status. Although the incidence of
question accurately and require further assess- gastroparesis is 4.6% in type 1 diabetics and
ment due to unknown functional capacity. 1.3% in type 2 diabetics [13], abdominal fullness
Exercise stress testing is typically the next step in or bloating are associated with diabetic gastropa-
objectively assessing functional status. This may resis [14] and should be factored into d etermining
11 Anesthesia for the DLS Patient: Minimizing Risk and Maximizing Safety 149
whether a patient is appropriately NPO. The Neuraxial anesthesia includes two techniques,
administration of increasing depths of anesthesia spinal and epidural. Spinal anesthesia involves
can lead to an inability to protect the airway and intrathecal injection of local anesthetic with or
the aspiration of gastric contents. In the inci- without an adjuvant, resulting in the abolition of
dence of an increased risk of aspiration, the motor and sensory transmission from the level of
anesthetic may be modified to use minimal to no the injected site. Epidural anesthetics involve
sedation with a regional anesthesia technique to injection in the epidural space. Catheters may be
preserve airway reflexes, or general anesthesia used for both techniques, allowing for the con-
with an endotracheal tube to ensure a secure tinuous infusion of local anesthetic. In addition to
airway. providing surgical anesthesia, neuraxial catheters
The intraoperative management of DLS can be used postoperatively for pain control.
patients can include general or regional anesthe- However, the catheter may be a conduit for
sia. General anesthesia is defined as the lack of potential infection, increasing with the amount of
response to surgical stimulus, allowing the sur- time the catheter remains in place. For this rea-
geon to safely focus on the procedure. General son, neuraxial catheters are usually used for
anesthesia involves administering a mixture of short-term periods. Contraindications to neurax-
sedatives, hypnotics, and analgesics that invari- ial blockade include patient refusal, infection at
ably lead to hypotension and airway obstruction. the injection site, systemic infection, coagulopa-
This may potentially result in organ damage, thy, hemodynamic instability or hypovolemia,
brain injury, and death if not managed by an preload-dependent states such as hypertrophic
experienced anesthesiologist. obstructive cardiomyopathy (HOCM), severe
Anesthesiologists are prudent about which compressive radiculopathy at the level of inser-
patients can safely be anesthetized as there are tion, and increased cranial pressure [19]. DLS
many considerations to be made prior to proceed- patients are vasculopathic and are commonly on
ing with general anesthesia. Other than cardio- anticoagulation and/or antiplatelet regimen,
vascular catastrophes, the ACC/AHA guidelines especially if recently revascularized. This must
do not address other concerns in the perioperative be weighed in the decision to pursue neuraxial
period. Patients with obstructive sleep apnea anesthesia due to the increased risk of epidural
(OSA) are at risk for many anesthesia-related hematoma [20].
complications [15]. These same patients are com- The use of neuraxial blockade intraoperatively
monly obese and may also have difficult airway raises concern as neural blockade of sympathetic
placement, which can significantly increase the fibers may lead to hypotension; however, this is
danger of inducing a general anesthetic [16]. usually reversible and can be treated with intrave-
General anesthesia is notorious for having a high nous hydration and vasopressors. Other intraop-
incidence of nausea, and prophylactic anti- erative concerns of neuraxial anesthesia include
emetics are routinely administered [17]. Due to paresthesia due to trauma to the spinal cord, car-
these risks and adverse effects, the use of regional diopulmonary compromise due to high spinal
anesthesia, which includes neuraxial anesthesia level, nausea and vomiting typically caused by
and peripheral nerve blockade, may be safer. hypotension, postdural puncture headache, uri-
Neuraxial anesthesia involves the injection of nary retention, and infection [21]. Additionally,
local anesthetic into the epidural and/or intrathe- neuraxial procedures require a cooperating patient
cal space to achieve surgical anesthesia at the spi- to appropriately position, which may not be fea-
nal cord [18]. When neuraxial anesthesia is sible for a bedbound, deconditioned DLS patient.
utilized, it obviates the need for general anesthe- Peripheral nerve (or perineural) blockade
sia. These patients generally tolerate surgery with extends the concept of neuraxial anesthesia, and
minimal or no sedation, which allows the anes- entails depositing local anesthetics around nerves
thesiologist to avoid the risks associated with distal to the spinal cord. The local anesthetic acts
general anesthesia. to halt the transmission of pain to the spinal cord.
Since injection around the spinal cord is avoided, tion [24]. Amputation may have sequelae of
peripheral nerve blockade circumvents many of residual limb pain (RLP), sometimes referred to
the aforementioned adverse effects related to as stump pain, and phantom limb pain (PLP).
neuraxial anesthesia, especially autonomic block- Both phenomena can develop into chronic pain
ade. For upper extremity procedures, common after amputation (CPAP) [25]. RLP occurs at the
brachial plexus nerve blocks include interscalene, actual site of the amputated limb and is caused by
supraclavicular, infraclavicular, and axillary nerve nerve entrapment, neuroma formation, surgical
blocks. For lower extremity procedures, common trauma, ischemia, skin breakdown, or infection
nerve blocks aim to block branches of the lumbar [26]. PLP is described as chronic, severe pain or
and sacral plexus, including the femoral, obtura- unpleasant sensation in a part of the body that no
tor, lateral femoral cutaneous, and sciatic nerves. longer exists after amputation. PLP develops as
Ankle blocks target the distal branches of the early as 24 h to 1 week after amputation. The
femoral and sciatic nerve and are commonly used prevalence of PLP varies from 40 to 80% depend-
for foot procedures. The type of block selected is ing on the site of amputation, causation leading
based on the location of surgery and the associ- to amputation, and time since amputation [27]. In
ated dermatomes, myotomes, and osteotomes. differentiating RLP from PLP, a thorough physi-
Like neuraxial procedures, peripheral nerve cal exam of the amputation site can rule out RLP,
blocks can be extended with the use of catheters and other pain findings such as the quality and
for postoperative pain control. severity of pain, sensation, allodynia, and hyper-
Peripheral nerve blocks were historically per- algesia should be noted as well. Patients with
formed based on anatomic landmarks and patient chronic back pain with radiculopathy can be mis-
feedback via transient paresthesia. The advent of taken for PLP and should be ruled out [28]. The
peripheral nerve stimulators allows the anesthesi- exact cause for the development of PLP is
ologist to assess if the location of the needle is unclear, but has been found to be multifactorial
adequate based on the motor response elicited including peripheral, central, and psychological
relative to a programmed current. The develop- factors. Phantom limb sensation (PLS), RLP, pre-
ment of ultrasound technology has allowed pro- amputation pain, and diabetes are risk factors for
viders to achieve successful nerve blockade at a developing PLP [29].
higher rate with a lower amount of local anes- While treatment of RLP involves addressing
thetic, thus reducing the risks of local anesthetic the underlying cause, treatment for PLP) is more
systemic toxicity among other adverse effects difficult and focuses on symptom management.
[22]. Similar to neuraxial anesthesia, peripheral Poor management of PLP may lead to increased
nerve blockade can be used to obtain surgical incidence of obesity, cardiovascular disease,
anesthesia with minimal to no sedation. sleep disorders, chronic joint pain, and lower
Peripheral nerve blocks also avoid many of the back pain [30]. A conservative, interdisciplinary
risks related to neuraxial anesthesia. Although approach to preventing PLP involving physical
rare, nerve injury, infection, and local anesthetic therapists, prosthetic professionals, mental health
systemic toxicity may occur with any regional professionals, and pain specialists is beneficial in
anesthesia technique. Due to the relative safety of addressing potential RLP and PLP.
this approach, peripheral nerve blockade is an Common pharmacotherapies for PLP such as
attractive alternative [23]. NSAIDs and acetaminophen are starting points
for any pain regimen. Opioids are commonly
used, but should be used conservatively to avoid
Postoperative Recovery Optimization tolerance and dependence, and are best used with
adjuvants. Adjuvant medications include tricyclic
Up to 40,000 amputations are performed in the antidepressants (TCAs) such as amitriptyline,
United States (US) annually. In 2005, 1.6 million and anticonvulsants such as gabapentin and pre-
people in the US were living with a limb amputa- gabalin. Although both TCAs and anticonvul-
sants have been extensively studied, both show Regional anesthesia is also beneficial in man-
mixed results, and evidence has been inconclu- aging early postoperative pain. A retrospective
sive for recommendation. NMDA antagonists study in Turkey found that epidural anesthesia or
such as ketamine may be helpful, especially in peripheral nerve blockade can reduce RLP and
patients with chronic pain syndromes. One PLP in the first week after limb amputation com-
review analysis recommends a regimen of intra- pared to general anesthesia and spinal anesthesia,
venous ketamine and intravenous morphine for but has no difference across anesthetic techniques
acute treatment of PLP and oral morphine for at 14–17 months postoperation [33]. Another
intermediate- to long-term treatment (8 weeks to cross-sectional survey found neuraxial anesthesia
1 year) [31]. Topical capsaicin can help reduce led to better pain control in the first postoperative
hypersensitivity, and botulinum toxin type B can week, but was not different from general anesthe-
improve hyperhidrosis to facilitate prosthetic use. sia in the development of RLP or PLP at the
However, a Cochrane review for the current phar- 14-month mark [34]. A large retrospective cohort
macologic interventions in treating PLP con- study in South Korea determined that the inci-
cluded the available studies are not large enough dence of PLP after limb amputation was highest
to demonstrate evidence that pharmacologic ther- when general anesthesia was used, then neuraxial
apies should be recommended in the treatment of anesthesia, and the least with perineural nerve
PLP [32]. Pharmacologic therapy will remain a blockade [35]. Although it appears that anesthetic
mainstay in patient care due to familiarity with technique does not impact long-term develop-
the usage of medications, and the convenience of ment of chronic pain, perhaps preoperative pain
having a treatment modality that physicians can control helps in preventing postoperative pain. A
prescribe in the outpatient setting for patients to prospective controlled study in England found
self-administer at home. that an epidural infusion of bupivacaine, cloni-
There is much research without definitive evi- dine, and diamorphine started 24–48 h preopera-
dence for non-pharmacologic options such as tively and maintained for at least 3 days
transcutaneous electrical nerve stimulation postoperatively led to a significant reduction in
(TENS), spinal cord simulation (SCS), peripheral the incidence of PLP) at the 1-year follow-up
nerve stimulation (PNS), sympathetic nerve [36]. A randomized, prospective trial in Greece
block, mirror therapy, augmented reality biofeed- demonstrated perioperative pain control, whether
back, acupuncture, and stump revision. Surgical via neuraxial or intravenous patient-controlled
techniques include peri-neuromal lidocaine analgesia (PCA), will lead to better pain scores
injection, targeted nerve implantation, and tar- and reduced PLP at 6 months [37]. Despite the
geted muscle re-innervation. These techniques numerous studies on perioperative pain and the
have shown some efficacy in preventing PLP. subsequent development of RLP, PLP, and CPAP,
Peripheral nerve blockade has been studied as the sample subgroups remain relatively small and
a non-opioid, non-systemic, targeted pharmaco- difficult to compare [38]. However, studies have
logical therapy for preventing and treating PLP). shown that perioperative pain control can reduce
A pilot study in 1991 found that a catheter acute perioperative pain [39] and perineural cath-
inserted in the transected nerve sheath infused eters are recommended as part of the analgesic
with 0.25% bupivacaine at 10 mL/h for 72 h sig- regimen in all patients undergoing amputation
nificantly reduced postoperative opioid consump- [40]. Despite the promising results of these stud-
tion. The patients did not develop PLP at the ies on the benefits of perineural catheters in pre-
12 month follow-up despite the presence of preventing the onset of RLP, PLP, and CPAP, the
operative limb pain. With the growing body of evidence remains small and the results are con-
evidence, perineural analgesia is an essential flicting [41].
component of the multimodal approach to post- Neuraxial and perineural catheters can lead to
operative limb amputation and in preventing the infection, especially in diabetic patients [42], and
development of chronic pain. the recommendation is to remove and/or replace
both neuraxial and perineural catheters after 4 References

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Debridement of the Diabetic Foot
and Leg
12
Christopher E. Attinger and Jayson N. Atves
Introduction Debridement is merely one albeit vital factor

in modern wound bed preparation. The funda-
The word “debridement” derives from the French mental tenets in the management of most lower
débridement, which translates into “to remove a extremity wounds include the eradication of
constraint.” This term was first used by Henri infection, optimization of local and systemic
LeDran (1685–1770) (Fig. 12.1) in the context of healing factors, adequate offloading, and/or
an incision of skin and fascia to release swelling immobilization with achievement of a biome-
associated with injury [1]. However, during eigh-
teenth and nineteenth century wartime this defi-
nition was greatly refined to include “removal of
all materials incompatible with healing in order
to prevent gangrene” and it is this definition that
still guides clinicians today [2]. Debridement is
the excision of foreign, dead, dying, damaged, or
infected tissues in order to optimize the healing
potential of the remaining healthy and viable tis-
sues. It is performed in a myriad of ways and set-
tings in preparation for soft tissue closure within
the steps of the plastics and reconstructive ladder
ranging from simple primary closure to the use of
complex flaps [3, 4].
C. E. Attinger ∙ J. N. Atves (*)

Department of Plastic Surgery, Georgetown
University School of Medicine and MedStar
Washington, DC, USA Fig. 12.1 Henry LeDran (1685–1770) first published on
e-mail: [email protected]; debridement in the context of an incision of skin and fas-
[email protected] cia to release swelling associated with injury

158 C. E. Attinger and J. N. Atves
chanically stable and well-aligned extremity imal ambulatory function within each patient’s
through biomechanical correction or accommo- physical and medical capacity. Debridement
dation. Diabetic foot and leg wounds in particular though, in its varied forms, is truly the foundation
require adherence to a multifactorial treatment and perhaps the single most important compo-
algorithm that affords the greatest potential for nent of this limb salvage cascade (Fig. 12.2).
healing while also mitigating costs and minimiz- In this chapter we review the guiding tenets of
ing the possibility for recurrence. debridement and offer an assortment of strategies
Although outside the scope of this chapter, and techniques aimed at appropriate method
there are numerous factors which may contribute selection, successful performance, and ultimately
to an acute wound’s stagnation into the chronic a prosperous wound bed preparation. The goals
state and consideration of these factors in addi- of this chapter will be to gain an understanding
tion to sufficient debridement is essential to and appreciation for the exceptional potential of
obtaining and preserving a healthy wound bed. adequate tissue debridement and its place as a
Factors may include a patient’s comorbidities, powerful tool in the surgeon’s arsenal.
nutrition, glycemic control, smoking status,
ambulatory status, wound etiology, biomechani-
cal aberrations, tissue perfusion, access to Wound Healing
resources, adherence to prescribed rehabilitation,
and perhaps most importantly, wound location A review of the normal wound healing cascade is
and topography. Once the patient and wound necessary to more clearly understand the complex
have been optimized, several options exist on the wound state. Wound healing is a natural physio-
plastics reconstructive ladder for definitive logical reaction to tissue injury. An acute wound is
wound closure, including primary intention, sec- defined as a recent wound that has yet to progress
ondary intention, skin grafting, local tissue trans- through the sequential stages of wound healing.
fer, and free tissue transfer [4]. However, this is not a simple phenomenon but
Determining the etiology of a patient’s wound, rather involves a complex interplay between
though, is of the utmost importance in order to numerous cell types, cytokines, mediators, and the
guide decision making regarding the most appro- vascular system. The traditional cascade of wound
priate course of wound optimization, including the healing is described as the sequential and overlap-
type of debridement performed. However, it is ping progression through three phases: inflamma-
imperative to understand that debridement type, tion, proliferation, and remodeling [6]. The initial
just as the wound character, may evolve over time, vasoconstriction of blood vessels and platelet
especially in the comorbid population, including aggregation is designed to stop bleeding. This is
individuals with diabetes. Consequently, a thought- followed by an influx of a variety of inflammatory
ful understanding and careful consideration of the cells, starting with the neutrophils. These inflam-
patient, the wound, and feasible methods of matory cells, in turn, release a variety of mediators
debridement are vital to a successful outcome [5]. to promote angiogenesis, thrombosis, and reepi-
The achievement of an infection-free, well- thelialization. The fibroblasts, in turn, lay down
aligned and structurally stable lower extremity extracellular components which will serve as scaf-
combined with an appropriately selected mode folding for ultimate wound healing and closure.
for soft tissue closure, with optimization of local The inflammatory phase begins with hemosta-
and systemic healing factors and appropriate off- sis at the initial insult after platelets have col-
loading and immobilization where warranted, lected and adhered at the site of injury to form a
will provide for the best opportunity of a success- hemostatic plug. In this phase, the body activates
ful outcome both in the acute phases of healing the clotting cascade and forms a clot to stop con-
and in the long-term durability and function of tinued bleeding. During this process, platelets
the patient. Ultimately, the primary goal in this which have traveled to the site of injury come
cascade is the achievement or restoration of max- into contact with collagen, resulting in their acti-
12 Debridement of the Diabetic Foot and Leg 159
a b
Fig. 12.2 Clinical representation of a sequentially cate infection and stimulate healing potential (a) which
“primed” wound bed (a, b). In this patient, surgical led to the formation of a “primed” wound bed (b) and ulti-
debridement and local wound care were utilized to eradi- mately definitive closure via split-thickness skin graft
vation and aggregation. Thrombin initiates the growth factor (EGF), and vascular endothelial
formation of a fibrin plug, which strengthens the growth factor (VEGF). These cellular interac-
platelet clumps into a stable clot. Additionally, tions and communications are critical elements in
platelets contain intracellular structures includ- the wound healing cascade. This phase normally
ing alpha-granules that contain growth factors, lasts a matter of days after the initial insult.
clotting factors, and other proteins involved in The proliferation or epithelialization phase
wound healing. Transforming growth factor begins with the proliferation and migration of
(TGF-beta) and platelet-derived angiogenesis epidermal cells. Epidermal cells will form link-
factor (PDAF) play roles in wound matrix pro- ages with one another and initiate deposition of
duction by promoting collagen production and basement membrane components and degrade
new capillary formation. Platelet-derived growth the extracellular matrix. Neovascularization
factor (PDGF) is one of the key components of occurs at the wound bed causing the formation of
wound healing which recruits and activates pro- granulation tissues, which infiltrates the tempo-
inflammatory cells such as fibroblasts, macro- rary matrix. Fibroblasts play a crucial role in
phages, monocytes, and neutrophils. These cells, orchestrating the reorganization of the extracel-
in turn, secrete growth factors such as TGF-beta, lular matrix into a collagenous matrix through
fibroblast growth factor (FGF), endothelial the use of proteases and other enzymes. Growth
factors such as VEGF contribute to the stimula- closure. Functionally speaking the overarching
tion of angiogenesis to support wound healing. goals of wound bed preparation include effec-
This phase of wound healing can normally last tively removing any and all tissues which would
days to weeks in duration. otherwise allow bacterial burden to proliferate,
The remodeling or maturation phase involves decreasing the overall demand of the local wound
slow advances in new tissue strength and flexibil- site and systemic physiological stress, and stimu-
ity with wound contraction facilitated by fibro- lating the underlying health of the remaining tis-
blasts that have converted to myofibroblasts sues in order to produce a wound bed which is
stimulated by growth factors. Collagen is contin- “primed” for closure (Fig. 12.3). Debridement is
ually remodeled through enzymatic degradation the predominant means of achieving these goals
by matrix metalloproteinases (MMPs) until final of wound bed preparation and should be thought
collagen deposition and wound reepithelializa- of as not just the gold standard but a necessary
tion have occurred. This phase’s duration can treatment modality for nearly every wound type
vary greatly lasting from weeks to years. in nearly every patient. Various modes of debride-
ment exist and although most are readily avail-
able regardless of clinical setting, individual
Wound Bed Preparation choice of the particular method of debridement to
undertake may depend on clinician and patient
Adequate preparation of a wound bed is the prin- access to resources and the logistical feasibility
cipal aspect of wound management and eventual of its implementation (Fig. 12.4).
a b
c d
Fig. 12.3 Clinical representation of a sequentially (a) with supplementation via skin substitute grafting (b)
“primed” and ultimately closed wound bed (a–d) in a were utilized to produce a “primed” wound bed (c) with
patient with a transmetatarsal partial foot amputation. In subsequent definitive closure via split-thickness skin graft
this patient, surgical debridement and local wound care (d)
Fig. 12.4 Five modes of debridement exist, including most common and varied form of debridement; however,
mechanical, enzymatic, autolytic, biologic, and finally depending on a variety of factors an understanding of the
surgical. Overwhelmingly, surgical debridement is the assorted options for debridement is essential
Types of Debridement microorganisms such as Clostridium histolyticum

or from plants, including collagenase, varidase,
Mechanical papain, and bromelain. This method is most use-
ful for debridement of wounds with a large
Mechanical debridement is perhaps the oldest amount of necrotic tissue and poses little risk to
form of debridement and involves the use of healthy tissues. This mode of debridement is con-
moist or wet flushes or dressings, which are sub- sidered selective in nature; however, judicious
sequently removed from contact with the wound use of these products must be implemented so as
bed. The removal and physical wound base dis- not to create an environment nonconducive to
ruption causes nonselective debridement of loose overall tissue healing.
tissues and slough. Examples include direct
wound irrigation with saline, wet-to-dry dress-
ings, and hydrotherapy, including bath and whirl- Autolytic
pool. Dressing changes are quite simple and can
be performed independently by the patients in Autolytic debridement uses the body’s own
many cases. However, because mechanical enzymatic processes to debride necrotic tissues
debridement is considered nonselective in nature, and slough. This process interrupts dead and
it may remove or damage healthy tissues if not devitalized tissue over time by allowing wound
performed judiciously (Fig. 12.5). fluids to maintain contact in the wound bed to
hydrate, soften, and liquefy necrotic tissue and
eschar. This method is achieved with the use of
Enzymatic occlusive or semi-occlusive dressings with or
without the supplementation of hydrocolloids,
Enzymatic debridement involves using chemical hydrogels, and transparent films and is suitable
agents to slough necrotic wound tissue. for cases in which the amount of dead tissue is
Collectively, these enzymes are derived from not extensive and there is no infection.
a b c d
e f g h
Fig. 12.5 Mechanical debridement in a sequential manner ment secondary to limitations with pain and inability to
is appreciated spanning approximately 6 months (a–h). safely undergo anesthesia for operative debridement
This specific patient utilized mainly mechanical debride-
Autolytic debridement is selective for necrotic Biologic

tissues, is easy to perform, and is virtually
painless to the patient. However, it is by far the Biologic debridement employs the use of medi-
slowest type of debridement, and the wound cal maggots that have been raised in a sterile
must be rigorously monitored for signs of environment [7]. Several young larvae of the
infection. For these reasons, this method is green bottle fly (Lucilia sericata) are introduced
often reserved for patients with poor access to into a wound bed and secured with a permeable
resources and those contraindicated for the dressing which allows for larvae respiration [8].
other debridement methods, such as those with The maggots feed selectively on the necrotic tis-
intractable pain to the wound during other sue of the “host” without injuring living tissue
debridement modes (Fig. 12.6). and can quite effectively debride a wound in a
a b c d e
Fig. 12.6 Autolytic debridement in a sequential manner ment secondary to limitations with access to and resources
is appreciated spanning approximately 4 months (a–e). and contraindications for operative debridement
This specific patient utilized mainly autolytic debride-
an optimum environment, maggots molt twice,

increasing in overall size and leaving a clean
wound free of necrotic tissue once they are
removed. This method has gained popularity
over time, but some patients find the method
painful, and a patient’s aversion to maggots
being placed onto the body may impede its use.
However, this method has the advantage of being
non-surgical in nature and performs quite expe-
diently compared to autolytic or enzymatic
debridement with minimal risk to healthy tissues
(Fig. 12.7).
Surgical
Surgical debridement is arguably the most com-

mon and varied type of debridement. A myriad of
Fig. 12.7 Use of medical maggots for biologic debride-
ment is a useful and underutilized modality of debride- instrumentation and adjuncts are used to physi-
ment. An appropriate maggot “house” dressing will cally excise dead, dying, or infected tissue from
permit biologic respiration in order to prevent occlusion, the wound bed, either at the bedside, in the clinic,
anoxia, and ultimately death of the medical maggots or in an operating room (Fig. 12.8). The surgeon
will debride tissue to viability, as determined by
matter of just a few days. The larvae derive nutri- tissue character and the presence of vascularity in
ents by secreting a broad spectrum of enzymes healthy tissues, using any combination of
that liquefy necrotic tissue for consumption. In instrumentation.
a of vascularity in healthy tissues, using any combina-

tion of instruments, such as rongeur, curette, scis-
sors, and scalpel blade (Fig. 12.9). The onus of
determining the most appropriate instrumentation
should be based on the surgeon’s individual prefer-
ence, availability of instrumentation, and specific
wound character, location, and topography. Wounds
with overt infection will require arguably more
aggressive debridement to reach the level of healthy
and living tissues, whereas wounds with no acute
b signs or symptoms of infection or bioburden may
require relatively less overall aggressive debride-
ment. Regardless, surgical debridement should
always be performed with the most appropriate
instrumentation as deemed by the surgeon and in a
manner which is considerate of the surrounding tis-
sue integrity. Perhaps the most deleterious potential
complication of surgical debridement is the possibil-
ity of injury to the surrounding healthy tissues.
Adjunctive instrumentation for surgical
Fig. 12.8 Surgical debridement of severely necrotic tis- debridement such as the micro water jet device
sues of the leg is appreciated both pre-debridement (a) has been developed for an even more meticulous
and post-debridement (b)
and selective debridement (Fig. 12.10). This
device produces a pressurized stream of saline
Surgical Debridement which is dispelled at high speed from its tip and
immediately suctioned into the handpiece where
Indications the jet action of the saline effectively pulverizes
the tissues placed between the outflow and inflow
Surgical debridement is best suited for progressive portion of the tip. The authors find this of particu-
or recalcitrant wounds; larger sized wounds and/or larly advantageous use in large surface area
those in atypical or precarious locations; grossly wounds where controlled debridement is required.
infected wounds; and wounds considered to be of However, it should be noted that the water jet
an unknown etiology, which necessitate surgical device, although quite beneficial from a practical-
biopsy or resection. Surgical debridement is con- ity standpoint and which provides for precise and
sidered the most expedient method of debridement controlled debridement, has significant limita-
because it is very selective and limited only by the tions in its ability to debride certain tissue type
skill, experience, and judgement of the surgeon. (i.e., tendon and ligament) and variable tissue
Overall, surgical debridement affords superior topographies and thus should only be used as a
control over which and how much tissue is supplement to the standard manual instrumenta-
removed, is the fastest manner to achieve a clean tion for traditional surgical debridement.
wound bed, and can expedite the healing process Furthermore, the depth at which the water jet is
in most patients with diabetic foot and leg wounds. able to debride in a single pass is fairly shallow
and this level of control should not lull the sur-
geon into believing that use of the water jet alone
Instrumentation is a sufficient debridement technique. Again,
manual instrumentation is the gold standard for
The surgeon will debride to the level of viable tissue, surgical debridement and the water jet should
as determined by tissue character and the presence only be utilized as an adjunct, not a replacement.
Fig. 12.9 Surgical debridement instrumentation is appreciated. The time-honored instruments utilized for surgical
debridement include, but are not limited to, rounguers, curettes, scissors, and scalpel blades
M.D. (1882–1957) (Fig. 12.11), first coined the

term “atraumatic technique” to describe how tis-
sues ought to be handled during surgery [9].
Although written a century ago, his tenets of tis-
sue handling have remarkably withstood the test
of time and are quite pertinent to all surgical spe-
cialties today. In the debridement of foot and leg
wounds an atraumatic technique should be
implemented at all times in order to preserve
vascularity to the existing and surrounding tis-
sues and maximize the potential for healing.
This is perhaps no more pertinent than in the dia-
Fig. 12.10 The micro water jet device is a useful adjunc- betic and comorbid population, where the risk
tive instrument utilized for meticulous debridement of tis-
sues of the foot and leg. Despite its obvious benefits, its for complication is exponentially increased. One
use should be judiciously implemented as a supplement to should minimize excessive traction and manipu-
the normal manual instrumentation for traditional surgical lation of the tissues. This is best accomplished
debridement with strictly intent motions and manipulations
and blunt retraction only when necessary for
Technique appropriate visualization. Proper instrumenta-
tion selection is key to preserving an atraumatic
Atraumatic Technique technique. A thorough understanding and knowl-
Regardless of the precise location, topography, edge of the available instrumentation and more
or etiology of a wound, proper tissue handling is importantly how well a particular surgical task
paramount and may quite literally “make or can be performed in one’s own hands is crucial.
break” an attempted wound closure, especially For example, the authors often prefer to forgo
in the comorbid population. Sterling Bunnell, the use of forceps for tissue handling unless
blistered, it is unlikely that it will survive. This is

the equivalent of a third-degree burn. No advan-
tage can be gained by waiting in the hopes that
this skin suddenly revitalizes. At the edges and
under the dead skin, there is a high concentration
of harmful proteases with or without bacteria to
inhibit subsequent healing. The protracted course
necessary for the dead skin to separate itself from
the underlying tissue may lead to functional loss,
poor scarring, deeper tissue damage, and dissem-
inated infection. Therefore, the approach to non-
viable skin should be to remove it as soon as
possible. If the border between live and dead tis-
sue is demarcated clearly, then the skin should be
excised along that border. If the border demarca-
tion is unclear, then one should start at the center
and remove concentric circles of skin until the
level of viable tissue is appreciated. When excis-
ing skin, one should seek bleeding at the normal
skin edge. Thrombosed venules at the skin edge
Fig. 12.11 Dr. Sterling Bunnell (1882–1957) first coined reflect a complete interruption in the local micro-
the term “atraumatic technique” to describe how tissues circulation and are an excellent indicator that fur-
ought to be handled during surgery. His tenets remain per- ther skin excision is needed. Only when there is
tinent to all surgical specialties today, especially in the
debridement of the foot and leg
normal arterial bleeding at the edge of the wound
can one be satisfied that the cutaneous debride-
ment has been adequate.
absolutely necessary, especially during suturing When removing the skin, it is important to
as this will cause repeated trauma to the micro- examine the subcutaneous tissue. If the tissue
vasculature of the remaining tissue periphery. appears viable but is infected, then a topical anti-
Rather, the use of strategically positioned and biotic should be placed on the wound [10–12].
oriented sutures are best utilized for transposi- For Pseudomonas infections, 0.25% acetic acid
tion, rotation, and overall manipulation of tis- or gentamicin ointment may be more appropriate.
sues during a definitive wound closure attempt. For MRSA infections, mupirocin (Bactroban) is
Ideally, when utilizing suture material one an appropriate initial topical antibiotic; however,
should use a nonabsorbable monofilament. The one should keep in mind that resistance can
authors prefer a vertical mattress technique when develop quickly [13].
reapproximating most skin layer closures
directly for its superior mechanical hold of ten- Debridement of Subcutaneous Tissue
sioned stresses. Absorbable monofilament Subcutaneous tissue consists of subcutaneous
sutures are used when affixing split thickness adipose tissue, cutaneous vessels, and cutaneous
skin grafts or skin substitute grafts with staple nerves. However, due to the decreased concentra-
supplementation where warranted; however, this tion of blood vessels in the subcutaneous fat,
is largely driven by surgeon preference. bleeding at the tissue’s edge is not always a reli-
able indicator of tissue viability. Healthy fat has a
Debridement of Skin shiny yellow color and is soft and resilient. Dead
Debriding skin consists of removing nonviable fat has a grey pallor to it, is hard, and is non-
and/or nonbleeding skin. Anecdotally, if the pliable. Fat should be debrided until soft yellow
injured skin does not blanch, is insensate, and has normal-appearing fat is attained. Undermining
should be avoided as it threatens the viability of debridement period to avoid desiccation and ulti-
the overlying skin. To prevent desiccation, it is mately necrosis. The underlying muscle must be
important to keep the fat in a moist environment examined as well. Healthy muscle has a bright
after debridement. Small blood vessels should be red, shiny, and resilient appearance to it and con-
coagulated with bipolar cautery to minimize tracts when grasped with forceps or touched with
damage to the surrounding tissues. If the vessels electrocautery. In neuropathic patients, the mus-
are larger than 2–3 mm, then they should be cle may have a pale, perhaps yellowish, color and
ligated. Liga-clips are the least reactive foreign may appear nonviable. It will, however, have
body material to accomplish this task. If a suture some tone and bleed when cut. Frankly dead
is to be used, then a small diameter monofilament muscle will be swollen, dull, and grainy when
suture should be used to minimize the risk of palpated and falls apart when pinched. If viability
facilitating further infection. For example, silk of the muscle is questionable, it is best to err on
acts like a foreign body and stimulates a vigorous the side of caution and remove only what is not
foreign-body reaction, and bacteriostatic, bleeding and appears nonviable. Subsequently,
polyglycolic-woven suture has multiple recesses the wound should be serially debrided until only
within which bacteria can survive in a semi- viable muscle remains. There is always a ques-
protected state. tion of whether to remove the entire muscle when
Nerves, when viable, have a shiny, white, glis- part of it is dead. Generally, one should remove
tening appearance to them. In the subcutaneous only what is dead because removing the viable
tissue, the cutaneous nerves are sensory in func- portion of the muscle involves further dissection
tion. Intact exposed sensory nerves in a sensate that may very well compromise blood flow to the
patient can be painful. The decision must be surrounding tissues. Tendon debridement is
made whether to remove or preserve them. If the always complex because sacrifice of most ten-
nerve is to be preserved, then it has to be kept dons may lead to a significant loss of function.
moist until it can be covered with adequate tissue. All attempts should be made to preserve viable
A skin graft alone does not provide an adequate paratenon surrounding the tendon. The tendon
tissue interface to prevent pain on contact to the must be kept moist after debridement, and this
nerve and thus consideration should be given to requirement becomes all the more important
burying the nerve underneath other tissue or a when the paratenon is removed. The tendon
flap. If the nerve is to be sacrificed, then longitu-should be covered with viable tissue as soon as
dinal traction should be utilized to allow the the wound is stabilized. Otherwise, the tendon
nerve to retract within normal tissue when it is will desiccate, necrose, or become infected.
cut at the edge of the wound. Taking the epineu- Infected tendon looks dull, soft, and grainy with
rium and sewing it over the nerve fascicles with parts fraying, liquefying, or both. The treatment
8-0 or 9-0 suture can minimize the possibility of is to shave the tendon to viable, hard, and shiny
stump neuroma formation. texture and appearance and then ensure that it
stays moist until it granulates sufficiently to be
Debridement of Deep Tissues skin grafted or is clean enough to be covered with
Healthy fascia has a distinct white, glistening, other tissue. If the tendon is small or infected, all
and hard appearance and should be preserved if it of the exposed portions should be removed. It is
appears viable. When devitalized or dead, the important to make a proximal and distal incision
appearance is dull, soft, and stringy and is in the above and below the exposed tendon to ensure
process of liquefactive necrosis. All necrotic fas- that any hidden necrotic tendon is removed also.
ciae should be debrided until solid normal- When the extensor tendons on the dorsum of the
appearing fascia is reached. Since neurovascular foot become exposed, it is hard to preserve them
bundles can be close to the overlying fascia, unless they quickly are covered with healthy tis-
debridement should proceed with caution. The sue. If the tendons remain in place while the
viable fascia must be kept moist in the post- wound progresses to the point at which it is ready
to be closed, they usually become infected and bone. When burring the cortical bone, the process
impede further wound healing until they are is continued until punctate bleeding is visualized
removed. When the tendon is larger (i.e., Achilles emanating from the cortical bone (Paprika sign).
tendon, anterior tibial tendon, etc.), only that por- This signifies that healthy bone has been reached.
tion of the tendon that is necrotic or infected When debriding cancellous bone, bleeding and a
should be debrided. The hard, shiny tendon normal-appearing marrow is ideal. Biomechanical
underneath should be left intact. Great care considerations should not deter the surgeon from
should be taken to keep the remaining tendon debriding enough bone to ensure that all osteo-
moist. The Achilles tendon deserves special men- myelitis has been eradicated. Correction of the
tion since it is the largest tendon in the body and resultant biomechanical aberration can be made
receives excellent blood supply from the poste- once the wound has been stabilized or healed.
rior tibial and the peroneal arteries. If exposed Current orthopedic techniques, including bone
and healthy, it should be covered with a local, grafting, antibiotic spacers, and the use of exter-
pedicled or free flap as soon as the wound is sta- nal fixators allow repair of many bone defects
ble. If part of the tendon is necrotic, it should be with a preservation of alignment and stability. It
debrided to a hard, shiny tendon. It should be is important to obtain cultures of what is consid-
kept moist with an occlusive dressing while gran- ered a normal bone margin proximal to the area
ulation tissue forms. Once surrounded by granu- of debridement and of the debrided osteomyelitic
lar tissue the tendon can be skin grafted atop. bone. Once the infected bone has been removed
Granulation tissue formation can be accelerated and only bleeding healthy bone is left behind,
with the vacuum assisted closure (V.A.C.) device then the wound is “primed” to close, assuming
(first covering the tendon with a Vaseline mesh the surrounding soft tissue is also healthy. When
gauze) or with the combined usage of hyperbaric healthy uninfected bone remains, only 2–5 days
oxygen treatments and a topical growth factor of appropriate antibiotics may be necessary after
product or skin substitute “graft” [14]. wound closure [15]. The exception to a 1-week
course of antibiotics post closure is when the sur-
Debridement of Bone geon suspects that the bone left behind may still
Debridement of necrotic or dead osseous tissue is harbor osteomyelitis. In this instance, a longer
relatively straightforward. Any soft, nonbleeding course of antibiotics may be indicated.
bone should be removed. Useful manual instru-
ments include rongeurs, curettes, and rasps. Staged Approach
Power instrumentation such as the sagittal saw Much has been recognized on the use of a staged
and the rotary cutting burr is also quite useful, if approach to lower extremity pathology especially
not necessary. The key in debriding bone is to in instances of large soft tissue loss or bony defi-
remove only what is dead and infected, leaving cit. In truth, surgical wound management is per-
bleeding bone behind. Care should be taken not haps the prototypical procedure type for a staged
to significantly disrupt viable bone. In this regard, approach due to the precarious and potentially
power instruments are safer to use than rongeurs, catastrophic stakes associated with improper
chisels, or osteotomes. The best way to debride wound management, especially in the diabetic
the osteomyelitic smaller long bones (phalanx, and comorbid population. The successful eradi-
metacarpals, or metatarsals) is to cut slices of cation of infection with minimization of bacterial
bone serially until healthy bone is reached. For bioburden should be considered the primary goal
larger bones (tibia, fibula, calcaneus, talus, etc.) a of surgical debridement. In this light, it is impera-
rotary cutting burr should be used to remove tive to accurately and confidently determine the
layer-by-layer of the osteomyelitic bone until successful acquisition of an infection-free wound
healthy bleeding bone is encountered. Copious bed. This goal may seem simple to the untrained
irrigation should be used to ensure that the heat or inexperienced clinician. However, a staged
generated by the burr does not damage the healthy approach is the only manner in which to guaran-
tee the appropriate preparation of a wound bed. “dirty” table is utilized for the bulk of surgical
Especially in the comorbid population, the eradi- debridement and infective source control.
cation of infection and bacterial burden can prove Following sufficient debridement and copious
to be a burdensome and exhaustive struggle lavage of the wound site the second or “clean”
necessitating numerous returns to the operative table setup is utilized. Between chronological use
theater for continued surgical debridement [16]. of the dual tables both outer gloves, draping, and
Ideally, prior to definitive closure the wound will light handles are changed to a new sterile setup.
yield negative microbiology cultures and a This tact alone provides for significant control of
healthy progressive character which has not stag- possible cross-contamination of the pre-
nated nor digressed in character with continued debridement wound tissues and flora with the
infection, bacterial harborization, or tissue necro- post-debridement wound state [17].
sis. Rather, tissues will display a progressive
improvement in overall character with perhaps ave as Much Tissue as Possible Prior
S
improvement in overall wound size. Only once a to Closure
wound has successfully completed the primary An indispensable tact for permitting the greatest
goal of eradication of infection and minimization potential for soft tissue envelope closure options,
of bacterial bioburden has it reached candidacy regardless of the exact location or topography of
for soft tissue closure. For these reasons we advo- the wound, is to save as much of the healthy and
cate for a staged approach to surgical wound viable tissues prior to the definitive closure as
management in order to maximize the potential possible. This discretion provides several distinct
for a confident closure while minimizing the like- advantages when it comes to the potential closure
lihood for recurrence. of a wound site. Namely, by saving as much tis-
Additionally, we routinely utilize and lobby sue as is possible during earlier surgical debride-
for the universal use of a two-table or “dual” ments, one does not commit to a specific surgical
operative setup for each surgical debridement plan which may very well evolve or change as the
(Fig. 12.12). In this operative setup the first wound and the patient react to staged surgical
Fig. 12.12 The two-table setup during surgical debride- between the “dirty” (1) and “clean” (2) tables is of the
ment is a mainstay in our institutions “dirty” operative utmost importance in order to prevent the spread of bacte-
cases. The judicious prevention of cross-contamination ria and to avoid the falsification of tissue cultures
debridements. All too often, a surgeon will ampu- which can provide for the much-needed tissues
tate all toes or rays as part of a drainage amputa- used during a closure attempt.
tion to a localized area of infection of the forefoot.
While this often ensures the zone of infection has Methylene Blue
been eradicated, it needlessly disposes of healthy A method employed by the authors to ensure a
and viable portions of tissue of the toes and fore- more accurate evaluation and thus more effica-
foot which may have otherwise been utilized dur- cious debridement, especially those pending soft
ing an attempted closure and allows a general tissue closure, is to topically “paint” the wound
contracture of the remaining soft tissues, which with methylthioninium chloride (methylene blue)
can severely limit or even ruin the possibility of a immediately prior to surgical debridement
future closure attempt. Saving healthy and viable (Fig. 12.13). Sharp debridement, sufficient to
tissues permits the maintenance of length of remove all of the blue-stained tissue, provides a
tissues, as in the case of a partial foot amputation, clear delineation between more superficial
Fig. 12.13 The sequential use of methylthioninium chlo- the blue-stained tissue, provides a clear delineation
ride (methylene blue) is a novel method employed at our between tissues that harbor bacteria and underlying
institution. Sharp debridement, sufficient to remove all of healthy tissues
exposed tissues that harbor bacterial burden and tency of tissues are incredibly helpful determi-
the healthy tissues below with no deleterious nants of tissue viability, or nonviability.
effects to the viable tissues themselves [18]. The “color flag” of tissue viability is a useful
diagnostic determinate of tissue quality based
merely on the color of tissues upon their observa-
Assessing Tissue Viability tion (Fig. 12.14). Healthy and viable tissues will
appear red, white, and/or yellow in color. Care
A vital consideration for the processes of debride- should be taken to preserve these tissues during
ment, especially for surgical debridement, is the the debridement process. Unhealthy and nonvia-
assessment and ultimately the determination of ble tissues will have a black, blue (except for
tissue viability. Those tissues which are foreign, veins), purple, green, brown, and/or orange color
dead, dying, or infected must be removed from to them. These tissues should be clearly and
the wound bed and failure to do so will mean definitively excised in order to properly eradicate
assured failure of healing. While those tissues their burden within a wound.
that are overtly infected or dead are quite easy to Additionally, the consistency of tissues upon
delineate from the frankly healthy and uninjured palpation and manipulation is a useful determi-
tissues, it becomes increasingly difficult to make nant of overall viability. Those tissues, especially
an accurate declaration of tissue viability for when seen on the periphery of a wound, which
those tissues which are merely injured or altered are severely indurated, hardened, and immobile
from the wound progression or surgical interven- are to be considered nonviable tissues which
tions and lie somewhere between the two ends of should be excised. Truthfully, the excision of
the spectrum of tissue health. Additionally, tis- pathologically altered tissue consistency often
sues of all varieties and depths may endorse an permits the mobilization of the remaining tissues
altered character depending on the overall health for use in primary or delayed primary closure.
of the patient. For these reasons the determina- Alternatively, the removal of indurated and effec-
tion of tissue viability becomes a matter of sub- tively nonviable tissues will account for the
jective or qualitative judgement rather than removal of stalled tissues which would otherwise
objective or quantitative calculation. Fortunately, impede the healing process of a wound.
through the meticulous process of tissue evalua-
tion one can reliably predict the viability of most Microbiological Determination
tissues based on a thorough clinical and micro- Routinely, we perform operative tissue cultures
biological assessment. both prior to and immediately following the per-
formance of surgical debridement. These
Clinical Determination “pre-debridement” and “post-debridement” cul-
A meticulous clinical evaluation of the tissue tures are an important and guiding diagnostic
character is paramount in determining tissue via- aspect of wound management. In truth, the cul-
bility. The character of the tissues encountered ture data can determine the presence of latent
during surgical debridement may be quite varied infection or chronic bacterial harborization of a
and a sufficient evaluation for their viability can wound and are especially useful when the clinical
be difficult. One should aim to determine the determinants of tissue viability are misleading, as
viability of tissues as they relate to the tissue’s when the wound appears clinically viable and
inherent character. Tissues which deviate more healthy but is actually not yet sufficiently
widely from normal quality may be considered “primed” for closure techniques due to subclini-
nonviable and should be excised. Again, this cal bacterial harborization. Additionally, culture
determination may be easier said than done. data are an indispensable adjunct for catering
However, in this light, we suggest the utilization antibiotic choice and duration and when com-
of several clinical determinants in order to gauge bined with clinical and medical determinants of
tissue viability. Namely, the color and consis- tissue infection and health can significantly aid in
Fig. 12.14 Viable tissues will appear red, white, and/or yellow in color (“Color Flag” of Tissue Viability). Nonviable
tissues will appear black, blue (except for veins), purple, green, brown, and/or orange color to them
the clearance of infection and progression of to the etiology of the wound being more difficult
healing. It is important to obtain aerobic and to determine, and the measures to reverse the
anaerobic cultures of the wound as soon as pos- medical abnormalities are often much more com-
sible by obtaining a piece of deep, initially unex- plex. Even when the wound etiology has been
posed tissue. A swab culture of superficial tissue identified and addressed, debridement still plays
is of limited utility as it merely reflects the pres- the prominent role. Debridement converts the
ence of superficial skin flora as opposed to the chronic wound into an acute state so that it may
actual underlying bacteria responsible for the progress through the normal sequential stages of
infection. If there is access to a quantitative bac- healing. The key is for clinicians to be aggressive
terial culture laboratory, then a minimum of and not allow reservations about the residual tis-
0.3 cm3 of tissue specimen is necessary for the sue defect to limit an appropriate tissue
culture to be processed. A concentration of debridement.
greater than 105 bacteria per gram of tissue Multiple factors and considerations are at
reflects a significant infection that will inhibit play in the diabetic and comorbid populations
healing [19, 20]. and must be given attention, respect, and careful
consideration in both their assessment and man-
agement. A fundamental understanding and
Conclusion working knowledge of the complex interactions
between the numerous and varying physiologic
With the myriad of local and systemic complica- components involved in wound healing is para-
tions seen in the diabetic and comorbid patient mount. Advances and innovations in research
population, treating the complex foot and leg and technology will likely continue to evolve
wound environment can be a monumental under- our understanding and ability to efficaciously
taking for both the patient and physician alike. In treat this pathology. To this day, debridement
chronic wounds, healing is more protracted due remains the primary means of wound treatment
and is necessary in order to anticipate a success- tal lower extremity wounds. Plast Reconstr Surg.
2015;136(5):722e–3e.
ful outcome. However, the surgeon must adapt 9. Bunnell S. An essential in reconstructive surgery:
to the wound as it presents and evolves and cater atraumatic technique. Calif State J Med. 1921;19:204.
their treatment modalities to the patient and the 10. Kucan JO, Robson MC, Heggers JP, Ko F. Comparison
environment in which they are treated. of silver sulfadiazine, povidone-iodine and physi-
ologic saline in the treatment of chronic pressure
Regardless of the exact setting, the multidisci- ulcers. J Am Geriatr Soc. 1981;29:232–5.
plinary approach should be pursued and uti- 11. Tredget EE, Shankowsky HA, Groeneveld A, et al.
lized. This consortium of disciplines and A matched-pair, randomized study evaluating the
patient-specific treatment modalities is para- efficacy and safety of Acticoat silver coated dressing
for treatment of burn wounds. J Burn Care Rehabil.
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miology of mupirocin resistance among methicillin-
Acknowledgments No acknowledgements are made. resistant Staphylococcus aureus at a Veterans’
Affairs hospital. Infect Control Hosp Epidemiol.
2000;21:459–64.
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4. Attinger CE, Clemens MW, Ducic I, Levin MM, 16. Elmarsafi T, Garwood CS, Steinberg JS, Evans
Zelen C. The use of local muscle flaps in foot and KK, Attinger CE, Kim PJ. Effect of semiquanti-
ankle reconstruction. In: Dockery GD, editor. Lower tative culture results from complex host surgical
extremity soft tissue & cutaneous plastic surgery. 2nd wounds on dehiscence rates. Wound Repair Regen.
ed. Kidlington: Elsevier Science; 2011. p. 269–88. 2017;25:210–6.
5. Attinger CE, Janis JE, Steinberg JS, Schwartz J, 17. Carroll AM, Kim KG, Walters ET, Phillips BK, Singh
Al-Attar A, Couch K. Clinical approach to wounds: B, Dekker PK, Steinberg JS, Attinger CE, Kim PJ,
debridement and wound bed preparation including the Evans KK. Glove and instrument changing to prevent
use of dressings and wound-healing adjuvants. Plast bacterial contamination in infected wound debride-
Reconstr Surg. 2006;111(Suppl 7):72S–109S. ment and closure procedures: a prospective observa-
6. Broughton G, Janis JE, Attinger CE. The basic science tional study. Int Wound J. 2021;18:664.
of wound healing. Plast Reconstr Surg. 2006;117(7 18. Dorafshar AH, Gitman M, Henry G, Agarwal S,
Suppl):12S–34S. Gottlieb LJ. Guided surgical debridement: stain-
7. Shi E, Shofler D. Maggot debridement therapy: a ing tissues with methylene blue. J Burn Care Res.
systematic review. Br J Commun Nurs. 2014;Suppl 2010;31(5):791–4.
Wound Care:S6–13. https://doi.org/10.12968/ 19. Krizek TJ, Robson MC. The evolution of quantita-
bjcn.2014.19.Sup12.S6. tive bacteriology in wound management. Am J Surg.
8. DeFazio MV, Felder JM III, Economides JM, 1975;130:579–84.
Attinger CE. Home improvement in Maggot therapy: 20. Robson MC, Heggers JP. Delayed wound clo-
designing a simple, cost-effective, closed-system sure based on bacterial counts. J Surg Oncol.
habitat to facilitate biodébridement of complex dis- 1970;2:379–83.
An Evidence-Based Approach
to Treating Osteomyelitis
13
Benjamin A. Lipsky and Suzanne A. V. van Asten
Introduction osteomyelitis in children and young adults were

steady between the years 2000 and 2009, the rate
Infections of the foot are a common, complex, almost tripled among individuals older than 60
and costly complication of diabetes mellitus [1]. years, partly driven by a significant increase in
They are associated with considerable morbidity, DFO [5]. Furthermore, in this study, despite
cause substantial discomfort, require extensive treatment in a renowned referral medical center
medical care (in both outpatient and hospital set- (the Mayo Clinic), 68% of those with DFO
tings), and frequently lead to serious complica- underwent an amputation.
tions [2, 3]. Among persons with diabetes, about It is clear that DFIs that involve underlying
a quarter will develop a foot wound, just over half bone, compared to just skin and soft tissue, are
of which will be infected; the rate of osteomyeli- more difficult to successfully treat and are associ-
tis in these diabetic foot infections (DFIs) ranges ated with worse clinical outcomes. A study from
from <20% in mild infections to up to 80% in Pittsburgh found that among patients hospital-
severe infections (Fig. 13.1). Perhaps the most ized for a DFI, those with bone involvement,
frequent major complication of diabetic DFI is compared to those with just soft tissue infection,
lower extremity amputation. This outcome is had a significantly higher: number of operative
associated with 5-year mortality rates of about procedures (an extra 0.5); mean hospital length
50% [4], which exceeds that those of most can- of stay (by 1 day); and rate of lower extremity
cers. Most of the DFIs that lead to hospitalization amputation (OR 5.6) [6]. Studies from Dallas [7]
or amputation are those that progress to involve and Istanbul [8] have shown similar findings, and
underlying bone. Thus, diabetic foot osteomyeli- also significantly longer durations of both antibi-
tis (DFO) has become one of the leading, and otic therapy and time to wound healing for the
fastest growing, causes of bone infection. One DFO cases. Similarly, a meta-analysis of 12 stud-
study from the USA found that while the rate of ies of DFO found that the likelihood of isolating
a multidrug-resistant pathogen was threefold
higher than in soft tissue DFI [9]. Thus, optimiz-
B. A. Lipsky (*)
Department of Medicine, University of Washington, ing management of DFO is crucial in limiting a
Seattle, WA, USA variety of associated complications, but espe-
e-mail: [email protected] cially lower extremity amputations.
S. A. V. van Asten
Department of Medical Microbiology, Leiden
University, Leiden, The Netherlands

176 B. A. Lipsky and S. A. V. van Asten
Fig. 13.1 The epidemiology of diabetic foot infections [3]
Pathophysiology infection can spread horizontally and vertically,

following the path of least resistance along the
Most cases of DFO represent contiguous spread tendons to involve progressively deeper soft tis-
of infection from adjacent soft tissues to bone sues. At some point the infection can involve the
[1]. These infections typically begin with a break cortex of underlying bone (osteitis), and then
in the skin envelope, most often related to a dia- make its way into the bone medulla or marrow
betic foot ulcer. The main predisposing factors (osteomyelitis). Only in rare instances is DFO
for these ulcers are the long-term presence of specifically a consequence of vascular insuffi-
peripheral neuropathy, usually accompanied by ciency, hematogenous spread, or direct inocula-
peripheral arterial disease. Similarly, limited tion of microorganisms.
joint mobility or structural deformities (either
spontaneous, traumatic, or postoperative) may
lead to abnormal weight bearing, thus ulceration. Microbiology
Microorganisms, almost always bacteria, from
either contiguous skin flora or an exogenous Any microorganism that infects the skin can
inoculation, will colonize any open wound. As spread to involve bone. The etiologic agents
diabetes of long duration is often accompanied causing DFI depend on many factors, including
by various humoral and cellular immunological the geographic location of the patient (e.g., cli-
perturbations [10], colonizing organisms can mate and socio-economic issues), the chronicity
reach critical levels, usually defined as ≥105 col- of the wound (which can evolve over time),
ony forming units/gram of tissue. At this point where the infection was acquired (e.g., home ver-
signs and symptoms of inflammation, classically sus a health-care institution), specific exposures
redness, warmth, swelling, pain or tenderness, or (e.g., waterborne pathogens like Pseudomonas),
purulent secretions, may appear. The presence of and any recent antimicrobial treatment (often
two or more of these findings classifies the leading to antibiotic-resistant pathogens). Most
wound as infected. Unchecked, this superficial DFIs in North American and European countries
13 An Evidence-Based Approach to Treating Osteomyelitis 177
are caused by aerobic gram-positive cocci, espe- tissue specimens near the bone [14, 15]. In gen-
cially Staphylococcus aureus, and to a lesser eral, specimens of bone, compared to those of
extent streptococci, enterococci, and coagulase- soft tissue, grow fewer isolates, and most often
negative staphylococci [11]. Cultures of speci- the predominant pathogen is S. aureus. Optimally,
mens from chronic wounds often grow multiple a specimen of bone should be obtained by aseptic
isolates on wound cultures, particularly if they sampling, either at the time of open surgery or by
were from a swab rather than tissue. Wound cul- percutaneous puncture though closed and unin-
tures from a patient presenting in a warm climate, fected skin. Bone specimens taken through an
with a chronic infection, or who has been recently open wound are likely to grow organisms that are
treated with antimicrobials are more likely to contaminants [16]. As with all bacterial cultures,
grow aerobic gram-negative organisms, includ- recent or current antibiotic therapy may result in
ing Enterobacteriaceae and P. aeruginosa. false-negative results. In this case, conducting a
Obligately anaerobic bacteria are likely present histopathologic examination of the specimen
in many infections, but relatively infrequently may help detect evidence of infection, and even
isolated because: (1) anaerobic cultures are not show the Gram-stain morphology of the infecting
specifically ordered or available; (2) appropriate organism(s). Only a few studies have examined
specimens for growing anaerobes (tissue) are not the results of employing molecular microbiologi-
collected; (3) microbiology laboratories often do cal techniques on bone specimens from DFO. In
not process specimens optimally for anaerobes; one study of 20 patients in Sydney, DNA sequenc-
and (4) reports of the presence of anaerobes are ing found that 70% of the bone samples had poly-
often provided separately and later, and thus do microbial flora, with the most commonly isolated
not influence treatment. When anaerobic organ- species being Corynebacterium, followed by
isms are reported, they are most often isolated Finegoldia, Staphylococcus, Streptococcus,
from necrotic or ischemic wounds; they are also Porphyromonas, and Anaerococcus [17]. Another
more often detected by molecular (genotypic) study found that molecular, compared to standard
than standard (phenotypic) microbiologic tech- culture, techniques for DFO bone specimens
niques [12]. more often revealed anaerobic and fastidious
As with other DFI, bacteria causing DFO may organisms [12]. These results are similar to those
be resistant to commonly used antibiotics, espe- from molecular microbiologic studies of soft tis-
cially if the patient has recently been treated with sue infections. It remains unclear, however, how
antibiotics (topical or systemic). The most com- to use these data clinically—specifically, which
mon drug-resistant pathogen in DFO is of the several isolated organisms are pathogens
methicillin-resistant S. aureus (MRSA) [13]. The that must be specifically targeted with antibiotic
incidence of MRSA in DFI, after rising in the late therapy.
twentieth and early twenty-first century, has While sampling a bone specimen provides the
decreased more recently. A preliminary study most accurate microbiological information for
from Rome (likely conducted in the early 2000s) both diagnosing osteomyelitis and selecting
reported that of 765 episodes of DFI among 482 pathogen-specific antibiotic therapy, it is not
patients, 59.4% of S. aureus isolates were MRSA required in every case [18]. Certainly, obtaining a
[13]. More recently, a case series of 302 patients bone specimen is easy if the plan is to operate on
with osteomyelitis of the foot and ankle (84% of the foot. If not, percutaneous bone biopsy is safe,
whom had diabetes) from northern California but it requires a skilled clinician, adds expense
found that MRSA was isolated in 28.3% of (for both obtaining and processing the specimen),
selected patients in 2005, but only 10.6% of and takes extra time both to obtain the specimen
selected patients in 2010 (p = 0.03) [11]. and for processing (especially for histopathol-
Several studies have shown that in cases of ogy) [14]. While not always needed, sampling
DFO, cultures of specimens from bone are more bone is particularly useful when the diagnosis of
accurate than those from soft tissues, even deep osteomyelitis remains uncertain based on other
diagnostic studies, or in cases where predicting be high. One study that followed 184 cases of
the pathogen (or its antibiotic susceptibility) is foot osteomyelitis (89% of which were in patients
difficult. known to have diabetes) for a mean of 9 months
after they underwent surgical resection found that
an unplanned resection of bone or major amputa-
Treatment tion occurred in 34% of the patients at 1 year, and
in 41% by 2 years [26]. Significant risk factors
Osteomyelitis is a difficult infection to treat [19]. for failure by multivariate analysis included
Reasons for this include: the infection is usually infection with P. aeruginosa or E. coli and inad-
chronic (characterized by necrotic bone) by the equately addressed peripheral arterial disease.
time it is diagnosed; bone has a limited blood Perhaps the most recent and comprehensive guid-
flow (and therefore relatively few leukocytes); ance for treating DFO is found in the recently
and the most common pathogens are virulent updated guidelines on infection from the
(e.g., S. aureus) and usually biofilm producers [9, International Working Group on the Diabetic
20]. Biofilm infections are characterized by bac- Foot (IWGDF) [3]. The IWGDF recommenda-
teria with a low multiplication rates and reduced tions specific to managing DFO are summarized
susceptibility to antibiotics [21]. in Table 13.1.
Before the 1940s, surgical resection was the
only proven successful method of eradicating
bone infection. Amputations (most often above- Surgical Treatment
the-knee) were the main treatment for DFO
because of concern, in the absence of antibiotic Surgical resection of infected and necrotic bone
therapy, for infection spreading proximally if all was the first, and perhaps remains the principal,
infected bone and soft tissue were not removed. approach to treating chronic osteomyelitis. It
In the early 1940s oral sulfonamide therapy was allows rapid and effective reduction of the bacte-
tried, but with what degree of success is unclear. rial load at the infected site, removes necrotic tis-
It was the arrival of penicillin antibiotics in the sues, and may allow reconstruction that will
mid-1940s that led to dramatically improved suc- avoid future foot ulcerations [27]. Surgery may
cess rates in treating DFO [19]. While surgical be required in several situations, as when: bone
resection was still frequently employed, along protrudes through the ulcer; imaging reveals
with antibiotics, they were more often bone- extensive bone destruction or progressive bone
sparing and any required amputations could usu- damage in a patient undergoing antibiotic treat-
ally be performed at a more distal level. ment; the soft tissue envelope is destroyed; or
Starting in the mid-1980s reports of outcomes there is gangrene or spreading soft tissue infec-
for DFO patients who either refused or could not tion [28]. The presence of either limb ischemia or
tolerate surgery demonstrated that antibiotic ther- soft tissue infection (especially both) in a case of
apy without bone resection could cure some DFO is associated with a worse prognosis. One
cases. There are now many published cases series study reported that when neither of these compli-
[22, 23], and at least one randomized controlled cated DFO, conservative surgery achieved 100%
trial [24], demonstrating that antibiotic therapy success, while in the cases with ischemia and
without surgery for properly selected patients spreading soft tissue infection 78% required
with DFO can offer similar results to those with some type of amputation and the mortality rate
surgery. A review of 10 studies of DFO managed was 13% [29]. The planned surgical approach to
with nonsurgical antibiotic treatment found DFO should balance removing as much infected
remission rates of 64–83% (Fig. 13.2) [25]. Even bone as possible against preserving foot function
with combined antibiotic and surgical therapy, [28]. In the hands of experienced surgeons, “con-
however, failure rates of treatment for DFO can servative” (foot sparing) surgery, based on preop-
83% 81% 80%

Study Design 75% 75% 73%
70% 67%
64% 64%
RCT
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Retrospective
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Fig. 13.2 Reported rates of remission of diabetic foot osteomyelitis treated with antibiotic therapy but without surgical
resection. (Modified from [25], with permission). RCT randomized controlled trial
Table 13.1 Recommendations from the International Working Group on the Diabetic Foot (IWGDF) 2019 guidelines
specific to treatment of diabetic foot osteomyelitis (DFO) [3]
Strength of
Number of the recommendation; level
recommendation Brief description of recommendation of evidence
Recommendation (A) In uncomplicated forefoot DFO with no other indication for Strong; moderate
21 surgery, consider antibiotic therapy without surgical resection of
bone
(B) With probable DFO and concomitant soft tissue infection, Strong; moderate
urgently evaluate the need for surgery and intensive postoperative
medical and surgical follow-up
Recommendation Select antibiotic agents for DFO from among those that have Strong; moderate
22 demonstrated efficacy for osteomyelitis in clinical studies
Recommendation (A) Treat DFO with antibiotic therapy for ≤6 weeks. If infection is Strong; moderate
23 not improving within 2–4 weeks: reconsider the need for bone
culture; undertake surgical resection; or select an alternative
antibiotic regimen
(B) Treat DFO with antibiotic therapy for just a few days if there is Weak; low
no soft tissue infection and all the infected bone has been surgically
removed
Recommendation For DFO initially requiring intravenous therapy, consider switching Weak; moderate
24 to an oral regimen with high bioavailability after ~5 to 7 days, if the
likely or proven pathogens are susceptible to an available oral agent
and there is no clinical condition precluding oral therapy
erative imaging and intraoperative evaluation Systemic Antibiotic Therapy

with attention to conserving bones and the soft
tissue envelope, has produced good long-term Patients who undergo surgical resection for DFO
outcomes. One prospective study reported a rate should almost always also receive systemic anti-
of recurrence of infection after conservative sur- biotic therapy. Exceptions may include cases in
gery for DFO of only 4.6% [30]. which it is clear that all infected bone and soft
tissue have been removed. Treating patients with Route of Administration

DFO exclusively with antibiotics may offer the
potential to avoid: hospitalization; the expense To ensure achieving adequate bone levels of antibi-
and risk involved with surgical procedures; and otics, clinicians assumed that high serum concen-
biomechanical problems (e.g., transfer or recur- trations were needed [31]. Achieving these high
rent ulcers) that may be induced by surgical serum levels to treat osteomyelitis was thought to
resection of all or part of the foot [20]. Appropriate require parenteral (generally intravenous) therapy.
cases for nonsurgical treatment are generally For almost 40 years, however, evidence from case
those: (1) with infection limited to the forefoot; reports and case series suggested that therapy with
(2) that do not require extensive soft tissue resec- orally administered antibiotics that had high bio-
tion; and (3) in which the causative pathogen is availability could successfully treat DFO
susceptible to highly bioavailable oral antibiotic (Table 13.2). The recently published OVIVA study,
agents. a randomized controlled multicenter trial in the UK
After the introduction of penicillin, several of 1054 evaluable patients treated for complex
other newly developed antibiotic agents were bone and joint infections (including DFO), demon-
found to be useful for treating bone infections. strated that predominantly oral antibiotic therapy
Starting in the 1970s, studies conducted mainly was noninferior to intravenous antibiotic therapy
in the laboratories of Carl Norden (Pittsburgh) when used during the first 6 weeks, and was associ-
and John T. Mader (Galveston) with experimen- ated with few catheter-related complications and
tal animal models provided information on char- lower financial costs [32]. A retrospective cohort
acteristics of antibiotics that were associated with analysis from Switzerland assessing the role of oral
better outcomes [22]. In addition to covering the amoxicillin/clavulanate in treating DFI reported on
most frequently isolated pathogens, agents that the results of 794 cases, including 339 with DFO
penetrated bone (i.e., had a high bone/serum con- [33]. They found that the rate of clinical remission
centration) appeared to be most clinically useful with this oral agent was 74%, similar to that with
(Table 13.2). These included penicillins, amino- other antibiotic regimens and specifically similar
glycosides, clindamycin, vancomycin, cephalo- for cases with DFO.
sporins, co-trimoxazole, fluroquinolones,
linezolid, and especially rifampi(ci)n. Some
believe that bactericidal antibiotics provide better Specific Agents
outcomes than bacteriostatic agents for treating
osteomyelitis, but there is little published evi- Recent studies have addressed the value of antibi-
dence to support this assertion. otics that have been available for decades, but for
Table 13.2 Bioavailability, bone to serum concentration, and activity against biofilm of oral antibiotics for diabetic
foot osteomyelitis [27, 31]
Antibiotic agent Oral bioavailability (%) Bone/serum concentration (%) activity Biofilm activity
Fluoroquinolones 65–85 65 Yes
Co-trimoxazole 50 70–90 Yes
Tetracyclines >90 >70 Yes
Clindamycin >90 40–67 Yes
Linezolid >90 >70 Yes
Rifampi(ci)n >90 40–>90 Yes
Fusidic acid 80–90 44 Yes
Amoxicillin/clavulanate <80 – No
Flucloxacillin 5–20 40–75 No
Cefuroxime-axetil <80 – No
Clarithromycin <80 – ?
Metronidazole >90 100 ?
which there have been few studies in DFO ies available, treatment of osteomyelitis with oral
(Table 13.3) [34]. A narrative review of the litera- flucloxacillin (a narrow spectrum, safe, low-cost
ture from Switzerland found that, in contrast to agent) does not appear to be associated with more
prevailing opinions and the few descriptive stud- clinical failures than other oral antibiotic agents
Table 13.3 Systemic (intravenous and/or oral) antibiotic agents to consider for treating diabetic foot osteomyelitis
based on bioavailability and bone concentration [34]
Infection
severity Pathogens Possible antibiotics Comments
Mild Staphylococcus aureus (MSSA) Levofloxacin QD dosing; substandard for S. aureus
(MSSA) Amoxicillin- Relatively broad spectrum and anti-anaerobic
clavulanate Cephalexin Requires QID dosing; inexpensive
Streptococcus spp. Dicloxacillin/ Narrow spectrum; QID dosing; inexpensive
flucloxacillin
Clindamycin Covers (most macrolide sensitive) MRSA
and anaerobes
Methicillin-resistant Doxycycline MRSA, some gram negatives; QD dosing
S. aureus (MRSA) Trimethoprim/ MRSA, some gram negatives; undefined
sulfamethoxazole against Streptococcus species
Moderate/ MSSA; Streptococcus spp.; Ertapenema QD dosing. Broad-spectrum anti-anaerobic;
severe Enterobacteriaceae; obligate poor against Pseudomonas aeruginosa
anaerobes
Ampicillin-sulbactam Relatively broad spectrum but not for P.
aeruginosa or other resistant gram negatives
Imipenem-cilastatin Broad spectrum; not active for MRSA;
(other carbapenems) consider for proven/suspected ESBL
producing pathogens
Levofloxacin or Both oral and parenteral dosage forms
ciprofloxacin with suitable. Limited studies of clindamycin for
clindamycin severe S. aureus infections; possible
anti-toxin effect
Moxifloxacin QD dosing. Broad spectrum, including
anaerobes
Ceftriaxone QD dosing (IV or IM); 3rd gen.
cephalosporin
MRSA Linezolida Oral and IV; adverse effects, drug
interactions
Tigecycline Broad spectrum including MRSA; frequent
gastrointestinal upset; less effective than
others
Vancomycin Narrow spectrum; rising MICs in MRSA
isolates
Daptomycin QD dosing; monitor CPK levels
Pseudomonas aeruginosa Piperacillin- TID or QID dosing
tazobactama
MRSA, Enterobacteriaceae, P. Vancomycin plus: Very broad spectrum for empiric therapy in
aeruginosa, anaerobes severe infections; narrow spectrum when
– Piperacillin- culture and sensitivity results become
tazobactam, or available
– Ceftazidime vs.
cefepime, or
– A carbapenem
MRSA methicillin-resistant Staphylococcus aureus, MSSA methicillin-sensitive Staphylococcus aureus
a
US FDA-approved for diabetic foot infection indication
[35]. The authors concluded that the few pub- mannii. These agents, if shown to be effective for
lished studies demonstrate that after any required DFIs (and specifically DFO), might be useful for
debridement, treatment with flucloxacillin by a treating those that are more serious, polymicro-
short intravenous course followed by oral bial, and particularly caused by drug-resistant
administration is a safe and effective option for infections.
treating osteomyelitis, perhaps including DFO.
Rifampi(ci)n is an antibiotic agent that has
high bioavailability when taken orally, good pen- Duration of Therapy
etration into bone, and activity against biofilm
organisms, including S. aureus. It has been used Antibiotic therapy is generally given for a con-
(always in conjunction with another agent active siderably longer duration for osteomyelitis than
against S. aureus to avoid development of resis- for soft tissue infections—typically 4–6 weeks.
tance) for decades (especially in Europe) to treat Many clinicians, however, treat even longer if all
osteoarticular infections, but many clinicians necrotic and infected bone has not been resected
avoid using it because of concerns about resis- [2]. This longer duration of therapy is based more
tance and frequent interactions with many other on the theoretical problems associated with treat-
drugs [22]. Recent interest in the potential value ing infected bone, as discussed above, than on
for adding rifampi(ci)n to combination therapy data from trials comparing different durations of
for DFO led to an observational cohort study therapy [22]. Certainly, prolonged treatment of
using the database of the US Veterans Health DFO is associated with adverse effects. For
Administration [36]. They found that among example, a study from Dallas of 143 patients with
6174 patients treated for DFO with antibiotics bone biopsy proven osteomyelitis found that 47
(and no amputation), only 130 (2.1%) received (33%) developed acute kidney injury [39]. If
rifampin. But, these patients had a significantly there were evidence that prolonged therapy is
lower rate of mortality and amputation within 2 associated with better clinical outcomes, this
years of diagnosis than those treated without benefit might well outweigh the potential risks of
rifampin (odds ratio by logistic regression 0.65, higher rates of drug-related adverse events,
p = 0.04). Spurred by these findings, this group is increased chances of antibiotic resistance devel-
currently conducting a randomized controlled oping, or greater financial costs of therapy. The
trial of 6 weeks of rifampin therapy (versus pla- limited available published evidence has not,
cebo) added to conventional treatment (without however, demonstrated any benefit for prolonged
rifampin) to see the effect on reducing pedal therapy.
amputations (VA INTREPID) [37]. One open-label, multicenter, controlled ran-
Some newly marketed antibiotic agents have domized study from France compared nonsurgi-
been approved for treating acute bacterial skin cal treatment of DFO with 6 weeks versus
and soft tissue infections (ABSSI), but none have 12 weeks of antibiotic therapy [40]. Among the
been specifically investigated for DFIs [38]. 40 evaluable patients, the remission rate was
These include delafloxacin (available in IV and 65%, with no significant differences between the
oral formulations), which differs from older fluo- treatment groups, but with significantly fewer
roquinolones in having an expanded spectrum of gastrointestinal adverse events in the shorter (6
activity that includes MRSA, P. aeruginosa, and week) treatment group [40]. Similarly, a retro-
common obligate anaerobes. Another new agent spective cohort analysis study from Switzerland
is omadacycline (available in oral formulation), a employing a cluster-controlled Cox regression
tetracycline derivative that is approved for ABSSI model assessed factors related to remission of
that has a very broad spectrum, which even DFIs, including DFO [41]. They found that DFO
includes vancomycin-resistant enterococci, episodes treated with <3 weeks of antibiotic ther-
extended spectrum beta-lactamase producing apy had similar outcomes to those receiving
gram-negative bacilli, and Acinetobacter bau- >3 weeks. They also noted that outcomes were
not significantly different between episodes DFO [45]. The authors deemed that the quality of
treated with more than 1 week of intravenous most of the studies was good, and found no sig-
therapy (including the intravenous route nificant differences in the outcomes between the
throughout the entire course) than for shorter various treatment arms, except for poorer out-

durations of intravenous therapy. comes with tigecycline compared to ertapenem.
Based on these observations, a recent random- An evidence-based narrative review of treatment
ized, non-inferiority pilot trial in Switzerland of DFO that particularly focused on the role of
compared clinical remission and adverse event surgical as well as antimicrobial therapy included
rates in patients with DFO who underwent surgi- 65 articles [27]. The authors concluded that the
cal debridement, and were then randomized to main advantage to treating DFO “medically” is
either 3 weeks or 6 weeks of antibiotic therapy that it avoids the biomechanical changes that may
[42]. Among 93 enrolled patients, remission of occur after surgical procedures, and that it may
infection was noted in 84% of patients in the be more cost effective. They noted that the medi-
3-week arm compared to 73% in the 6-week arm, cal approach is limited by the need for prolonged
and the rates of adverse events were similar. The administration of antibiotics, which is associated
same group of investigators is currently conduct- with drug-related side effects (including
ing a larger trial (with a planned enrollment of Clostridioides difficile disease and the emergence
400 diabetic patients with soft tissue or bone of antibiotic-resistant organisms), risk of relaps-
infection of the foot) designed to see if they can ing infections (from failing to adequately steril-
confirm the results of this pilot study [43]. A ize bone tissue), and the persistence of any
group from the UK is also currently undertaking existing bone deformity at the site of the inciting
a randomized controlled open-label non- foot ulcer. They point out that antibiotics that
inferiority trial on duration of systemic antibiotic achieve the preferred bone to serum concentra-
therapy for orthopedic infections treated operation ratios of >0.3 (i.e., fluoroquinolones, sulfon-
tively with local antibiotic therapy [44]. They amides, tetracyclines, macrolides, rifampi(ci)n,
plan to enroll 500 patients (including those with fusidic acid, and oxazolidinones) are also those
DFO) who will be treated with either a short with the highest oral bioavailability, making them
course (≤7 days) or long course (≥4 weeks) of potentially good candidates for prolonged treat-
systemic antibiotic therapy. The primary end- ment of outpatients with DFO.
point will be definite treatment failure within
12 months of surgery, while secondary outcomes
will include treatment side effects, quality of life Intra-osseus or Topical Antimicrobials
scores, and cost analysis. For now, it seems
unnecessary to treat DFO for more than 6 weeks, For decades clinicians have treated DFO with a
and even shorter durations may soon be proven to variety of antimicrobial agents (particularly gen-
be sufficient. tamicin, tobramycin, or vancomycin) delivered
Several authorities have reviewed various directly into infected bone in one of several dif-
issues concerning the treatment of DFO in the ferent ways, including in the form of beads (usu-
past few years. A narrative review from France ally polymethylmethacrylate, and more recently
noted that most of the antibiotics that exhibit both calcium sulfate/hydroxyapatite), spacers, or
satisfactory bone diffusion and oral bioavailabil- cement [46]. These agents have been used not
ity, especially rifampi(ci)n, fusidic acid, and fluo- only to deliver antibiotics to treat bone infection,
roquinolones, have a substantial propensity to but to fill dead space, and in some cases to try to
select for resistant mutants; thus, they should be prevent infection [47]. Ideal delivery agents
prescribed in combination with agents active should: be biocompatible; have minimal toxicity;
against the causative pathogen [31]. A systematic allow for osteointegration; and yield prolonged
review of interventions for management of DFI drug release. Although local antibiotic treatments
identified 11 studies conducted in patients with are widely used, there is little high-quality evi-
dence on the appropriate indications, techniques, reliable to confidently use this information in
dosages, types of antibiotics, elution properties, selecting an antibiotic regimen. Clinicians should
or pharmacokinetics [48, 49]. select agents that have demonstrated their effec-
tiveness in clinical trials. Second, antibiotic
agents that are active against biofilm organisms
Outcome of Treatment may be more effective in treating bone infection.
Third, treating osteomyelitis for more than 6
Determining the outcome of treatment of osteo- weeks is usually unnecessary, and even shorter
myelitis requires having an agreed upon defini- durations (perhaps 3 weeks) may be sufficient.
tion of clinical resolution of infection. Clinically, Fourth, antibiotic therapy administered predomi-
healing of any overlying soft tissue infection or nantly by the oral route appears to be as effective
wounds suggests likely clearing of the underly- (with lower rates of adverse effects and cost)
ing bone infection. Bone imaging can be helpful compared with intravenous therapy. Finally, in
in demonstrating probable resolution of infection appropriately selected cases, antibiotic therapy
but, just as evidence of the presence of infection without surgical resection can resolve DFO. As
lags the clinical course, resolution of bony noted, there are several ongoing trials that should
changes can lag as well. A fall in previously ele- soon further inform our approach to managing
vated serum inflammatory markers, especially this common and difficult infection.
the erythrocyte sedimentation rate and to a lesser
degree C-reactive protein and procalcitonin, may
also suggest resolution of infection [14, 15]. In References
one study of 24 cases of bone biopsy proven DFO
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Practical Lessons Learned
in Managing Diabetic Foot
14
Infections
Andrew I. Abadeer, Mark R. Abbruzzese,

and William Davis
Introduction ceptibility of the diabetic foot to infection is beyond

the scope of this chapter, a brief review must frame
The infectious implications in the diabetic foot can- the clinical management. The disruption of the
not be overstated. While it is well known that dia- homeostatic mechanisms of blood glucose in the
betics have an increased propensity to develop both diabetic results in a chronic state of hyperglycemia.
systemic and localized infections, the diabetic foot This, in turn, is the cause of upregulation of multi-
offers a self-perpetuating cycle for infection that has ple metabolic pathways which ultimately results in
been well studied as the most common precipitating vascular insufficiency. Nerve damage and subse-
event leading to lower extremity amputation [1–3]. quent paresthesia impair the natural protective sen-
As such, a firm understanding of the pathophysiol- sation of the foot. The immune system is similarly
ogy and the medical, surgical, and vascular modali- impaired with studies demonstrating a stunted
ties available to the clinician charged with the care immune response to infection with decreased TNF-
of the infected diabetic foot must inform the alloca- alpha and interleukin-6 release from macrophages,
tion of multimodal therapy that is requisite in good demonstrated in animal models [7], impaired poly-
outcomes in this population. morphonuclear leukocyte migration, and decreased
Approximately 85% of lower extremity ampu- efficacy of intracellular killing [5]. Chronic hyper-
tations are preceded by a non-healing foot ulcer glycemia (beginning as low as serum glucose l evels
[4]. Complicating this picture, the presence of >150 mL/dL [8]) also impairs opsonophagocyto-
infection increases the risk of lower extremity sis, the expression of MHC-I expression on
amputation by 50% [5]. In focusing on the diabetic myeloid cells [9, 10], as well as myriad other
foot, current research has demonstrated that the mechanisms that continue to be elucidated. As
unique demands in addition to the homeostatic such, any physical insult to the diabetic foot
insult of the disease process inherent to the diabetic becomes immediately compounded by a lack of
make the diabetic foot uniquely sensitive to clini- sensation, lack of perfusion, and a dysregulated
cally devastating infection [6]. While an exhaustive and inefficient immune system.
review of the mechanisms that propagate the sus- Given the “perfect storm” of such disparate
factors that balance the diabetic foot into a pre-
carious homeostasis, it is important that the clini-
A. I. Abadeer (*) · M. R. Abbruzzese · W. Davis
Medstar Georgetown University Hospital, cian approach the infected diabetic foot armed
Washington, DC, USA with an informed understanding of the severity of
e-mail: [email protected]; the patient’s presentation, the utility of investiga-
[email protected];
tory studies and imaging, and the indications,
[email protected]

188 A. I. Abadeer et al.
efficacy, and appropriateness of a prescribed anti- the temporal changes in symptomatology, incit-
biotic regimen. ing events, and antecedent trauma. The patient’s
baseline ambulatory status before and after the
current presentation must also be elucidated.
The Initial Presentation Similarly, glycemic control in the weeks leading
up to presentation should be interrogated
The infected diabetic foot can present along a informed by a current Hemoglobin A1C.
broad spectrum ranging from clean ulcers, to a Upon clarification of the presenting history,
mild cellulitis, to a life-threatening necrotizing the physical exam in the infected diabetic foot
fasciitis. As such, in an attempt to objectively must first begin with a localization of the area of
grade the severity of the diabetic foot infection, interest and its character. Often, providers will
many classification criteria have been set forth. find that patients have kept a photographic
The IWGDF has defined a system ranging from a account of their wound which can greatly assist
Classification of 1 (uninfected) to 4 (severe infec- the clinician in establishing the progression or
tion) based on a combination of physical exami- regression of a wound. Infection without a cor-
nation findings as well as objective laboratory responding wound should be delimited, circum-
data. Confirmation of infection in this grading scribed, and dated, with a marking pen to assess
system includes physical findings such as local for attrition. In open wounds, the size of the
swelling/induration, peri-wound erythema, local wound should be measured and compared to his-
pain/tenderness, or purulent discharge. The dis- toric values. Specific attention should be sequen-
tinction in the IWGDF classification between tially given to the base of the wound and the
moderate and severe infection is defined as the surrounding tissues. The base of the wound
presence or absence of two or more of systemic should be qualified according to the substrate
inflammatory response syndrome symptoms (bone vs. soft tissue) as well as the presence or
(SIRS, criteria of which include body tempera- absence of granulation tissue, fibrous exudate,
ture, heart rate, respiratory rate, and white blood and purulence. Should there be suspicion of bone
cell count) [2]. The Infectious Diseases Society at the base of the wound, the probe-to-bone test
of America (IDSA) also has a similar grading should be employed out of concern for osteomy-
system based on similar criteria with classifica- elitis [13]. This test consists of the use of sterile
tions ranging from “Uninfected” to “Severe metal probe to assess if bone comprises the base
Infection” [11, 12]. It is important to note, how- of the diabetic ulcer. In the context of cortical
ever, that these classification systems do not then irregularities on X-ray, and laboratory values
correlate to a prescribed clinical course of action. suggestive of infection, this triad of findings is
The first clinical decision point to be made by sufficient to diagnose osteomyelitis without fur-
the clinician in the ambulatory or emergency set- ther imaging [2]. The surrounding tissues should
ting is a determination of the setting of care also be inspected closely for fluctuance or indu-
including but not limited to ICU admission, floor ration, lymphangitis, or proximal
admission, or clinic follow-up. Given the sys- lymphadenopathy.
temic derangements mentioned previously it is Laboratory values such as the white blood cell
often difficult to efficiently characterize a count (WBC), C-reactive protein (CRP), and
patient’s wound and the need for admission. In erythrocyte sedimentation rate (ESR) have an
recognition of this, we recommend a systematic important role in supplementing and informing
and organized approach to the initial evaluation the findings of the history and physical exam.
of the infected diabetic foot with emphasis on a The white blood cell is an aggregate marker of
thorough and focused history and physical exam lymphoid and myeloid cells in the bloodstream.
informed by the judicious use of labs and imag- Leukocytosis is generally accepted as suggesting
ing. The clinician must elicit the relevant course a pro-inflammatory state with differential diag-
of the diabetic foot with particular emphasis on noses including infection, autoimmune disorders,
14 Practical Lessons Learned in Managing Diabetic Foot Infections 189
or hematologic neoplastic proliferation. While a care, and interval of follow-up must also be
markedly elevated or depressed white blood cell thoughtfully considered when evaluating the
count may indeed point to underlying infection, infected diabetic foot patient for potential outpa-
the white blood cell count in diabetics should be tient management. In fact, many a patient’s
used with caution, particularly when normal. wound has deteriorated due to a failure to opti-
Often, given the immunologic derangements mize one or more of these factors when the
described previously, the WBC of a patient with a wound was clinically stable upon initial
diabetic foot infection does not correlate to the presentation.
severity of the infection with some studies dem-
onstrating more than half of patients admitted
with diabetic foot infections having a normal anagement of the Diabetic Foot
M
WBC [14]. As such, a normal WBC should not Infection
deter the clinician from escalating care when
confronted with clinical exam findings concern- The management of diabetic foot infections is
ing for severe infection. naturally a multidisciplinary endeavor. Due to the
Due to the limitations of the WBC in deter- generally complex medical and social comorbidi-
mining the presence or absence of infection, a ties of this population, a coordinated approach
number of adjunctive laboratory measures have between infectious disease, medicine, and sur-
been investigated to supplement the information gery must be undertaken to optimize patient care.
gleaned from the WBC including ESR and The mainstay of the clinical approach to the
CRP. In the author’s experience, these values infected diabetic foot ulcer must be comprised of
have little utility in isolation, but act as an addi- surgical debridement and antibiosis. Both the
tional datapoint with either an equivocal physical surgical team and the infectious disease team
exam or in the monitoring of treatment efficacy. should adopt a microbiology-driven approach
In the infected diabetic foot ulcer, a markedly based on the available microbiological testing of
elevated ESR may also hint at the presence of their specific institution. Ideally, sterile tissue
osteomyelitis in addition to soft tissue infection. cultures would be obtained and sent prior to the
Importantly, in comparison to ESR, CRP levels initiation of any antimicrobial therapy (the “sen-
are more responsive to the progression and reso- tinel” culture). Still, this is often not possible in
lution of infection, making it of higher clinical the septic or systemically ill patient in whom
utility in tracking treatment efficacy [15, 16]. antimicrobial therapy should be initiated imme-
The decision to hospitalize or manage a diately. Upon presentation to the operating room,
patient as an outpatient depends heavily on each it has become our practice to obtain a culture
of these factors. Additional reasons to manage a prior to any debridement if it is the first formal
patient in an inpatient manner include the need debridement the patient has undergone. After
for advanced diagnostic or interventional proce- appropriate debridement (discussed at length in
dures, parenteral antibiotics, surgical consulta- Chap. 13) and irrigation, a sterile tissue culture is
tion, the failure of outpatient antibiotics, or the again taken and sent for microbiological assess-
management of preexisting or exacerbated medi- ment. The type of culture will depend largely on
cal conditions including congestive heart failure, the capability of the individual institution though
coronary artery disease, chronic obstructive pul- the sensitivity and specificity of tissue specimens
monary disease, or acute/chronic kidney disease are generally higher than those of swabs [18–21].
[2, 17]. Still, while the clinical and laboratory We do not routinely obtain blood cultures on any
data that define the severity of infection must be patient that is not demonstrating signs of sys-
a core axis upon which to make the decision for temic infection.
inpatient admission, this cannot be the only fac- The duration and type of antimicrobial ther-
tor informing the care setting. Social support, apy is made upon the basis of the extent of infec-
wound stability, patient reliability, complexity of tion, the involvement of bone, and the type of
190 A. I. Abadeer et al.
pathogen. Osteomyelitis demonstrates a unique Special populations in the infected diabetic

challenge in the treatment of the infected diabetic foot ulcer include those with recent or threatened
foot ulcer. With a positive probe-to-bone test, and skin grafts, free flaps, and underlying hardware.
consistent X-ray and clinical findings, the Given the high-risk nature of these circum-
treatment of osteomyelitis is based upon surgical stances, close consultation with the surgical team
and infectious disease consultation. A sterile is necessary to determine the scope and duration
bone biopsy obtained after debridement of an of antimicrobial therapy in a case-by-case
infected ulcer remains the gold standard for diag- manner.
nosis of osteomyelitis as these cultures will assist
in the determination of duration and scope of
antibiotic therapy. In consultation with infectious Conclusion
disease, it is our general practice to treat osteo-
myelitis with antibiotics at the higher end of the Diabetic foot infections are a devastating, multi-
recommended range and for a longer duration faceted, and self-perpetuating consequence of the
than patients who have a soft tissue infection diabetic insult to homeostasis. Inadequacy of
alone [22]. Discussion with the surgical team diagnosis, treatment, or follow-up can lead to
after completion of debridement is paramount. adverse outcomes including amputation. A
Should the surgical team be confident in a com- thoughtful and thorough history and physical
prehensive osseous debridement back to clini- examination, buttressed by judicious use of imag-
cally normal bone supported with a negative ing and laboratory values, will empower the cli-
sterile bone culture supporting these findings, it nician to appropriately triage these patients into
is reasonable to then reduce the duration of anti- an appropriate treatment plan. Close consultation
biotic therapy. with surgery as well as an objective, culture-
Whether by swab, or tissue specimen, a based approach is critical in determining the
culture-based approach to antimicrobial therapy duration, scope, and intensity of treatment.
is critical both for antibiotic stewardship, and to Finally, close surveillance is key to allow for
appropriately target and comprehensively treat a early detection of failure to improve or worsen-
patient’s specific infection. Should empiric cov- ing infection that may warrant a further workup
erage be required, this is done based on institu- or an alternative treatment regimen.
tional statistics for most likely pathogens.
Coverage for gram-positive cocci should nearly
always be included in initial empiric coverage, References
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9. Mazade MA, Edwards MS. Impairment of type III 17. Wukich DK, Hobizal KB, Brooks MM. Severity of
group B streptococcus-stimulated superoxide produc- diabetic foot infection and rate of limb salvage. Foot
tion and opsonophagocytosis by neutrophils in diabe- Ankle Int. 2013;34(3):351–8.
tes. Mol Genet Metab. 2001;73(3):259–67. 18. Nelson A, Wright-Hughes A, Backhouse MR, Lipsky
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AIF, Stagg AJ, Knight SC. Methylglyoxal modulates in diabetic foot ulcer infection): a cross- sectional
immune responses: relevance to diabetes. J Cell Mol study of wound swab versus tissue sampling in
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Chohan F, et al. Use of the SINBAD classification 19. Huang Y, Cao Y, Zou M, Luo X, Jiang Y, Xue Y,
system and score in comparing outcome of foot ulcer et al. A comparison of tissue versus swab culturing
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Managing Soft Tissue Infection
in the Diabetic Foot: Cultures,
15
Drugs, and Source Control
Eric Senneville and Romina Deldar
Soft Tissue Infection aureus or beta-hemolytic streptococci (e.g.,

of the Diabetic Foot Streptococcus agalactiae) may lead to an acute
infection. Non-healing ulcers seen in patients liv-
Diabetic foot infection (DFI) is classically ing with diabetes mellitus (DM) are mainly a
defined by the multiplication of microorganisms consequence of peripheral neuropathy which per-
and invasion of the tissues surrounding a wound mits the patient to keep walking on the wound
located under the malleoli. Although the microor- because of the loss of pain sensation and/or
ganisms that invade the skin and soft tissues peripheral arterial disease (PAD) both of which
(SSTs) around and/or beneath a wound ulcer can- can delay ulcer healing and, as result, favor the
not be seen on physical examination, they are occurrence of a DFI. Although not fully under-
consistently present on the ulcer surface [1]. The stood, the immunological dysfunction associated
consequences of these postulates are (a) infection with diabetes increases the risk of infection [3].
of a diabetic foot ulcer cannot be established by Pathogenic bacteria and commensals (e.g., S. epi-
means of microbiological assessment and (b) the dermidis, Corynebacterium spp.) coexist in non-
best way to diagnose infection is to assess the healing foot ulcers and interact with each other as
SSTs around the ulcer for the presence of clinical they do in other wounds [1]. Recent advances in
signs of infection [2]. knowledge about the microbiota of DFUs have
DFIs usually are due to a neuro/vasculopathic promoted the concept of pathogenicity of bacte-
ulcer but other causes include a simple puncture, ria in DFUs as bacterial communities rather than
a wound in the interdigital space, or from the nail independent specific bacteria [4]. The bacterial
plate. The colonization of the wound by patho- population present in a DFU is therefore now
genic microorganisms such as Staphylococcus considered a functional unit that organizes itself
as functionally pathogroups secondary to the
interactions between commensals and virulent
bacteria. For instance, the commensal bacterium
E. Senneville Helcococcus kunzii can reduce the virulence
Infectious Diseases Department, Gustave Dron
Hospital, Tourcoing, France expression in S. aureus [5].
R. Deldar (*)
Department of Plastic and Reconstructive Surgery,
MedStar Georgetown University Hospital,
Washington, DC, USA

194 E. Senneville and R. Deldar
Microbiology of the Diabetic Foot iagnosis of Soft Tissue Infections

D
of the Diabetic Foot
Numerous distinct microorganisms including
bacteria and fungi can be identified in DFUs [6]. The diagnosis of a DFU infection is a major step
Studies have principally addressed bacteria that that allows for the implementation of all thera-
are consistently identified in DFUs. S. aureus is peutic measures, but also importantly can help
by far the most prevalent microorganism identi- reduce the unjustified use of broad-spectrum
fied in temperate regions, while Gram-negative antibiotics since no clinical studies have demon-
bacilli especially Pseudomonas spp. are most strated any benefit of systemic antibiotic therapy
commonly identified in warm climate countries on the evolution of an uninfected diabetic foot
[7, 8]. wound [17]. According to the definition of DFI
The duration of a DFU is a major reason it proposed by the International Working Group on
can become infected. S. aureus strains present in the Diabetic Foot (IWGDF), the clinical elements
non-healing DFUs are likely to harbor antibiotic suggestive of a DFU infection include at least
resistance and encode staphylococcal entero- two of the following: local swelling or indura-
toxin genes resulting in nonspecific stimulation tion, erythema >0.5 cm around the wound limits,
of a wide population of T cells responsible for sensibility, or local pain (rare), increased local
persistent inflammation which delays the heal- heat, and the presence of pus located under the
ing process [5]. The expression of bacterial viru- malleoli [2]. The IWGDF proposes to grade the
lence influences the evolution of a DFU towards severity of the infection according to the surface
infection; this has been observed in S. aureus in and depth extension (moderate infection), pres-
which several virulent genes have been signifi- ence of systemic signs (severe infection), and
cantly associated with the evolution to infection involvement of underlying osteoarticular struc-
[6]. Enterobacterales (e.g., Proteus mirabilis, tures (see Chap. 17) [2].
Escherichia coli, Klebsiella sp., or Enterobacter
sp.) and strict anaerobes (e.g., Finegoldia sp.,
Bacteroides sp.) are usually encountered during icrobiological Assessment of Soft
M
chronic wound infections [9–12]. Fungal agents, Tissue Infections
in particular Candida sp., are not uncommon of the Diabetic Foot
[13]. More than half of infected DFUs are poly-
microbial [9–12]. Recent data suggest that the Once a clinical suspicion of DFI is established, a
expression of virulence can be attenuated by microbiologic assessment is recommended to
antibiotics and also stress conditions in the ulcer best target antimicrobial therapy [18]. Overall,
environment (e.g., oxygen pressure, low temper- tissue samples (curettage-biopsy, true-cut biopsy,
ature, elevated glucose concentration, nutrient needle aspiration, especially in the case of a sub-
limitation) [14]. These elements lead to the cutaneous abscess) have a sensitivity and speci-
emergence of quasi-dormant subpopulations of ficity higher than those of simple swabs which
bacteria, including small-colony variants likely are not recommended as they do not allow for the
to exhibit antibiotic resistance and biofilm for- distinction between pathogens and colonizers
mation that are inaccessible to most antibiotic [19]. One technique using swabs (Levine’s tech-
agents [15]. Polymicrobial biofilms, in which nique) has been validated for microbiological
bacterial strains organized in pathogroups can assessment of a DFU. It consists of rotating the
escape the host immune responses, are involved wound swab over a 1-cm2 area of the wound [20].
in 60–80% of non-healing DFUs compared to The quality of the sample is very important since
6% in acute DFUs [16]. the detection of live bacteria in a tissue sample
15 Managing Soft Tissue Infection in the Diabetic Foot: Cultures, Drugs, and Source Control 195
taken appropriately to avoid contamination is a be used to assess the evolution of infection as it

strong argument for the pathogenicity of the increases rapidly at the beginning of an infection
microorganism(s) identified. However, it may not and then decreases when the infection improves.
always be practical or feasible to obtain the most The level of leukocytes and/or neutrophils is not
sophisticated samples, thus it is preferable to at helpful to diagnose infection as they can be nor-
least obtain a sample even if it is not of optimal mal in more than half of cases [25]. However,
quality than to not do it at all. In cases when leukocyte counts may be useful since it is part of
obtaining a culture is not feasible, any microbio- the criteria for defining a severe infection (grade
logical information, such as Gram stain [21], can 4 in the IWGDF classification; see Chap. 15).
help tailor antibiotic treatment, especially in
cases of poor evolution after first-line antibiotic
treatment. The concordance between Gram stain anagement of the Diabetic Foot
M
and culture results established in diabetic patients Infection
with SST infection of the foot is likely to aug-
ment the pathogenic role of the identified bacte- urgical Part of the Treatment
S
ria and may help providers choose the most of Infection
appropriate antibiotic regimens [2].
New molecular techniques can now identify The surgical management of DFIs and osteomy-
most of the microorganisms present in a elitis is detailed in Chap. 14. It is important to
DFU. These techniques cannot, however, differ- consider surgical intervention as a major, even
entiate living from dead microorganisms, and indispensable in some cases, mode of infection
they do not provide data about the antibiotic sen- source control. Surgical debridement is a radical
sitivities of identified bacteria. At best, they can weapon against infection to remove any necrotic
determine the presence of certain resistance material and drain purulent collections, which are
genes. Moreover, there are no criteria to ascertain not accessible to the activity of most antibiotics.
that isolated bacteria are responsible for an infec- Neglecting this essential therapeutic step can
tion diagnosed clinically. As a result, although lead to the spread of infection and treatment fail-
these new techniques are essential to understand ure. In addition, exposing high bacterial loads to
the pathophysiology of wound infection and the inappropriate antibiotic concentrations because
relations between microbes and wound healing, of the necrotic nature of infected tissue will likely
they do not yet have a place in the daily care of favor the emergence of multidrug-resistant
patients with DFIs [2]. One exception is the bacteria.
detection by direct polymerase chain reaction
(PCR) of methicillin-resistant S. aureus (MRSA)
nasal carriage, which has been significantly asso- Antimicrobial Therapy
ciated with MRSA DFI and can aid in the choice
of antibiotics in patients with DFIs and screening General Aspects
for MRSA colonization in DFU patients [22, 23]. Antimicrobial therapy of DFIs is almost always
empiric since it is recommended to start treat-
ment as soon as the infection is diagnosed as the
Biomarkers of Infection outcome of the infection is not predictable in this
setting [2]. Knowledge of which microorganisms
Serum biomarkers of inflammation, such as are likely to be involved in DFIs can aid in choos-
C-Reactive Protein (CRP) and procalcitonin, ing empirical antimicrobial treatment. Therefore,
may be useful in situations where the clinical to tailor empiric antibiotic therapy, it is important
diagnosis of DFI is uncertain [24]. They can also to consider epidemiological data on bacterial
ecology, if available, and to involve microbiolo- ntibiotics Useful for the Treatment
A
gists/infectious disease consultants in complex of SST DFIs
cases [26]. The goal of empiric initial antibiotic As only one randomized study has established
therapy is to cover the likely pathogens and to the superiority of ertapenem over tigecycline
avoid the use of unnecessary broad-spectrum [27], the current recommendations for empiric
antibiotics, as antimicrobial resistance is more antibiotic therapy for DFIs are mainly based on
likely to emerge with broad versus narrow expert opinions [2].
antibiotics. Intravenous vancomycin can be used empiri-
The choice of an antibiotic regimen to treat a cally to cover Gram-positive cocci (i.e.,
DFI should be based on the likely methicillin-resistant staphylococci) in conjunc-
microorganism(s) and its(their) antibiotic suscep- tion with antibiotics against Gram-negative
tibilities. Patients with infected non-necrotic bacilli (GNB) and strict anaerobes, such as
acute wounds who have not recently been treated piperacillin-tazobactam or carbapenems, in mod-
with antibiotics are likely to be infected with S. erate to severe cases due to the narrow-spectrum
aureus and/or beta-hemolytic streptococci [2]. In of vancomycin. The IDSA recommends a dose of
warm climate countries, the higher prevalence of 15–20 mg/kg every 8–12 h for S. aureus to
Gram-negative bacilli may justify the use of achieve a minimal inhibitory concentration
broader-spectrum antibiotics. Strict anaerobes (MIC) ≤1 mg/L [28]. The use of vancomycin in
involved in DFIs are generally susceptible to patients who are age 65 years or older with renal
most antibiotics, except Bacteroides species. disease and/or take other nephrotoxic medica-
Other important criteria include infection sever- tions exposes those patients to the risk of renal
ity, existing data on the efficacy of the agent in toxicity. Daptomycin, a cyclic lipopeptide, has
treating DFIs, its tolerance profile, including the the same antibacterial spectrum as vancomycin,
risk of drug-drug interactions, mode of adminis- with a higher and faster bactericidal effect and
tration, and cost. almost no renal toxicity.
Parenteral antibiotic therapy is indicated ini- The combination of the group A penicillin
tially in some moderate and all severe DFIs. A agent, amoxicillin, with the beta-lactamase inhib-
switch to oral form should be considered once the itor (BLI) clavulanic acid confers a broad-
patient is clinically improving, as long as he/she spectrum oral antibiotic against beta-hemolytic
has no contraindications to oral therapy and an streptococci, methicillin-susceptible staphylo-
oral regimen is available. In other cases, patients cocci, some GBN (e.g., Proteus mirabilis and
with DFIs can be treated with oral agents provid- some strains of E. coli), and almost all strict
ing the oral bioavailability is correct (i.e., oral anaerobes. This combination is recommended for
oxacillin should be avoided, but cephalexin is a the treatment of mild to moderate SST DFIs
good option). especially chronic ulcers in which polymicrobial
The duration of antibiotic therapy for DFI is a communities may be involved, DFIs, and local-
matter of debate. The recommendations have ized cellulitis. The drug does not provide any
evolved in the past few decades to include dura- coverage against bone infections.
tion of 1–2 weeks for SST DFIs. Prolonging Among the anti-Gram-negative antibiotics,
treatment for up to 3–4 weeks is proposed by both ceftazidime and cefepime have the advantage
IWGDF in cases of extensive infection that is to cover Pseudomonas aeruginosa, although the
improving slower than expected or if the patient direct pathogenicity of this bacterium has been
has severe peripheral artery disease [2]. It is questioned, as it was for Enterococcus faecalis, in
important to specify a treatment end date when the setting of SST DFIs. Cefepime exhibits some
prescribing an antibiotic regimen to avoid unnec- activity against AmpC (depressed chromosomic
essary prolonged treatments and to discourage cephalosporinases)-producing GNB, particularly
prolongation of treatment until the wound has Enterobacter sp. Both ceftazidime and cefepime
healed [17]. can result in serious adverse nervous system
effects; thus plasma concentrations must be moni- both Gram-positive (streptococci and staphylo-
tored, especially in patients with renal impairment cocci) and anaerobic bacteria but no activity
and/or previous history of seizure disorders. The against GNB. The activity of clindamycin against
combination of piperacillin and the BLI tazobac- some strict anaerobes such as Bacteroides spp.
tam can cover P. aeruginosa, E. faecalis, and strict has decreased these last years, making it no lon-
anaerobes, as well. This broad-spectrum antibiotic ger appropriate as empiric antibiotic treatment in
should be limited to the moderate and severe DFIs cases where anaerobes may potentially be
in conjunction with amikacin in cases of septic involved. The D-test should be available for
shock to both enhance the bactericidal activity and detecting inducible resistance to clindamycin,
augment the antibacterial coverage to extended- especially in the case of MRSA-related DFIs.
spectrum beta-lactamases (ESBL)-producing Clindamycin may modify taste (bitter or metal-
GNB. The Food and Drug Administration (FDA) lic) and is frequently associated with diarrhea,
has approved piperacillin-tazobactam for the treat- including Clostridium difficile infections, espe-
ment of complicated SST DFIs but not for diabetic cially in fragile and elderly patients. Clindamycin
foot osteomyelitis. Among the carbapenems, does not require adaptation to renal function.
ertapenem has broad-spectrum bactericidal activ- Metronidazole has a very broad anti-anaerobic
ity directed against a wide spectrum of Gram- spectrum of activity except for Cutibacterium
positive cocci, GNB, and anaerobes, except acnes, complete oral bioavailability, and excel-
enterococci and Pseudomonas sp. (which differs lent tissue diffusion. The use of this antibiotic
from imipenem and meropenem), and its use is may however result in peripheral neuropathy and
approved by the FDA for treating DFIs [29]. It is toxic encephalopathy, especially with a treatment
effective against ESBL and AmpC-producing bac- duration longer than 2 weeks. In addition, patients
teria. Confusion and/or seizures may occur espe- should be cautioned not to drink alcohol while
cially in elderly patients with renal insufficiency. taking metronidazole due to the risk of tachycar-
The main advantage of ertapenem is its long dia, palpitations, nausea, and vomiting (disulfi-
half-life which allows for once-daily dosing via ram effect).
intravenous/intramuscular/subcutaneous adminis- Fluoroquinolones are concentration-
tration. Prolonged infusions, including continuous dependent bactericidal antibiotics with good cov-
infusion of beta-lactam agents, are likely to maxi- erage against GNB and Gram-positive bacteria,
mize the time that serum concentrations remain including Streptococcus spp. and E. faecalis, for
above the MIC of the bacteria within the infected levofloxacin, moxifloxacin, and even some
sites about the time-dependent activity of beta- fluoroquinolone- resistant staphylococci for the
lactam agents. new agent delafloxacin. These agents achieve
Doxycycline is a bacteriostatic tetracycline excellent tissue diffusion and high oral bioavail-
antibiotic with broad coverage against Gram- ability (levofloxacin) but are limited in the treat-
positive bacteria including most MRSA strains, ment of SST DFIs given the risk of selection of
GNB including Klebsiella sp., E. coli, some resistant mutants, especially with staphylococci,
Enterobacter strains, and Clostridium sp. The and should probably be reserved for the treatment
overall tolerance of doxycycline is good with of diabetic foot osteomyelitis (DFO).
only a few cases of pruritus, photosensitization,
few cases of diarrhea, and exceptional lupus- Choice and Adaptation
induced reactions reported. The drug is contrain- of the Antimicrobial Therapy
dicated in patients with esophageal lesions, liver Some propositions inspired by the 2019 updated
cirrhosis, and portal hypertension due to the risk IWGDF guidelines for the empiric antibiotic reg-
of hemorrhage. Doxycycline does not need renal imens are presented in Table 15.1.
or body weight dosing. The use of microbiological results is another
Clindamycin is a member of the macrolide important step in the management of DFIs. These
family with a bacteriostatic effect directed against results are usually available within 3 days of sam-
Table 15.1 Empiric antibiotic regimens for non-osteomyelitic soft tissue diabetic foot infections
Additional factors Usual pathogen(s) Potential empirical regimens
Mild (grade 1) infections
No complicating GPC S-S pen; 1st-gen. cephalosporin
features
β-lactam allergy or GPC Clindamycin; FQ; TMP-SMX; doxycycline
intolerance
Recent antibiotic GPC + GNB βL-βLaseI-1; TMP-SMX; FQ
exposure
High risk for MRSA MRSA Linezolid; TMP-SMX; doxycycline; macrolide
Moderate to severe (grade 2 and 3) infections
No complicating GPC ± GNB βL-βLaseI-1; 1st, 2nd, 3rd-gen. cephalosporin
features
Recent antibiotics GPC ± GNB βL-βLaseI-1, 2nd, 3rd gen. cephalosporin; group 1
carbapenem (depends on prior therapy; seek advice)
Macerated ulcer or GNB, including P. βL-βLaseI-2; S-S pen + ceftazidime or cefepime;
warm climate aeruginosa ciprofloxacin; group 2 carbapenem
Ischemic limb/ GPC ± GNB ± strict βL-βLaseI-1 or 2; group 2 carbapenem; 2nd/3rd gen.
necrosis/gas forming anaerobes cephalosporin + clindamycin or metronidazole
MRSA and multi-resistant GNB
MRSA risk factors MRSA Consider adding, or substituting with, glycopeptides;
linezolid; daptomycin; fusidic acid; TMP-SMX
MDR GNR risk ESBL Carbapenems; FQ; aminoglycoside and colistin
factors
Highly resistant GNB GNB, carbapenemases- New βL-βLaseI (ceftazidime-avibactam); cefiderocol
risk factors producing rods
Inspired by 2019 IWGDF guidelines
“Usual pathogens” refers to isolates from an infected foot ulcer, not just colonization at another site
Antibiotics should be at the usual recommended doses for serious infections. Where more than one agent is listed, only
one of them should be prescribed, unless otherwise indicated
Consider modifying doses of agents selected for patients with comorbidities such as azotemia, liver dysfunction, and
obesity when required according to the recommendations for each molecule
Oral antibiotic agents should generally not be used for severe infections, except as follow-on (switch) after initial par-
enteral therapy
Fluoroquinolones (FQ) and Rifampin may ease the emergence of resistant mutants and should be restricted to osteomy-
elitis complicating DFIs (authors’ personal opinion)
βL-βLaseI: β-lactam, β-lactamase inhibitor; βL-βLaseI 1: amoxicillin/clavulanate, ampicillin/sulbactam; βL-βLaseI 2:
ticarcillin/clavulanate, piperacillin/tazobactam; doxy: doxycycline; ESBL: extended-spectrum β-lactamase-producing
organism; FQ: fluoroquinolone with good activity against aerobic gram-positive cocci (e.g., levofloxacin, moxifloxacin
or delafloxacin); gen: generation; GNB: Gram-negative bacilli; GPC: Gram-positive cocci (Staphylococcus aureus and
β-hemolytic streptococci); group 1 carbapenem: ertapenem; group 2 carbapenem: imipenem, meropenem; ceph: cepha-
losporin; MRSA: methicillin-resistant S. aureus; S-S pen: semisynthetic penicillinase-resistant penicillin; cipro: antip-
seudomonal fluoroquinolone, e.g., ciprofloxacin: TMP-SMX, trimethoprim/sulfamethoxazole
pling and the patient’s situation should be outcome and before broadening the antibacterial
assessed at that time. If signs of infection have spectrum of treatment, a non-microbiological
decreased, treatment should be maintained unless cause of failure should be sought such as poor
the spectrum of the initial antibiotic regimen is adherence to treatment, presence of deep collec-
too broad and, therefore, should be reduced (de- tion, improper or no off-loading of the foot ulcer,
escalation). On the contrary, in the event of a etc. Alternatively, when the infection resolves
favorable outcome but resistant bacteria have under an antibiotic regimen that does not cover
been identified, the treatment should not be mod- the microorganisms identified from the ulcer, the
ified given the limited accuracy of most ulcer treatment should not be modified unless the
sampling techniques. In cases of an unfavorable infection worsens.
iofilm and Soft Tissue Infections

B biotic agents on the microbial diversity in healed
of the Diabetic Foot versus non- healed wounds, especially when
While acute DFIs due to metabolically active used topically [37, 38]. Topical antibiotic treat-
planktonic bacteria involve a direct host- ment of infected DFUs with gentamicin-laden
controlled response to virulence expression, sponges showed no beneficial effects [39, 40].
chronic episodes mostly related to polymicrobial Topical cadexomer iodine, which combines a
biofilms involve an inefficient inflammatory broad-spectrum antimicrobial and antibiofilm
response [30]. Biofilm formation is a complex effect, is efficacious in a recent meta-analysis on
process that involves different communities of the treatment of chronic wounds, including
microorganisms that are embedded in an DFUs [41].
extracellular matrix made of glycoproteins, poly-
saccharides, proteins, and deoxyribonucleic acids
[31]. The biofilm structure differs from one DFU Resolution of Infection
to another, given the multiple different microor-
ganisms potentially involved. The consequences While the definition of successful management
of biofilm formation are globally deleterious for of SSTs can easily be based on the resolution of
the wound healing process and the response to clinical signs of inflammation, including inflam-
antibiotic therapy by impairing antibiotic contact matory biomarkers, and not on microbiological
with bacteria and their antibacterial activity given cure, the issue is much more challenging for
the reduced metabolism of the microorganisms DFO. Given the high rate of recurrence of DFO,
present in the biofilm environment. The produc- it is generally recommended to evaluate the
tion of degradative enzymes results in an inflam- results of DFO at least 1 year after the end of
matory response which is depicted by some treatment.
experts as a biofilm-related infection [32]. The The origin of DFIs being a foot wound in
frustrated host immune response results in almost all cases and the prevention of a recurrent
chronic inflammation (depicted by some authors foot ulcer are of utmost importance (see Chap. 8).
as “chronic biofilm infection”) which delays
ulcer healing and creates tissue damage [30, 33].
Given the limitation of this phenomenon in a References
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Surgical Management of Diabetic
Foot Infection and Osteomyelitis
16
Venu Kavarthapu and Javier Aragón Sánchez
Introduction sentations; one study reported a figure of 51.7%

of mortality in a 6.5-year follow-up study [9].
Foot infection in people with diabetes is a dra-
matic complication. The most common point of
entry of the infection to the foot is an ulcer that Clinical Assessment
often is due to associated neuropathy, peripheral and Classifications
arterial disease, or both complications of diabe-
tes. It is estimated that 40–80% of diabetic foot A detailed and systematic clinical assessment of
ulcers (DFUs) become infected at any moment a patient with diabetes and foot infection by the
during their clinical course [1]. The epidemiol- surgeon is crucial for successful management. In
ogy of foot complications showed an increased the presence of diabetic peripheral neuropathy,
trend of diabetic foot infections (DFI), including the local and systemic clinical signs are often
osteomyelitis (OM) and necrotising fasciitis subtle, and it is critical that the clinical assess-
despite an 8-year decrease in the trend of DFUs ment is performed in a structured manner that
[2]. Infection is known to increase the costs asso- included appropriate history and clinical exami-
ciated with the treatment, often due to the need nation and supplemented with relevant investiga-
for patients’ admission [3]. Factors related to tions. This allows the surgeon and the
infection, such as depth, OM, and severity, will multidisciplinary team decide if the patient
condition the short-term outcomes in terms of requires an emergency procedure or delayed sur-
mortality and amputations [4]. Severe infections gery after a period of conservative management
carry a high rate of limb loss at 29.6% [5]. DFIs with antibiotics. Surgery should not be delayed in
also carry a readmission rate of about 10% [6, 7] rapidly spreading and deep infections because
to 24% [8], due to recurrence of infection. Finally, these are not well tolerated by patients with dia-
long-term mortality is high in this group of pre- betes and the risk of progression to diabetic foot
attack is high. That is especially true in cases of
severe infections which are associated with an
V. Kavarthapu (*) inflammatory systemic response [10].
King’s College Hospital, London, UK Some diabetic foot infections are not only
e-mail: [email protected] limb, but life threatening, and such presentations
J. A. Sánchez are often best managed in a multidisciplinary
Department of Surgery and Diabetic Foot Unit, setup. Sometimes, a timely minor amputation
Hospital La Paloma, needs to be considered for prevention of a major
Las Palmas de Gran Canaria, Spain

204 V. Kavarthapu and J. A. Sánchez
amputation, and a major amputation for saving tenosynovitis, and necrotising soft tissue infec-
the patient’s life. Limb salvage can sometimes be tions (necrotising cellulitis, necrotising fasciitis,
difficult when surgery is inadvertently delayed necrotising tenosynovitis, and myonecrosis),
because it allows the infection to proliferate and including diabetic foot attack (DFA) [23, 24].
destroy tissues beyond recovery and a timely sur- Deep abscesses and deep necrotising soft tissue
gical intervention is the key [11–13]. That is infections always require surgery and admission.
especially true in cases of deep tissue infections, The infection committee of the International
defined as those below the fascia [14]. Prompt Working Group on Diabetic Foot (IWGDF) has
surgical treatment including extensive use of recently suggested modifying the classification
revascularisation may reduce the need for above- of the severity of the infection. They proposed
ankle amputations [13, 15–17]. Such presenta- adding ‘(O)’ to moderate and severe infections
tions are best managed by a multidisciplinary groups that have an associated diagnosis of dia-
diabetic foot team (MDFT) that has access to betic foot osteomyelitis (DFO) [10].
specialist diabetic foot surgeons that can perform Another DFI classification commonly used is
surgery in a timely manner and offer functional from Infectious Diseases Society of America
limb salvage. The maxim ‘time is tissue’ is totally (IDSA). This classifies the DFIs as group 1 with
true in cases of DFIs with associated significant no infection, group 2 as mild soft tissue infection
ischemia. Another key point is deciding if the (STI), group 3 as moderate or severe STI, and
patients require admission or can be treated in an group 4 is moderate or severe bone infection
ambulatory basis. For these reasons, it is impor- [25]. Studies have shown that patients with DFO
tant to perform a detailed clinical assessment, had worse outcomes, more surgeries including
determine the grade, and classify the type of amputations, longer hospitalisations, higher rates
infection in patients with diabetes. of recurrent infection and readmission than
DFIs are classified according to their severity, patients with moderate and severe STI [25]. DFO
by International Working Group on the Diabetic has frequently been reported as a risk factor for
Foot (IWGDF) as mild, moderate, and severe amputation and poor outcomes [4, 8, 26] and for
[18] and this classification has later been vali- that reason suspecting osteomyelitis is critical at
dated [5]. IWGDF classifies DFI presentations the initial clinical evaluation. However, it has
that have associated systemic manifestations (of recently been reported that in cases of surgical
the systemic inflammatory response syndrome) diabetic foot infections, the presence of bone
as severe infections [10] and recommends con- infection was not associated with worse progno-
sidering hospitalisation for severe DFIs, and sis [27].
those with a moderate infections that are complex The management of DFO may be different
or associated with key relevant morbidities [10]. from those infections involving exclusively soft
Admission is also necessary in cases of failure of tissues. Osteomyelitis should be suspected in
outpatient management, when the patient is wounds that extended to a bone or joint and in
unable or unwilling to comply with outpatient- cases in which the patient has previous history of
based treatment, there is a need for more complex a wound and recurrent ulcers [28]. Checking the
dressing changes than patient/caregivers can pro- depth of the infection after removing infected
vide or when a careful, continuous observation is callus and tissue slough is important. However, it
needed [10]. However, the current evidence on has been reported that nearly 90% of the wounds
the protocol recommended for the need for hos- in one series were not evaluated for involvement
pitalisation is low [19]. of underlying structures [29]. Instrumental evalu-
From a pathological point of view, DFIs can ation is very useful for determining depth and
be classified into two main groups: soft tissue and detecting fistulous tracks, cavities, and bone
bone infections although it is very usual to find involvement. A blunt, 14.0-cm, 5F, stainless steel
both types together [20–22]. Soft tissue infec- eye probe [30] or a metal forceps (Halsted-
tions are then classified as cellulitis, abscesses, mosquito) [31, 32] is gently introduced through
16 Surgical Management of Diabetic Foot Infection and Osteomyelitis 205
the wound and the probe-to-bone (PTB) is con- needed not only for diagnosing DFO, but also
sidered ‘positive’ if bone (a hard or gritty sur- detecting the soft tissue involvement and spread
face) is palpable. PTB test had a sensitivity of of the infection in deep tissue planes. Magnetic
0.95, a specificity of 0.93, positive predictive resonance imaging (MRI) has been suggested as
value of 0.97, and a negative predictive value of the most useful imaging study to evaluate both
0.83 in advanced cases of infections in one study deep soft tissue infections and osteomyelitis [38].
[33]. A systematic review reported a pooled sen- However, the exact role of advanced imaging
sitivity of the PTB test of 87% (95% CI, 75–93%), studies to plan the surgery and determine the
specificity of 83% (CI, 65–93%), positive level of bone resection has still not been clarified.
predictive value (PPV) of 98%, and negative pre- Some studies on DFO reported that the extent of
dictive value (NPV) of 70% [34]. We can sum- infection could have been overestimated on an
marise that a positive PTB test in advance cases MRI [39]. Furthermore, preoperative MRI in
reinforces the suspicion of DFO. cases of DFO in ischaemic feet may be less effec-
The location of the point of entry of the infective for distinguishing osteomyelitis from reac-
tion in the foot is very important to predict the tive bone marrow oedema in cases of neuropathic
infection spread in deep tissue planes and com- ulcers [40].
partments. Suppuration through the ulcer while
palpating at a location distant from the ulcer is
consistent with a spreading infection. In some pplied Anatomy of Diabetic Foot
A
presentations, the index ulcer is located on the Infection
plantar aspect and there is cellulitis and fluctua-
tion on the dorsum of the foot. In such cases, it is It is essential that the treating surgeon has a good
frequent that the infection had involved the bone understanding of the compartmental anatomy of
migrating from a high-pressure plantar area to the foot. The foot is divided into rigid compart-
the low-pressure dorsal area. For this reason, it is ments and when an infection penetrates into a
uncommon that infections arising on the dorsal compartment, this can lead to raised compart-
aspect of the foot spread to the plantar area. ment pressures resulting in a compartmental syn-
Presence of tissue necrosis is a worrying sign in drome. When the compartmental pressure
such infections, especially when the patient has a exceeds the capillary pressure, necrosis of deep
good distal blood supply. In such cases, the sur- tissues including muscle and tendons appears.
geon should suspect the existence of a necrotis- Bacterial growth, toxins, and leucocyte response
ing soft tissue infection [23, 24] that often may also induce necrosis by direct tissular dam-
resulting in raised pressure inside the foot’s age and producing a neutrophilic vasculitis lead-
compartments. ing to secondary thrombosis and local ischemic
The initial imaging study to evaluate a DFI changes. These factors increase the extension of
infection is weightbearing plain radiographs of tissular death. Another consequence is that anti-
the foot in two standard views. It permits to detect biotics cannot penetrate to the infection site due
any foreign body, free gas in soft tissues, and to capillary blockage.
bone involvement. The reported sensitivity of The floor of the compartments is formed by
plain radiography in the diagnosis of osteomyeli- plantar aponeurosis, which is attached to the cal-
tis is usually low, especially in early stages of caneus and spread distally to the toes. There are
infection [35, 36]. In cases of high suspicion of three plantar compartments: medial, lateral, and
DFO and an X-ray without pathological findings, central. The medial and lateral compartments are
a sequential X-ray studies may be useful. That is separated from the central compartments by the
due to the fact that bone abnormalities can only medial and lateral intermuscular septum. The
be detected at least 2–4 weeks after the onset of interosseus compartment is located between the
bone infection when significant bone resorption metatarsal bones and contains the interossei mus-
is evident [37]. Advanced imaging studies are cles. Finally, the dorsal compartment located on
the dorsal aspect of the foot that contains a thin debridement is methodical and provides consis-
layer of subcutaneous tissue and the extensor ten- tent and complete resection of the infected and
dons. Infections of the first toe spread along the necrotic tissue to achieve infection clearance.
medial compartment, those involving second to Red–amber–green (RAG) model of surgical
fourth toes spread along the central compartment, debridement provides a structured model for the
and of the fifth toe spread along the lateral com- performing surgeon to achieve this [43]. The
partment. Sometimes, in cases of infections with- RAG model highlights the importance of under-
out appropriate treatment the infection breaks the standing different zones of infection spread and
septum and may involve the adjacent promotes the surgeon achieve full infection clear-
compartment. Furthermore, the infection may
ance. The infected diabetic foot has a central
migrate from the plantar to dorsal compartment zone of active infection with tissue necrosis that
through the interosseous compartment. Increasing is recognised as the ‘red zone’. This is surrounded
pressure into the interosseous compartment by an area of reactive tissue—a relatively avascu-
results in thrombosis of the blood vessels leading lar and fibrous tissue that potentially harbours
to toe necrosis even in well vascularised feet. small pockets of infections within it, considered
The forefoot, involving the phalanxes and as the ‘amber zone’. Outside this area is the
metatarsal heads, is the most frequent location of ‘green zone’ that contains normal and healthy tis-
diabetic foot osteomyelitis [23, 41]. A surgical sue that has a full healing potential. The RAG
series demonstrated that osteomyelitis was model recommends removal of all tissue in the
located at the forefoot in 90% of the cases, at the red and amber zones, until the green zone is
midfoot in 5%, and at the rear foot in another 5% reached circumferentially. This principle is appli-
of the cases [23]. Others have reported higher fig- cable to bone debridement as well.
ures of mid- and rear foot osteomyelitis [42]. In The internal spread of diabetic foot infection
the case that a joint is involved, the infection pro- is often along the tissue planes, from the zones/
duces a septic arthritis. If the infection progresses, compartments of high pressure to low pressure.
then infection spreads to the cartilage and adja- This is frequently seen along the tendon sheaths
cent bone. The tip of the toes has neither joint nor and this route is recognised as the ‘super-
tendon attachments and ulcers located in this area highway’ for the spread. It is critical that these
can easily reach the bone because only subcuta- tissue planes and tendon sheaths are probed,
neous tissue lies between the skin and perios- explored, and laid open during debridement so
teum. Bone prominences from lateral deformities that all areas of necrotic and reactive tissue are
such as the medial eminence from bunions are excised. Such infections with extensive tissue
also high-risk locations for ulceration and spread often require repeat surgical debridement
osteomyelitis. as some of the tissue in the amber and green
zones and the edge if resection die back.
rinciples of Surgical Debridement

P
of Diabetic Foot Infections lean Margins in Surgical Treatment
C
of DFO
The aim of surgical management of infected dia-
betic foot is to achieve complete infection eradi- It is critical that during exostectomy and ampu-
cation while retaining all healthy and non-infected tation procedures for DFO presentations, all of
tissue. This is accomplished by attaining infec- the infected bone is excised. Residual infection
tion clearance through surgical removal of all in the proximal bone margins after undergoing
infected tissues, followed by eradication of amputation for osteomyelitis may be associated
retained pathogens in the surrounding normal with a worse prognosis after surgical treatment
looking tissues by providing targeted antibiotic of DFO. Usually, the surgeon decides the loca-
therapy. It is critical that the technique of surgical tion at which osteotomy is carried out based on
the intraoperative inspection of the bone. Bone urgical Management of Forefoot

S
appearance, its consistency, the presence of Osteomyelitis
vascular thrombosis, fracture pus, and discol-
ouration are considered by the surgeon to The forefoot is the most frequent location of
choose the location of osteotomy and the extent osteomyelitis in the diabetic foot. Forefoot
of bone resection. Bone biopsy is taken from includes toes, metatarsal bones, interphalan-
the edges of bone resection for microbiological geal and metatarsophalangeals joints. Forefoot
and histological studies. It has recently been osteomyelitis that does not respond to local
suggested a standardised surgical dictation debridement and targeted antibiotic adminis-
regarding bone appearance based on density, tration is usually treated by means of some
anatomic structure, vascular thrombosis, type of amputations [42]. The most common
colour, and draining sinus [44]. However, some amputations performed to remove infected
reports highlight that those findings may be bone and soft tissues in diabetic patients with
inaccurate. One group of authors reported that forefoot osteomyelitis are toe, ray, and trans-
35.1% of patients had positive margins (defined metatarsal resections [49]. Conservative sur-
by histopathology) in a retrospective cohort. gery in which the infected bone and non-viable
Residual osteomyelitis at the proximal margin soft tissue are removed without performing any
was associated with a higher rate of treatment type of amputation is an accepted alternative to
failure, despite the longer duration of antibiotic amputation in some presentations [23, 50, 51].
therapy. A retrospective observational study However, the impact of this type of surgery on
involving 27 patients with DFO showed that the the quality of life and long-term recurrences
overall rate of residual osteomyelitis (based on when comparing with minor amputations has
intraoperative bone culture) was 40.7%. Nine not been addressed. Some conservative surger-
out of 11 patients (81.8%) with positive mar- ies, as an alternative to toe amputation, have
gins had poor outcomes [45]. Other authors been described. Osteomyelitis of the tip of the
found that patients in which proximal bone minor toes can easily be removed through the
specimens had a positive culture were more ulcer. This procedure can be carried out com-
likely to undergo repeat surgical intervention. bined with percutaneous flexor tenotomy to
However, the authors stated that the reason for, reduce the deformity of the toe [52, 53]. When
and benefit of, this additional surgery was the interphalangeal joint of lesser toes is
unclear [46]. Guidelines suggest that it could be involved by the infection, a resection arthro-
useful obtaining a specimen of bone for culture plasty can be considered [23, 54–56]. In a
(and, if possible, histopathology) at the stump series of 72 toes, a group of authors reported
of the resected bone to administer post-resec- successful outcome of excision arthroplasty
tion antibiotic therapy if positive [10]. However, for infected IPJs by performing extensive
the evidence is weak for the moment and the debridement of bone and soft tissues, thorough
definitive role of proximal culture, histopathol- irrigation of the wound, and stabilisation of IPJ
ogy, or both to guide a reintervention is not well using a Kirschner wire. Just three cases in this
stated. Regarding postoperative antibiotic ther- series underwent toe amputations and no prox-
apy, a retrospective series reported that imme- imal spreading of the infection was observed in
diate postoperative stopping of antibiotics after any other cases during the follow-up period.
amputation in the absence of residual infection Open arthroplasties leaving the postoperative
was not a risk factor of failure of the treatment wound to heal by secondary intention has also
[47]. In cases in which residual infections are been described in cases of diabetic foot osteo-
apparent after surgery of DFO, a period of 3 myelitis [55, 57, 58].
weeks was non-inferior to 6 weeks of postop- Neuropathic plantar ulcers under the meta-
erative antibiotic therapy in a recent randomised tarsal head may become complicated by osteo-
clinical trial [48]. myelitis. In such cases, amputation of the toe
and partial ray amputation including the meta- urgical Treatment of Infected Heel
S
tarsal head are the available surgical options. Ulcers
Plantar or dorsal approach can be used for
removing the metatarsal head or the metatarsal Infected plantar heel ulcers in people with dia-
phalangeal joint [52]. Conservative surgery betic peripheral neuropathy carry a high risk of
consisting of resection of metatarsal head is major amputation as these not only result in
also widely used [23, 58–64]. A group of osteomyelitis of calcaneal body, but also lead to
authors retrospectively compared the outcomes destruction of plantar heel pad. Heel is the sec-
of both approaches and reported that there were ond most common anatomical location for pres-
no differences regarding time to healing but sure ulcers [76]. The reported outcomes of
patients operated by dorsal approach experi- surgical management of heel ulcers are variable,
enced a higher rate of postoperative complica- as the earlier studies showed healing rates rang-
tions [65]. Transfer ulcers due to biomechanical ing from 35% to 74% [77], but the most recent
changes in the foot are very common when a ones revealed better outcomes with 97–100%
metatarsal head is removed either as part of ray limb salvage reported from treating centres
amputation or in isolation. That is especially [78–80].
true in cases in which the first metatarsal head Various surgical techniques have been reported
is removed [66]. First ray amputation is associ- on the surgical management of calcaneal osteo-
ated with severe biomechanical disturbances of myelitis to achieve limb salvage. These include
the foot, subsequent amputations [67–71], and partial or total calcanectomy. Cook et al., in 2007,
even the development of Charcot reported a 71.4% healing rate during the first year
Neuroarthropathy [72]. It has been suggested in their series of 50 partial calcanectomies for
that a more proximal level amputation, such as chronic non-healing ulcers. However, they found
a balanced transmetatarsal, might provide a a high rate of ulcer recurrence after 1 year, with
better functional and reliable residual weight- higher negative outcomes in the presence of
bearing foot [71]. Conservative approaches MRSA infection, vascular compromise, low
leading to save the hallux could be an alterna- albumin levels, and higher grade of preoperative
tive but there is no long-term follow-up of these ulcer [77]. Paola et al. reported a 100% ulcer
procedures. One-stage resection and pin stabili- healing rate, within their follow-up period of
sation [73] or the use of external fixation after 12 months, in their cohort of 18 patients treated
removing the infected bone [74] has been with open partial calcanectomy and application
described in a short series. Another group of circular external fixator [78]. Ngwe et al.,
reported a cohort including 28 patients with more recently, reported the outcomes of surgical
osteomyelitis of the first ray treated by a tech- management of 30 diabetic neuropathic heel
nique requiring a one-stage surgical approach ulcers with no critical limb ischemia, managed
[75]. After surgical debridement with removal with ulcer debridement without partial calcanec-
of the infected bone, the authors placed antibi- tomy when COM was present [80]. At a mean
otic-loaded bone cement and stabilised the follow-up period of 28 months (12–83), 50%
treated area with an external fixator [75]. Four achieved full ulcer healing and 97% had limb sal-
patients (14.2%) developed a relapse of the vage. A mortality rate of 38% was observed in
ulceration after the procedure. No ulceration this cohort. Only 9 out of 24 ulcers with calcaneal
recurrences, transfer ulcerations, shoe fit prob- osteomyelitis (p value 0.044) achieved full ulcer
lems, or gait abnormalities were detected in the healing. Local antibiotic delivery as an adjunct
other 24 patients (85.8%) [75]. Bone debride- during partial calcanectomy can help eradicate
ment and antibiotic-impregnated cement spacer any residual infection and promote complete
may be another option [58]. However, it is nec- infection eradication. Antibiotic-loaded inject-
essary to highlight that additional controlled able bone substitute is injected in multiple chan-
trials are required to evaluate this further. nels created by making drill holes in the residual
calcaneal body to achieve this [80]. This provides response. This is often triggered by a blister or
high tissue concentration of antibiotic for several skin break from minor trauma that leads to local
weeks that eradicates any residual pathogens [81, spreading of infection in different tissue planes
82]. Dramploas et al. reported 100% infection resulting in development of ulceration and
eradication and healing rate using similar tech- spreading cellulitis. Such presentation is labelled
nique in their series of 12 patients with infected as diabetic foot attack (DFA) and without a
heel ulcers and calcaneal osteomyelitis [79]. timely and emergent intervention, it can be limb
and life threatening [83]. Vainieri et al. reported
the outcomes of 106 patients presented with dia-
Principles of Exostectomy betic foot attack, with a mean follow-up of
18.4 ± 3.6 months [84]. They noted a major
An infected plantar ulcer, as a result of peak plan- amputation free survival in 71% of patients dur-
tar pressures due to underlying bone prominence, ing the first 12 months from admission that
requires exostectomy in addition to ulcer debride- reduced to 55.4% by the end of the follow-up.
ment, to achieve eradication of infection and DFA presentation is best managed by a multi-
ulcer healing. The ulcer first is excised and thor- disciplinary diabetic foot team for optimal out-
oughly debrided down to the floor, exposing full comes. It is critical that the diagnosis is reached
area of exostosis. The bone prominence is marked rapidly by performing appropriate clinical assess-
by careful palpation, cross checking under fluo- ment and urgent investigations. The investiga-
roscopy. The edge of the bone prominence is tions should focus on assessing the extent of
scored with an oscillating saw by about 5 mm infection and obtaining microbiological sensitivi-
depth. A curved osteotome is used to excise the ties. Plain radiographs often show soft tissue
exostosis completely within the marked zone. changes, including the presence of gas shadow.
The bone surface of the excised area is examined Deep tissue specimens are obtained for microbio-
for any areas of necrosis, discolouration, and logical culture and sensitivities, before com-
altered consistency, which may represent residual mencing empirical intravenous antibiotic therapy
area of infection and if present, this is thoroughly [85]. In the absence of an open ulcer or wound,
explored and excised. The surface and the edge ultrasound examination can be performed for
of the excised area are carefully inspected and assessment of deep collection and aspiration for
palpated for any residual bone prominence and microbiological studies. MRI is the most useful
excised if present. Local antibiotic eluting cal- imaging investigation as it provides the diagnosis
cium preparation can be applied around the bone and information on the extent of infection spread
or injected into bone channels drilled in the exos- that can be useful for surgical planning. However,
tectomy area to eradicate any residual infection it is critical that the appropriate investigations are
[79, 80]. The choice of the antibiotic is based on performed in a timely manner so that the surgery
microbiological sensitivities of deep tissue or is not delayed.
bone biopsy specimen culture results. The open DFA often needs emergent surgical interven-
wound is managed with either a local transposition. Aggressive surgical debridement, using the
tion flap or negative pressure wound therapy principles described above, is performed soon
(NPWT). after diagnosis as delay can cause further tissue
necrosis and potential limb loss. Repeat surgical
debridement is often required if the systemic
urgical Management of Diabetic
S inflammatory response does not improve or any
Foot Attack further tissue necrosis is identified. Targeted
intravenous antibiotic therapy, based on microbi-
Diabetic foot infection presentations can occa- ological sensitivities, is continued until the infec-
sionally spread rapidly along the tissue planes tion is completely cleared, as noted by the
resulting in necrosis and systemic inflammatory improvement in the clinical findings and normali-
sation of serological markers. The open surgical 8. Arias M, Hassan-Reshat S, Newsholme

W. Retrospective analysis of diabetic foot osteomyeli-
wound is managed with NPWT followed by skin tis management and outcome at a tertiary care hospi-
grafting or a local tissue flap. Due to the degree tal in the UK. PLoS One. 2019;14:e0216701.
of soft tissue and bone loss from the spread of 9. Ghanassia E, Villon L, Thuan Dit Dieudonne JF,
infection and surgical debridement, the affected Boegner C, Avignon A, Sultan A. Long-term outcome
and disability of diabetic patients hospitalized for dia-
feet often require expert treatment after the reso- betic foot ulcers: a 6.5-year follow-up study. Diabetes
lution of DFA presentation, including deformity Care. 2008;31:1288–92.
corrective procedures. 10. Lipsky BA, Senneville E, Abbas ZG, Aragon-Sanchez
J, Diggle M, Embil JM, et al. Guidelines on the diag-
nosis and treatment of foot infection in persons with
diabetes (IWGDF 2019 update). Diabetes Metab Res
Conclusion Rev. 2020;36(Suppl 1):e3280.
11. van Baal JG. Surgical treatment of the infected dia-
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12. Faglia E, Clerici G, Caminiti M, Quarantiello A, Gino
range from simple presentations to complex limb M, Morabito A. The role of early surgical debride-
and life threatening DFA. These require thorough ment and revascularization in patients with diabetes
clinical assessment, often in a multidisciplinary and deep foot space abscess: retrospective review
setup, and address the sequala of such infections, of 106 patients with diabetes. J Foot Ankle Surg.
2006;45:220–6.
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Charcot Foot Syndrome: Aetiology
and Diagnosis
17
William Jeffcoate and Fran Game
The Bottom Line The 1, 2, 3 of Diagnosis of the Charcot Foot:

The Bottom Line
Although the Charcot foot is not rare, it is thought
to be rare by many clinicians and few are aware Every clinician who is approached for
that any delay in diagnosis may lead to irrevers- advice by a person with an inflamed foot
ible, and potentially life-threatening, damage. In which has no obvious cause should remem-
a recent survey of medical staff in a very large ber three simple points:
teaching hospital in Michigan, some 68% respon-
dents admitted that their knowledge of the condi- 1. Has this person got diabetes?
tion was either rudimentary or non-existent [1]. A 2. Has this person got peripheral
similar survey in any other hospital—or in non- neuropathy?
specialist practice—in any country of the world 3. If yes to either of these, it should be
would confirm that such ignorance is common. assumed that they have an active
And while most doctors would be mortified if Charcot foot until proved otherwise.
they missed a common cancer in its early stages They should be advised to minimise
and failed to arrange for early expert assessment, weight-bearing and should be referred
few realise that the same approach is needed for for urgent expert assessment.
the best management of the Charcot foot. There
are observational data to suggest that delay in
diagnosis of active Charcot syndrome is associ-
ated with a far worse outcome [2–4]. It is for I ntroduction
these reasons that this review starts with its bot-
tom line. The condition is known variously as the Charcot
foot, Charcot neuropathic osteoarthropathy or
neuro-inflammatory osteoarthropathy and is a
complex disorder which occurs in people with
W. Jeffcoate some form of peripheral neuropathy. It is charac-
Nottingham University Hospitals NHS Trust, terised by inflammation and varying degrees of
Nottingham, UK structural damage to the bones and joints of the
F. Game (*) foot. In some cases the damage is severe, dis-
University Hospitals of Derby and Burton NHS abling and potentially limb-threatening but in
Foundation Trust, Derby, UK other cases the changes are relatively minor.

216 W. Jeffcoate and F. Game
he Charcot Foot Is a Syndrome: Not

T Charcot’ is a misnomer and should be abandoned
a Disease in favour of ‘active Charcot’ [10].
The hallmark/principal feature of the active
The Charcot foot should be considered as a syn- phase is local inflammation. If there is any asso-
drome rather than a disease. It can be recognised ciated deformity (from dislocation, fracture), it
but has no definition and no current defined diag- may be apparent clinically and/or on imaging.
nostic criteria. There may or may not be associated discomfort.
Any discomfort or pain is, however, rarely, if
ever, as severe as would be expected from any
History changes seen on imaging. When the affected foot
is fully rested by immobilisation in a below knee
The condition was first described by Jean-Martin cast, the inflammation reduces but it does not
Charcot (1825–1893) in the spine and upper part settle completely until the underlying process
of the leg in 1868 and by Herbert William Page goes into remission.
(1845–1926) in the foot in 1881 [5]. In these Active disease is most commonly triggered by
reports, as well as in Charcot’s five case series of minor trauma. Such trauma was recalled by 36%
1883, the underlying cause was tertiary syphilis of 288 cases managed in 76 centres in the UK and
with tabes dorsalis and ‘progressive locomotor Ireland between 2005 and 2007. Other triggers
ataxia’. Charcot suggested that the problem was were preceding foot ulceration (35%), local sur-
in part the result of reduced pain sensation and in gery (12%) and osteomyelitis (7%) [11]. The
part the result of inflammation with increased observation that 7% cases in this series were trig-
blood flow. Non-syphilitic Charcot disease was gered by osteomyelitis has also been reported by
first described in people with diabetes in 1936. It Ndip et al. [12] and is of great importance—not so
can also complicate leprosy [6], alcohol abuse, much in the diagnosis of Charcot syndrome but in
chemotherapy and other causes of neuropathy. the assessment of apparent lack of resolution in
There have been a number of major reviews in cases of treated osteomyelitis. When a case of
recent years [7–9]. pedal osteomyelitis shows signs of deterioration
(either on clinical grounds or on imaging) despite
appropriate treatment, it might be assumed that
he Clinical Presentation
T the infection was still active. This may not, how-
of the Charcot Syndrome ever, be the case if the original infection has trig-
gered the onset of an active Charcot syndrome.
The condition is most often seen in the foot but it The possibility needs to be considered because it
may occur further up the lower limb and even in has clear implications for management. A bone
the spine. In this chapter, however, attention is biopsy for microbiological sampling could be
focused on the foot in diabetes—not least because considered, although more discriminatory radio-
it is by far the most common site affected and logical imaging may also be considered such as
diabetes is by far the most common cause in most radiolabelled white blood cell (WBC) scans [13].
parts of the world. The activity of the Charcot foot syndrome will
eventually prove self-limiting in many and the
foot will stabilise once the inflammation settles—
Active Phase even though any skeletal damage or deformity
will be permanent. Expert teams manage the con-
The active phase has been traditionally referred dition by minimising trauma by ensuring effec-
to as ‘acute Charcot’ but the word ‘acute’ can be tive off-loading [11] as well as the management
misleading in that the active phase of the disease of complications (including secondary deformity,
can be anything but ‘acute’ and can last for days, ulceration and infection). Currently, there is no
weeks or for up to 18 months. The term ‘acute effective systemic therapy to either prevent or
17 Charcot Foot Syndrome: Aetiology and Diagnosis 217
reduce the causative processes [14]. The condi- Aetiology: Predisposition

tion is associated with high levels of anxiety and
depression [3, 15]. The Charcot syndrome results from the variable
interaction of three principal factors: neuropathy,
fragility of bones and joint capsules and retention
Inactive Phase and Recurrence of the capacity to mount a local inflammatory
response to injury. Additional factors may con-
The majority will eventually enter remission but tribute when the neuropathy is the result of
this may not be for a number of months. There is diabetes.
some variation in the reported time to inactivity
following conservative management with mean Neuropathy
times varying from less than 6 months in Neuropathy affects up to 50% people with diabe-
Denmark [16], to a median of 51.5 weeks in one tes [21, 22]. The type and extent of nerve damage
centre in UK [17], and 10–12 months in the 76 varies from person to person but it is typically
UK centres in one large study from UK and symmetrical and affects one or more of many
Ireland [11]. Some of these differences will relate aspects of peripheral nerve function including
to some people having their off-loading discon- sensory, motor, cardiac and non-cardiac auto-
tinued inappropriately early and hence will be nomic, neurovascular and skeletal (variously
accompanied by a correspondingly high relapse involving bone, joints and bone marrow) innerva-
rate [18]. Some of the difference between tion. In the people presenting with an active
reported times to resolution will relate also to Charcot foot, however, the manifestation of neu-
inclusion of the time which elapses between a ropathy which is most obvious clinically is loss
decision being made that the condition has of protective sensation and this means that even
entered remission and the availability of the gross distortion of the foot is relatively pain-free.
required footwear needed for full ambulation. The loss of significant pain is common to cases
However, one of the main causes is that there is which complicate diabetes as well as to those
no agreed definition for resolution of the active which complicate other conditions, such as the
stage as demonstrated in a recent systematic tertiary syphilis in which the syndrome was first
review [19]. described. This is despite the neurological defects
Once, however, the disease is truly inactive, it being different in different diseases: loss of deep
is extremely rare for the disease to recur in the pain sensation in tabes dorsalis is from dorsal
same position in the index foot even though occa- column disease of the spine, for example, whereas
sional cases have been described [20]. Some 20% in diabetes it is mainly from dysfunction of
of affected people will, however, have disease peripheral sensory fibres.
affecting the contralateral foot—either at the
same time or usually a short time later. Effect of Neuropathy on Bone
The RANK/RANKL-NFkappaB and Wnt/β--

Aetiology of the Charcot Syndrome catenin Pathways
One key pathway in bone modelling is the
The Charcot syndrome can be regarded as a dis- RANKL/RANK signalling pathway. RANKL is
tortion of the normal complex responses of the derived from monocyte derivatives and is the
body to injury or insult with these responses polypeptide ligand for the RANK receptor,
being normally reliant on close intercellular sig- so-called because it is the receptor for the activa-
nalling. The factors contributing to its occurrence tion of the nuclear transcription factor,
are considered under the following subheadings: NFkappaB. NFkappaB has a number of functions
predisposition, permissive factors, precipitation, but one of these is the activation of osteoclasts,
presentation, perpetuation and resolution. with resultant bone breakdown. Osteoprotegerin
(OPG) acts as a decoy receptor for RANKL and (Chopart) joints. Such dislocation may be caused
thereby helps to limit its action. RANKL and by partial avulsion of the joint capsule as a result
OPG are both released at the same time, even of weakened attachment or, potentially from
though their actions are essentially opposite. The changes to the integrity of the capsule and other
ratio of the two at any one time could, however, soft tissues which are normally richly innervated
be of importance in the relative effects of RANKL with nerves secreting SP, CRGP and NPY [28].
vs. OPG on bone quality. While the loss of innervation is known to have
Another pathway which also affects both bone major effects on bone structure and fragility, it is
quality is the Wnt/β-catenin pathway. High levels also possible that it may compromise the integ-
of Wnt ligand prevent the breakdown of β-catenin, rity of the capsule in people with Charcot foot.
which in turn promotes osteoblast maturation and
therefore bone formation. Low levels, therefore, Effect of Neuropathy
would be consistent with bone breakdown. on the Vasculature
Sclerostin and Dickkopf-1 are inhibitors of Wnt It is well established that there is an association
and have been found to be significantly higher in between calcification of the cells of the arterial
a small series of post-menopausal women with walls and osteoporosis, including osteopenia
type-2 diabetes than in sex and age-matched con- associated with neuropathies and it is thought to
trols [23]. result from the contrasting effects of the RANKL/
Neuropathy is associated with osteolysis and OPG signalling system in the two tissues [29,
increased bone fragility. The integrity of bones is 30]. Both are also associated with neuropathy.
normally maintained by a variety of nerve- Neuropathy is particularly closely associated
derived neurotransmitters which encourage the with calcification of the tunica media of the
synthesis of OPG in preference to activation of medium to small arteries of the periphery (medial
RANK receptor and NFkappaB. These are arterial sclerosis, MAC; Mönckeberg’s sclerosis)
derived from both autonomic and somatic neu- [31, 32] where it has been shown to have the his-
rones and include calcitonin gene related peptide tological features of bone [33].
(CGRP), substance P (SP), vasoactive intestinal
polypeptide (VIP), tyrosine hydroxylase (TH), dditional Predisposing Factors
A
norepinephrine (NE), neuropeptide Y (NPY), Associated with Diabetes
glutamate and leptin [24, 25]. All are associated
with the release of anti-inflammatory factors, Effects of Neuropathy on the Vasculature
including IL-4 and Il-10 [26]. In contrast, a fur- There is a very extensive literature on the rela-
ther nerve-derived transmitter nitric oxide (NO) tionships between low grade, metabolic inflam-
favours the proliferation of osteoclasts. mation and disease of the heart and larger arteries
In one very small study of bone samples from in diabetes. In this context, the ‘inflammation’ is
eight people with diabetes, four samples from not clinically apparent but refers to the effects
those with neuropathy were found to have lower which result from the pro-inflammatory effects
levels of NO compared with the four non- of glucose, oxidised lipids and advanced glyca-
neuropathic diabetic control samples, as well as a tion end-products (AGEs) linked to reduced
trend towards an increase in CGRP [27], although expression of the AGE receptor (RAGE) [34].
the findings were not conclusive due to the small The broad subject has been well-reviewed else-
size of the study. where [35].
In the Charcot foot syndrome, however, it is
Effect of Neuropathy on the Joint Capsule the distal vasculature which is just as important
Dislocation is a common feature of the active and any predisposition in a person with diabetes
Charcot foot and may occur even in joints which will include the combined effects of both. Indeed,
are not otherwise prone to dislocation, including the findings of one controlled observational study
the tarso-metatarsal (Lisfranc) and talonavicular suggested that overt clinical signs of more proxi-
mal artery disease were associated with decreased higher than in any other at risk group. Of interest
likelihood of the Charcot syndrome [36]. is the observation by Valabhji [45] that the use of
It is recognised that there are changes in distal immunosuppressants may modify the clinical
limb blood flow associated with diabetic neurop- presentation.
athy [37, 38] and these are associated with altera-
tions of distal capillary function [39]. The Obesity
distribution of blood to the periphery—and the It is commonly thought that increased body mass
integrity of its normal regulation—is thus depen- index (BMI) predisposes to the onset of the syn-
dent on multiple processes in people with diabe- drome in diabetes [9] but the evidence is not
tes including cardiac function (including the strong and it is possible that it is the difficulties
effect of any medications on pulse and blood posed by obesity in the management of particular
pressure), patency of larger arteries, changes in individuals that encourages the belief in clinical
peripheral vascular resistance, effective constric- practice. There is one small study that which
tion and relaxation of smaller vessels and changes found no difference in BMI between matched
in capillary and extravascular structure and groups with and without Charcot syndrome [46].
function.
Genetic Predisposition
ther Predisposing Factors in Diabetes
O A small number of groups have reported associa-
While the clinical presentation of the Charcot tions with differing candidate genes but the evi-
syndrome may be broadly similar in all underly- dence is not currently strong [47–49].
ing pathologies, there are particular features of
diabetes that may make it more likely.
Aetiology: Permissive Factors
Skeletal Fragility in Diabetes
It is known that both type 1 and type 2 diabetes The frequency with which neuropathy compli-
are associated with increased risk of fracture cates diabetes contrasts with the relative rarity of
[40]. the Charcot syndrome, with available data sug-
gesting it might affect between 0.1 and 1.0 peo-
Chronic Renal Failure ple per thousand with diabetes [50]. This indicates
Chronic renal failure may predispose to the that while the presence of one or more compo-
development of the syndrome because of the nents of nerve dysfunction is essential, the syn-
osteopenia it causes. drome will not occur without one or more key
permissive factors.
Simultaneous Pancreas-Kidney Transplant Of these, it is likely that the most important
(SPKT) in Type 1 Diabetes factor required for the expression of the syn-
The incidence of active Charcot syndrome is very drome is the capacity to mount an adequate
high in the months following transplantation: inflammatory response by increasing blood flow
affecting between 5% and 15% within a year or to the affected area. One piece of evidence in tan-
two in recent published series [41–44]. The cause gential support is provided by the occasional
is likely to be multifactorial. Both neuropathy reports of the syndrome being triggered by revas-
and renal osteodystrophy are very likely in the cularisation of a major proximal artery [51].
treated population, while those with overt macro- More important evidence is provided by the
vascular disease will have been excluded prior to observations made by two groups that people
transplantation. It is also possible that post- who have had an episode of active Charcot foot
transplant Charcot syndrome was particularly can be distinguished from other people with neu-
common when higher doses of glucocorticoid ropathy by the fact that they have been shown to
immunosuppression were used and that the inci- retain patterns of pedal blood flow and they retain
dence is now falling—even though it remains far the capacity for it to increase [52, 53].
Aetiology: Precipitation suggested the involvement of a pathway other

than that of RANKL and OPG. There is a possi-
What Triggers the Onset bility that this pathway is that centred on the
of Inflammation at the Time That Wnt/β-catenin pathway for which Folestad has
the Charcot Process Becomes Active? since provided independent evidence [58]. High
While affected individuals may have underlying levels of Wnt ligand prevent the breakdown of
predisposition arising from any of the above pro- catenin which in turn promotes osteoblast matu-
cesses, it seems that the onset of the active ration and therefore bone formation. Low levels
Charcot syndrome is usually triggered by an therefore would be consistent with bone break-
external event and by trauma in particular—even down. Folestad and colleagues have also con-
though the severity of the trauma may often have firmed the involvement of TNF-alpha in active
been thought to be trivial at the time it occurred. Charcot foot, as well as IL-Iβ, IL-6 and other
Other important triggers are foot ulceration, interleukins [59, 60].
infection, surgery to the foot [11, 12] but in many
cases there is no identified precipitant. ffects of Clinically Overt Inflammation
E
Once triggered, the capacity to mount an on Bone
exaggerated and persistent inflammatory reac- Worsening inflammation is associated with
tion may be limited to those who produce a more increased osteocytic osteolysis with increased
intense response of pro-inflammatory cytokines bone fragility. In this respect it is worth reflecting
such as TNF-alpha, IL-1beta and IL-6 [54, 55] or that osteolysis is normally a prelude to new bone
there may be an inadequate capacity to terminate formation and is a key component of the early
an inflammatory response that has already phase of a protective response to skeletal injury.
occurred. The exaggerated osteolysis of the Charcot syn-
drome must occur only in those in whom the
capacity for auto-regulation is defective.
Aetiology: Presentation
The onset of an active Charcot foot is marked by Aetiology: Perpetuation

overt clinical inflammation. This will result from
increasing activation of pro-inflammatory cyto- Once the process is triggered, the person who is
kine pathways and is most likely to be centred on already predisposed to an exaggerated inflam-
the RANKL/OPG/NFKappaB pathway or, alter- matory reaction then enters a phase whereby
natively, the Wnt/β-catenin pathway. The resul- the inflammation further worsens bone fragility
tant clinical inflammation will only occur if the and capsular laxity with the increasing risk of
local microvasculature is capable of responding skeletal damage which is itself made more
with the necessary vasodilatation and hence is likely by loss of protective sensation and con-
restricted it to a small minority. tinued weight-bearing [61]. The bone of people
with active Charcot syndrome shows inflamma-
hanges in Pro-inflammatory Cytokine
C tory infiltration with reduced quality of the tra-
Expression When the Charcot Foot beculae [62].
Syndrome Is Active The process will eventually prove self-limiting
Active Charcot is associated with increased oste- and the foot will stabilise once the inflammation
olysis. Baumhauer et al. [56] demonstrated settles—provided that irreversible skeletal dam-
increased expression of the pro-inflammatory age does not lead to limb loss. Expert teams man-
cytokines IL-1, IL-6 and TNF-alpha in histologi- age the condition by minimising trauma by
cal specimens. Mabilleau [57] confirmed these ensuring effective off-loading as well as manage-
observations in a follow-up study, which also ment of complications (including secondary
deformity, ulceration and infection). Currently, but the lack of validated protocols, standardisa-
there is no effective systemic therapy to either tion of equipment and high quality studies mean
prevent or reduce the causative processes or to that uncertainty remains about the effectiveness
minimise their effects. for any [19].
tudies on the Expression of Pro-

S
inflammatory Cytokines During Prognosis
the Course of Active Charcot Syndrome
Folestad et al. [58–60] conducted a detailed anal- Recurrence
ysis of changes in the expression of circulating
cytokines in samples collected from 24 to 28 As noted above, some 20% of individuals with
people following the introduction of off-loading Charcot foot syndrome complicating diabetes
for active Charcot syndrome. They were able to will have or will develop similar changes on the
demonstrate that changes in the expression of contralateral foot before, during or after the index
IL-6, IL-8, IL-1β and TNF-alpha were all lower presentation. Long term relapse is, however, very
than in controls at the time of presentation with rare and this is most likely because the factors
active disease but that IL-6 and TNF-alpha rose that predisposed to or permitted the original
slowly and steadily after the introduction of off- attack no longer exist.
loading—suggesting an increased in bone lysis
as a prelude to remodelling [58]. In contrast, the
concentrations of IL-17A and IL-17E were no Mortality
different from controls at presentation and then
rose slowly over 2–4 months, while those of In one single centre series of 117 cases in the UK,
IL-17F were low at presentation and rose during survival was shown to be reduced to a median
follow-up to be no different from controls [59]. 7.9 years with a reduction in overall life expec-
Finally, they observed that sclerostin, Dkk-1 and tancy of 14.4 years. This reduction in life expec-
Wnt-1 were all low at presentation and rose over tancy was not, however, significantly different
2 years of follow-up and, while concentrations of from a matched control sample managed for neu-
OPG and RANKL were higher than controls at ropathic foot ulcer and hence is not related to the
presentation and fell during follow-up, the ratio Charcot syndrome per se [63] but more to the
of OPG/RANKL did not change [60]. Current population which is at risk of it.
knowledge of the detailed interaction of the mea-
sured substances is insufficient to allow detailed
interpretation to explain these fascinating Footnote
observations.
hy Is the Charcot Syndrome
W
So Uncommon?
Resolution Given that distal neuropathy is currently thought
to affect between a third and a half and of all
It is common clinical practice to accept a differ- people with diabetes, it is very remarkable that a
ence in the temperature of the skin over the area syndrome that is thought to be primarily the con-
of interest of <2 °C when compared with the non- sequence of neuropathy is so rare. It may be that
involved foot as sign of clinical resolution the primary cause is some particular facet of neu-
although the data to support this is poor. ropathy which is itself rare or, as suggested here,
Magnetic resonance imaging (MRI), repeated that the condition only occurs when a variety of
X-rays, repeated bone scans and infrared ther- predisposing and potentiating factors co-exist
mometry have been used to evaluate remission and that such co-existence is uncommon.
Diagnosis of Active Disease However, the main limitation of MRI lies in its
inability to distinguish bone oedema caused by
Diagnosis of Active Disease: Clinical infection (osteomyelitis) from active Charcot,
particularly if the two co-exist. A recent retro-
If a health care professional is asked over the spective review suggests that if bone infection is
phone about a patient who has developed unex- suspected in addition, then white blood cell
plained warmth and swelling of the midfoot, his (WBC) scintigraphy had a higher accuracy for
or her first thought should be to ask two ques- the detection of osteomyelitis as long as stan-
tions: has the person got diabetes and have they dardised protocols are used [13] and so may be
got distal neuropathy? If the answer to either is useful where there is clinical doubt. Other tests
Yes, then active Charcot syndrome must be con- involving radiolabelled isotopes such as triple
sidered. Early suspicion is essential—not least to phase bone scans have good sensitivity but lack
minimise weight-bearing until it has been the specificity of MRI scans for early diagnosis
excluded. The single most important stage in the [67]. 18F-fluorodeoxyglucose positron emission
diagnosis of the Charcot foot is to think of it. tomography (FDG-PET) scanning may be useful
Most people do not think of it as a possibility for differentiating acute Charcot from osteomy-
because they believe it is rare and that they are elitis [64] but a recent large series suggests that it
unlikely ever to see a case. The Charcot syn- lacks the accuracy of WBC scintigraphy and so it
drome is uncommon but it is not rare. is not currently recommended [13].
Other Investigations
iagnosis of Active Disease:
D There are no other investigations that are useful
Investigations for the positive diagnosis of active Charcot,
unless the intention is to look for other causes of
Imaging inflammation. While changes in inflammatory
Once the diagnosis of Charcot syndrome is con- cytokines have been described above, none is
sidered, a plain X-ray should be done immedi- specific to active Charcot and will be raised in
ately and the result reviewed. The foot must be almost any cause of inflammation, whether this
protected by off-loading until a diagnosis is be infective or metabolic, as in acute gout, for
made. Signs that may be seen on a plain film example.
include osteopenia and osteolysis, associated
fragmentation of subchondral bone, fractures,
dislocations, subluxations and later bony consoli- iagnosis of Active Disease:
D
dation [64]. Subtle dislocations, joint deformity Education of the Person
and collapse may be better visualised on weight- with Diabetes
bearing views. The sensitivity of plain X-ray to
exclude acute Charcot is not good even on Any person with diabetes and peripheral neurop-
weight-bearing films particularly in the early athy should know that they are at risk of future
stages [65]. foot problems. Their risk of foot ulcers far
More advanced imaging techniques have been exceeds the risk of developing an active Charcot
proposed including MRI, radiolabelled bone but it is most important that they know how to
scans and more recently 18F-fluorodeoxyglucose contact someone with the necessary expertise
positron emission tomography (FDG-PET). MRI should they develop an unexplained red hot swol-
is noninvasive and has much better sensitivity for len foot. It is just as important that the health care
the detection of early stage acute active Charcot professional should think of the diagnosis and
[66] with reported sensitivities of (77–100%) and make appropriate referrals for investigation and
specificities (80–100%) for the diagnosis [67]. off-loading without delay.
The Bottom Line 11. Game FL, Catlow R, Jones GR, Edmonds ME, Jude
EB, Rayman G, Jeffcoate WJ. Audit of acute Charcot’s
disease in UK: the CDUK study. Diabetologia.
The Charcot syndrome is uncommon but not rare 2012;55:32–5.
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elitis and/or surgery. Diabet Med. 2008;25:1469–72.
plained inflammation of the foot. When 13. Lauri C, Glaudemans AWJM, Campagna G, et al.
considered, the foot should be protected against Comparison of white blood cell scintigraphy, FDG
unnecessary trauma until the diagnosis has been PET/CT and MRI in suspected diabetic foot infec-
either proved or excluded. If the diagnosis is tion: results of a large retrospective multicenter study.
J Clin Med. 2020;30(9):1645.
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atic review and meta-analysis of randomized con-
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39. Østergaard L, Finnerup NB, Terkelsen AJ, et al. The monocytes and macrophages cell fate. Front Biosci.
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2 diabetes. Diabetes. 2016;65:1757–66. MS. Cytokine osteclastic bone reception in Charcot
41. Anthony ML, Cravey KS, Atway SA. Development arthropathy: an immunohistochemical study. Foot
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Surg. 2011;50:648–53.
Charcot Foot: Conservative
Management
18
Armin Koller
Introduction evidence of a link between neuropathy, bone

turnover, inflammation, and mechanical stress in
Conservative treatment in Charcot neuroarthrop- Charcot neuroarthropathy [2].
athy (CN) on the one hand represents an alterna- Since neuropathy cannot be reversed and
tive to surgical treatment; on the other hand it is mechanical stress is within the scope of casts and
always used before or after operations and there- orthoses, different drugs have been utilized to
fore an integral part of the treatment algorithm. normalize bone turnover and reduce inflamma-
Goals of conservative therapy are reduction of tion. Medication can never be a standalone treat-
inflammation by shielding the foot skeleton from ment but is intended to shorten time to resolution
mechanical stress, preservation of foot shape of the active neuroarthropathic process in combi-
until consolidation of CN, and redressment of nation with standard treatment by means of total
foot deformity prior to stabilization. contact cast or orthosis. However, none of the
There are several conceivable scenarios in drug treatments so far has supplied scientific evi-
which conservative treatment would be prefera- dence of a therapeutic effect that would justify
ble to surgery. A very morbid patient with high- unequivocal recommendation. Even adverse
grade limitation of walking distance due to his effects could be noticed with significant prolon-
medical conditions is not a good candidate for gation of the time to resolution using bisphos-
complex and high-risk operative reconstructions. phonates [3].
In general, functional improvement from recon- Edema typically coming along with the active
structive surgery has to justify the possibly sub- stages of CN interferes with proper fit of orthotic
stantial risk of operation or anesthesia. A foot devices and compromises wound healing. In
with mild to moderate deformity which is planti- return, treatment with effective immobilization
grade and capable of full weight-bearing in a of foot and lower leg leads to edema regression,
shoe or an orthosis does not necessarily need unless that is not a consequence of venous, lym-
operative treatment [1]. phatic, renal, or cardiac insufficiency. Anti-
Drug treatment is discussed as a complemen- edematous therapy includes compression
tary anti-inflammatory therapy. There is growing bandages, Unna boot, or semi-rigid casts (Photo
18.1). Additionally, patients should exert com-
plete off-loading of the affected limb, in the sense
A. Koller (*) of completely refraining from weight-bearing, by
Department of Technical Orthopedics, Hospital Dr. means of crutches, wheelchair, or even bed rest in
Guth, Hamburg, Germany the very acute stage of CN, when massive edema

228 A. Koller
external (walking, standing, and sitting!) and

internal (tendon pull) forces acting on the foot
skeleton. The result is strain of bones and liga-
ments. This deformation can only be eliminated
or minimized by a device that allows for a perma-
nent rigid three-dimensional fixation of foot and
lower leg. With this ensured, weight-bearing and
subsequent pressure on soft tissue is not a major
obstacle. Not recommended, however, is leaving
the device off even for the shortest walk.
Charcot Foot with Fractures
Beyond the contribution of inflammation and

deregulated bone metabolism to the multifaceted
etiology of CN, the disease has a lot in common
with fractures due to repetitive stress or trauma.
The basic principles of conservative fracture
treatment have been laid down nearly one hun-
dred years ago. Lorenz Böhler (1885–1973) [4],
one of the godfathers of modern trauma surgery,
Photo 18.1 Regression of the previously massive edema
of the foot and lower leg after only 1 day of flat position-
emphasized that accurate reduction of the dis-
ing and application of a semi-rigid cast (3M™ placed fragment is only sensible if subsequent
Scotchcast™ Soft Cast Casting Tape) measures are taken to keep the reduced bone
fragments in a good position—without any
with erythematous vulnerable skin makes interruption!
weight-bearing in a cast or splint impossible any- Fractures lead to deformity with resulting
way. When there is only mild to moderate swell- abnormal plantar pressure and repetitive micro-
ing of foot and lower leg, treatment with casts or traumata, which in turn are responsible for
orthoses can start. inflammation, osteoclast activation, and osteope-
Charcot neuroarthropathy quite often comes nia, increasing again the risk for further fractures.
along with pressure ulcers. Both conditions are Casts and orthoses are valuable tools to accom-
usually treated by so-called off-loading, but the modate deformity and abnormal loading patterns,
biomechanical principles of treatment are funda- since it is paramount to interrupt that vicious cir-
mentally different in both cases. That is quite cle [5].
understandable, since one condition affects the Since CN rather is a syndrome than a specific
soft tissue, the other one the skeleton. Neuropathic nosological entity, orthotic treatment cannot be
ulcers are caused by pressure exceeding a certain uniform. Active CN requires permanent stabiliza-
threshold, and treatment basically implies rever- tion, whereas inactive CN is treated sufficiently
sal of that process. As complete pressure elimina- with protected weight-bearing. The presence of a
tion is not always feasible, redistribution of plantar ulcer requires additional local pressure
forces acting on the plantar surface has to effect relief by plantar insoles or by load transfer to the
pressure reduction at the ulcer site to a subthresh- tibial condyles or patella. A mild to moderate
old level. deformity basically can be treated with an off-
Regarding only the mechanical aspects of the the-shelf walker, a pronounced deformity must
complex etiology, CN is not induced or aggra- be fitted with a cast or a custom-made orthosis.
vated by forces acting on the skin surface, but by The plane of the deformity also has to be taken
18 Charcot Foot: Conservative Management 229
into consideration. Sagittal plane deformity is supination movement of the midfoot against the
easy to accommodate; transverse plane or frontal hindfoot. This torsion also involves the tarsal
plane deformity, in particular, makes orthotic fit- bones, so that rigid fixation of that area of the
ting and compensation of static alignment quite foot skeleton does not only call for a stiff rocker
challenging. Circadian fluctuations of edema due sole, but also for an orthotic design able to con-
to cardiac or renal insufficiency are usually trol lower leg rotation. The triangular shape of
treated with compression stockings or bandages, the proximal tibia is the place where rotation can
but those are not always applicable together with be restricted by an accordingly molded pretibial
orthoses. As a consequence, the orthotic design shell of the orthosis. Counter-pressure at the calf
should have an adjustment mechanism that muscles must keep the proximal tibia in the
enables containment of a lower leg with volume desired position. Large area pressure helps to
variations without losing proper fit. avoid undue proximal constriction of venous and
Of course, the foot cannot be regarded quite lymphatic drainage.
apart from the patient, who will demonstrate dif- The concept of immobilization of foot joints is
ferent body weight and activity level. Heavy use not new. It was introduced by Morgan in 1993
of an orthosis must be countered with a heavy [6]. A long time ago protection from cumulative
duty construction. microtrauma was recognized to be the keynote
for orthotic treatment of Charcot feet.
Subsequently, this idea had been replaced by a
Orthotic Treatment focus on relief of plantar pressure [7]. Orthoses
were designed to reduce load transmission to the
General requirements for orthoses in treating midfoot or forefoot [8]. Indeed, measurement of
Charcot feet include accommodation of any high plantar pressure within an orthosis may
deformity, protection of vulnerable soft tissue, serve as an indirect proof of mechanical instabil-
and volume control. Patients should be able to ity or insufficient anatomical fit of the respective
don and doff the orthosis without an auxiliary device. However, it remains difficult to draw
person to keep their autonomy. Mobility needs clear conclusions from plantar pressure measure-
range from a few steps at home to long distances ment to joint or fragment movements. The effect
in the community. Hence, design of the rocker of tibial rotation on movement of foot joints can-
sole is either geared to stability or to dynamics. not be detected by means of plantar pressure
Geriatric patients need more safety and active measurement. The concept of joint immobiliza-
patients more agility. tion is consistent with up-to-date hypotheses
Specific requirements for orthoses in treating about the etiology of neuro-arthropathy, but there
CN depend on the respective pathology to be is still a need for well-designed studies on the
treated. Activity of the neuroarthropathic process mechanical effects of orthoses in a larger cohort
needs rigid three-dimensional fixation compris- of Charcot feet [9].
ing foot and lower leg. Activity finds its expres- Deformity of the Charcot foot of a certain
sion in inflammatory signs having a mechanical extent does not only call for individual fabrica-
component due to fracture or joint dislocation tion of the ankle foot orthosis, but also has nega-
which in turn are treated comparable to a skeletal tive impact on biomechanics of walking and
trauma. Ground reaction force during walking standing. Frontal plane deformity at the hindfoot,
and standing is not the major concern, but move- that is medial or lateral displacement of the calca-
ments of the foot within the device. neus, calls for an opposed enlargement of the
Rotation around the long axis of the leg does orthotic heel, so that the physiological plumbline
not only occur at the hip joint. At the same time of the leg is restored. A deformed but stiff foot is
the subtalar joint complex accomplishes an often easier to accommodate with an orthosis
inversion-eversion movement which has to be than a Charcot foot with instability. In particular,
compensated by a contrarotating pronation- when only partial redressment of the deformity is
230 A. Koller
possible, movements of the foot are responsible requires removal of the cast. For continued treat-
for friction within the orthosis causing skin ment, a new cast has to be applied. Frequent
breakdown. replacements of the cast are time-consuming.
If instability is due to an active neuroarthro- Well-trained cast technicians, or physicians, who
pathic process (Eichenholtz stage I or II), rigid are able to apply a TCC with the least possible
fixation in an orthosis or cast can support consoli- risk of skin lesions [10], are not omnipresent. A
dation and transition to Eichenholtz stage III with TCC limits the ability to walk to a greater extent
osseous fusion and permanent stability. But, if than walkers or orthoses.
instability comes with an inactive, chronic Removable TCCs are made by sawing them
Charcot foot, future stability of the foot skeleton open into a rear and a front shell. The two halves
is not guaranteed. In this case, orthotic treatment are then resealed with Velcro or cable ties. In this
precedes or replaces an operation, if the patient is way, inspections of the foot or dressing changes
too morbid for surgery or does not want operative are possible without having to fit a new cast each
treatment. time. This is more convenient for the treatment
Any bony prominence or exostosis must care- team and often less anxiety-provoking for the
fully be protected against excessive pressure, patient. However, these advantages are also coun-
especially if there is only thin soft tissue cover- tered by disadvantages. Mechanical stability is
age. If an ulcer occurs at the medial or lateral compromised, and the ability for the patient to
malleolus, it will take a very long time until interrupt therapy increases the risk of therapy
wound healing or it will even necessitate surgical failure.
wound closure.
Rehabilitation with casts and orthoses means
more than to teach autonomous donning and Prefabricated Diabetic Walker (DW)
doffing of the device. Partial weight-bearing,
which is necessary for postoperative treatment of The prefabricated diabetic walker (DW) is also
a wide range of surgical procedures, is not feasi- available immediately if it can be stored.
ble in the presence of peripheral neuropathy com- Depending on the model, mechanical stability
ing along with Charcot foot disease. Lack of decreases gradually, and a respective weight limit
sensory input interferes with controlled loading must be considered. Product information by the
of the foot. With this in mind, a stopwatch or a manufacturer rarely gives any recommendations
step counter instead of a weighting scale should for the use in the treatment of Charcot foot. As
be used to set stress levels of the foot skeleton. Charcot feet mostly retain at least some degree of
By implication, this means full impact for a few deformity after surgery, the DW is not the ortho-
minutes or steps in the beginning. Orthoses or sis of choice after reconstructive foot surgery in
casts have to be stable enough to protect the diabetic patients. Particularly high-grade foot
Charcot foot even with full weight-bearing. deformities are a problem, because the DW has
little scope for modifications. Its shape is
designed to enclose a foot with some swelling,
Total Contact Cast (TCC) but not with considerable deformity. Lower legs
with edema may be pressed into an unphysiologi-
The most significant advantage of the TCC is cal shape. Air chambers may be damaged and
instant availability. It is made of plaster of Paris lose function because patients may forget to
or fiberglass, cheap in fabrication, and can be inflate them, or in contrast, may cause skin
produced in most locations. Windowing of the lesions by overinflation of the air chambers.
cast allows treating wounds, which should not be In order to combine the compliance enforced
infected when using a TCC. The closed construc- in closed TCC with the simple and fast fitting of
tion enforces good compliance. The main disad- a walker, the idea of so-called instant TCC, or
vantage is that physical examination of the foot iTCC for short, was developed [11]. In this case,
a conventional prefabricated walker is made therefore be preferred if long-term use is

non-removable with the aid of plaster bandages, expected.
for example, but rapid and problem-free removal
of the aid remains possible. This therapeutic
measure, which has been successful in the treat- Frame Orthosis (FO)
ment of neuropathic ulcers, is also conceivable in
principle for Charcot foot, since it is precisely The frame orthosis focuses on immobilizing the
here that consistent immobilization is important. joint rather than relieving pressure. A pretibial
The name iTCC is somewhat misleading, how- shell is adapted to the triangular shape of the
ever, since a real TCC can be adapted very pre- tibia. Restriction of tibial rotation minimizes
cisely to the shape of the foot, which is not the transmission of leg motion to the tarsus. The
case with the iTCC, which is a ready-made orthotic frame with posterior entry and fixed heel
device. In the case of a Charcot foot with a more support wedges the lower leg from the tibial pla-
or less pronounced deformity, an iTCC therefore teau to the heel. Axial loading supports fragment
reaches its limits. To be more precise, there is a fusion in the hindfoot region. Arthrodesis in the
quantifiable risk of pressure points in the midfoot area is effectively protected from bend-
orthosis. ing movements. A lightweight design is available
as well as a heavy duty version. Like the CROW
and the DW, this type of AFO carries the risk of
harcot Restraint Orthotic Walker
C noncompliance. In the event of soft tissue shrink-
(CROW) age, adjustments are necessary to ensure contin-
ued function. Mode of action and medical range
The CROW fits more precisely than a TCC or a are most comparable to the CROW.
DW, as it is fabricated individually over a posi- A more recent development of the frame
tive model. The device is durable and enables orthosis is the combination of an inner semi-rigid
good control of edema. A rocker bottom allows socket, comparable to an inner shoe, with an
easier ambulation than with a TCC. Load trans- outer rigid monolateral frame. The inner socket
mission on lower leg depends on the way of fas- can be worn at night when protection is also
tening the device. High pressure on soft tissues required during bed rest. It is padded and closes
thereby enforces their atrophy, which can lead to with a zipper. The form-fitting closed construc-
worse fit of the orthosis and undesirable motions tion of the inner socket helps control edema.
in the area of the osteosynthesis or the joint to be Putting on is uncomplicated and reproducible. It
fused. Provided that the CROW is applied cor- is virtually impossible for the patient to put the
rectly and checked up regularly, it is a useful tool orthosis on incorrectly.
for mobilization of the patient but immobiliza-
tion of the Charcot joint(s). For physical exami-
nation the CROW can be removed without Shoes
difficulty. Removability of the CROW at the
same time involves the risk of noncompliance. Providing footwear is the goal of both conserva-
Compared to a double-shell TCC, the CROW has tive and surgical treatment of Charcot foot. In
a hygienic inner lining that can be easily cleaned case there is no significant deformity or instabil-
and disinfected. This is particularly advantageous ity, ready-made shoes may be sufficient for fur-
if an ulcer is still present at the same time. On the ther protection of the foot. Since this protection
other hand, with the TCC the two shells butt up should primarily consist of shielding the affected
against each other, with the CROW they overlap, joint sections from excessive torsional moments,
so that this aid allows adjustments to volume a stiffened rocker-bottom sole with an early pivot
fluctuations. The mechanical stability is much point is required. The apex of the sole roll is even
better than with the TCC. The CROW should further towards the heel in the case of affection of
232 A. Koller
Table 18.1 Minimum criteria for orthopedic footwear management of Charcot feet
Sanders 2, Sanders 4,
Sanders 1 Sanders 2, 3 3 + deformity Sanders 4, 5 5 + deformity
Stable Stiffened Stiffened rocker sole, Stiffened rocker sole, Stiffened rocker sole, Stiffened rocker
rocker sole bottine shoe bilateral ankle support bilateral ankle sole, stiff boot
support
Instable Stiffened Stiffened rocker sole, Stiffened rocker sole, Stiffened rocker sole, Stiffened rocker
rocker sole bilateral ankle stiff boot stiff boot sole, stiff boot
support
the hindfoot. At the same time, however, it should Monitoring

be noted that a very pronounced roller reduces
the standing area and can thus, in unfavorable Duration of postoperative treatment with ortho-
cases, also impair gait and stance stability, espe- ses is under debate. One aspect is fracture healing
cially in patients with high-grade polyneuropa- in neuropathic limbs. As it takes up to 3 months
thy. Full contact insoles trim the foot and work for Charcot fractures to heal, this is regarded as
with the shoe to absorb impact forces. Orthopedic the minimum length of time for additional
custom-made shoes are required in cases of pro- orthotic protection of the extremity. In case of
nounced foot deformity. If the position of the doubt, or when X-rays or CT scans reveal delayed
heel is largely physiological and the function of bone fusion, orthotic aftertreatment is continued.
the tibio-talar joint is at least partially preserved, Walking without orthosis or with an ill-fitting
it does not seem necessary to make a boot with a orthosis before complete bone fusion will lead to
stiff shaft. However, to counter pronator or supi- loosening and fracture of implanted hardware.
nator forces, it is then advisable to make at least a Delayed fusion or pseudarthrosis may also occur
bottine shoe with medial and lateral heel cap. after external fixation surgery. In either instance
As a precautionary measure to protect against functional outcome may be still favorable as long
re-fracture or inflammatory episodes, Charcot as there is no major relapse of deformity.
feet are usually fitted with a boot with a high and The other aspect is CN activity. The terminol-
stiffened shaft and a rigid roll-off sole following ogy “active and inactive CN” is less ambiguous
treatment with TCC or orthotics [12]. Such a type than “acute and chronic CN.” Monitoring of
of boot, by its very nature, provides optimal pro- activity is even more debatable than duration of
tection, but is nonetheless heavy, uncomfortable, orthotic aftertreatment. The key question is when
and sweat-inducing. Most importantly, such a has CN become completely inactive? Eichenholtz
uniform shoe fitting lumps together all the differ- stage III on plain X-rays indicates a cooled-off
ent problems of the Charcot foot. A patient with a CN. Quite often, a foot with Eichenholtz stage III
stable and still mobile ankle joint can benefit still shows bone bruise on MRI and some extent
from a shoe fitting that still allows mobility in the of skin temperature rise. Two scenarios have to
sagittal plane and only stabilizes the lower ankle be differentiated. A foot with congruent joints or
joint. However, if a destroyed ankle joint is pres- a solid bone fusion at the end of treatment is
ent, possibly even with deformity or instability in expected to cool off completely, and skin tem-
the frontal plane, a high and stiff shank is cer- perature will show no side difference. A foot with
tainly required for the shoe. In addition to these incongruent mobile joints (“bag of bones”) or a
purely foot-related biomechanical aspects, con- pseudarthrosis at the end of treatment is expected
textual factors also play a role, which consider to retain some extent of skin temperature rise,
the patient’s physical activity and weight, the ter- mainly after walking stress. The problem is com-
rain at the place of residence, and, if necessary, parable to a nondiabetic foot with post-traumatic
special requirements at the workplace arthritis. Of course, walking without orthosis or
(Table 18.1). with an ill-fitting orthosis has to be excluded.
Patient behavior and function of the device are mography is stretched to its limits [16]. Evaluation
scrutinized closely unless CN has cooled off after of therapeutic success in terms of skin tempera-
6 months contrary to expectations. ture on a neuroarthropathic process may lead to a
Just as skin temperature measurement, MRI false sense of security or, to the contrary, delay
detects activity of the neuroarthropathic process, termination of orthotic treatment needlessly.
but also of other pathological conditions associ- Thus, skin temperature measurement cannot be
ated with bone marrow edema. Therefore, it has recommended as the only instrument for moni-
basically the same limitations due to its low spec- toring CN activity.
ificity. A foot with incongruent mobile joints or
with a pseudarthrosis quite often retains bone
bruise permanently, so that MRI is not always MRI
suitable to determine convenient time to end
orthotic treatment. In this regard, bone scans are MRI does not only offer an anatomical picture
not superior in differentiating CN activity from but also different signal intensities that correlate
other forms of increased metabolic activity. with the activity of an inflammatory process
Doppler spectrum analysis of the first dorsal independently of its etiology. Given the diagnosis
metatarsal artery may be a modality to monitor of neuroarthropathy, signal intensity of bone
the activity of CN. In a study by Wu active marrow edema or extent of contrast medium
Charcot feet had a monophasic forward flow in uptake could be used for assessing intensity of
the pedal arteries different from the unaffected inflammation. As with clinical examination,
contralateral limb [13]. After 6–20 weeks of decrease of inflammation may indicate termina-
immobilization Doppler spectra returned to a tion of neuroarthropathy in the course of time.
normal triphasic pattern. Further investigations Contrast medium uptake correlates with clinical
are necessary to evaluate Doppler spectrum anal- findings as well as with severity of the disease
ysis of the foot as a tool for activity monitoring and estimated duration of treatment [17].
during the rehabilitation process. Comparable to temperature measurements, the
It is generally recognized that arthritis or area of the foot with small or big, few or many
pseudoarthrosis demonstrates swelling or warm- joints involved must be considered. Another
ing during or after mechanical stress of the foot. aspect is the presence of fracture and joint dislo-
A so-called inactive Charcot neuroarthropathy cation which have influence on duration of off-
nevertheless is often characterized by incongru- loading treatment. Inclusion of these features into
ent joints and pseudarthrotic bone fusion as seen scoring systems helps to identify patients with an
on plain X-rays. Inevitably, walking on an inac- expected necessity for longtime treatment [18].
tive Charcot foot with this radiological picture Unfortunately, MRI has comparable limitations
must result in edema and temperature rise. to temperature measurements by offering no dis-
Armstrong [14] and subsequently Schon [15] tinctly quantifiable marker for termination of
suggested to terminate casting and proceed to orthotic or cast treatment. Persistent bone and
shoe fitting when skin temperature difference joint fragmentation after CN consolidation is
between the affected site and the corresponding quite common in Charcot neuroarthropathy. The
area of the contralateral foot is less than 2°. presence of pseudarthrosis, instability, or defor-
However, it is necessary to make a distinction mity with abnormal loading patterns prompts the
between the areas of the foot where temperature persistence of mechanical irritation and subse-
measurements take place. Ankle joint and the quent inflammation. In those cases, complete
small (tarsal) joints behave differently regarding remission of bone or soft tissue edema as shown
heat production. When it comes to quantification on MRI cannot be expected even if the neuroar-
of inflammatory processes of small joints, ther- thropathic process is no longer active.
234 A. Koller
Conventional Radiography modulating neuropeptides is responsible for the

ignition of an inflammatory process [9]. On the
Conventional Radiography still has its place in mechanical level, stress and strain around the
monitoring neuroarthropathy. It is significantly affected joints can further deteriorate fractures
less expensive than MRI and available virtually and dislocations and stimulate inflammation that
everywhere in the world. In conjunction with the in turn weakens bone—a true vicious circle.
clinical examination, the X-ray provides valuable Under a technical aspect it is more difficult to
information about the consolidation of the neuro- control internal and external forces acting around
arthropathic process. Eichenholtz described three the ankle joint than around the tarsal or midtarsal
stages of osteoarthropathy [19]. The stage of res- joint. This may also explain why healing time
olution (I) shows joint and soft tissue swelling, differs with joint location in CN under conserva-
bone and cartilage detritus, intraarticular frac- tive treatment [21]. Mechanical disturbances can
tures, dislocations, and osteochondral fragmenta- be caused by ill-fitting orthoses or by leaving
tion. As a result of continued loading of the them off, occasionally, since neuropathic patients
sensation-impaired foot, persistent microtrauma- can walk free of pain without orthosis or cast.
tization occurs, leading to an inflammatory This is when mind comes in. Not as a synonym
response and increasing deformity. for (missing) understanding, but as a complex
The stage of reparation (II) shows incipient psychological reaction on peripheral polyneu-
healing. There is resorption of necrosis, decrease ropathy which is responsible for a neglect-like
in edema, and fusion of fragments. Sclerosis of phenomenon.
bone ends and osteoporosis near the joint are Slower bone healing due to neuropathy neces-
typical. This stage can only begin with unloading sitates a form of follow-up treatment that is dif-
of the foot and immobilization of the patient. ferent from traumatological standard procedures
The subsequent stage of restitution (III) is [22–24]. This is true for internal as well as for
characterized by revascularization and “remodel- external fixation techniques, since in both cases
ing” of bone ends with the aim of creating stabil- solid bone fusion generally is not completed after
ity. In some cases, grotesque joint formations 6–8 weeks [25, 26].
may result. Clinically, stage I is the active phase, Postoperative therapy follows the same prin-
while stages II and III are phases of healing [20]. ciples as in the conservative treatment of active
Just like a long persisting bone edema in MRI, neuroarthropathy. Plaster casts or orthoses are
swelling and hyperthermia may give the impres- used to protect arthrodesis after internal or also
sion that the inflammatory process is still active external fixation from damaging mechanical
in the clinical-radiological staging according to forces until a solid bony fusion is achieved. Only
Eichenholtz. It should therefore be mentioned then does the inserted osteosynthesis material no
again that this is also the case in a burnt-out longer have to bear any load. However, if the foot
Charcot arthropathy if this has left considerable is released for loading before the arthrodesis is
mechanical joint destruction. fully built up, exactly what happens regularly
with repetitive bending loads on metal work-
pieces happens: it breaks. And this is also true of
Postoperative Follow-Up Treatment very massive implants, which are inserted under
the assumption that the bone is too soft in Charcot
We find a combination of conditions with influ- foot. However, as already explained, it is the neu-
ence on healing time of neuroarthropathy. It is the ropathy that is responsible for the slower bony
role of molecules, mechanics, and the mind. On fusion. As a rule of thumb, a doubled time until
the molecular level, neuropathy impairs bone the arthrodesis is completed can be assumed, i.e.,
healing by deregulation of bone turnover where at least 3 months. In the case of arthrodesis in the
interaction of nuclear factor kappa b ligand and hindfoot, the time can also be half a year or lon-
osteoprotegerin plays an important role. Loss of ger. The information available on this in the
l iterature is quite inconsistent and is based on the org/10.1016/S0140-6736(05)67029-8. Epub 2005

Aug 10. PMID: 16338454.
experience of the respective centers. 10. Guyton GP. An analysis of iatrogenic complications
In summary, conservative therapy of Charcot from the TCC. Foot Ankle Int. 2005;26(11):903–7.
foot is sometimes a possible alternative to sur- 11. Piaggesi A, Macchiarini S, Rizzo L, Palumbo F,
gery, or actually always a complement. Especially Tedeschi A, Nobili LA, Leporati E, Scire V, Teobaldi
I, Del Prato S. An off-the-shelf instant contact casting
the follow-up treatment with casts or orthoses device for the management of diabetic foot ulcers: a
takes into account the specifics of the bone randomized prospective trial versus traditional fiber-
metabolism and the increased mechanical stress glass cast. Diabetes Care. 2007;30(3):586–90.
in neuropathy and should therefore be familiar to 12. Dahmen R, et al. Therapeutic footwear for the
neuropathic foot: an algorithm. Diabetes Care.
every foot surgeon who deals with Charcot feet. 2001;24(4):705–9.
13. Wu T, Chen PY, Chen CH, Wang CL. Doppler spec-
trum analysis: a potentially useful diagnostic tool
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acute Charcot’s arthropathy with infrared dermal ther-
neuroarthropathy: a perspective by the Charcot task
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[published correction appears in Diabet Foot Ankle.
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Charcot Foot: Surgical
Management and Reconstruction
19
Dane K. Wukich and Venu Kavarthapu
Introduction The growth of surgical intervention in

treating CN) appears to parallel the introduc-
The surgical management of Charcot neuroar- tion and acceptance of new methods of skel-
thropathy (CN) has evolved over the past sev- etal fixation. In 1958, “Arbeitsgemeinschaft
eral decades. Historically, CN has been treated für Osteosynthesefragen” or AO (translated to
nonsurgically with offloading and accommoda- Association for the Study of Internal Fixation)
tive footwear. Early attempts at surgical recon- was founded in Switzerland. The AO method of
struction were associated with high complication employing rigid internal fixation for the treat-
rates, and this may have contributed to a long- ment of fractures was revolutionary and consid-
standing bias against surgical reconstruction. ered radical by some surgeons, particularly in
In 1967, Johnson [1] reported on 118 cases of the USA. After two to three decades of basic sci-
neuropathic fractures and joint injuries. At that ence research and outcome studies, AO became
time he recognized that inadequately protected widely adopted globally. Specially designed
fractures, soft tissue sprains, and effusions of plates and screws offered a significant improve-
neuropathic joints were the precursors of joint ment in managing fractures and dislocations
destruction. He further stated that trauma in the [2]. Contemporaneously, in the Soviet Union,
form of surgery during acute stage could stimu- Professor Gavril Abramovic Ilizarov developed
late further resorption. Consequently, Johnson an equally revolutionary and radical method of
did not advocate surgery until resolution of the treating musculoskeletal injuries and deformities
acute inflammatory response. Johnson did not [3]. Ilizarov’s method utilized circular external
advocate surgery specifically for diabetes-related rings and fine wire transosseous fixation to sta-
neuropathic foot injuries because of the concern bilize fractures and deformities. The true genius
for “circulatory problems.” of Ilizarov was to create an “external ring fix-
ator” that enabled not only static correction, but
D. K. Wukich (*) gradual dynamic correction of major deformities.
Orthopaedic Surgery, University of Texas Ilizarov’s technique greatly expanded the surgi-
Southwestern Medical Center, Dallas, TX, USA cal management in treating osteomyelitis, and
e-mail: [email protected] the recognition that distraction osteogenesis was
V. Kavarthapu possible, contributed to success in limb salvage
Odense University Hospital, University of Southern surgery. Ilizarov’s methods remained isolated to
Denmark, Odense, Denmark
the Soviet Union and eastern bloc countries until
King’s College Hospital, London, UK the 1980s when surgeons from Italy were able to

238 D. K. Wukich and V. Kavarthapu
visit his center in Kurgan, Siberia. Subsequently, contribute to high rates of postoperative compli-
the methods of Ilizarov were disseminated cations [8–10].
across the globe, and circular external fixation Commensurate with the expanded methods of
has become a widely adopted technique that is fixation, enthusiasm for the surgical management
often employed in the treatment of CN. Finally, of Charcot neuroarthropathy has grown over the
another major advancement in skeletal fixation past 25 years. Historically, surgical intervention
was developed by Professor Gerhard Kuentscher was not recommended until the acute inflamma-
in Germany. Professor Kuentscher pioneered the tory response had resolved and consolidation had
intramedullary nailing method for the treatment occurred. One of the earliest reports from
of long bone fractures. His original book was Thompson and Clohisy [11] recommended surgi-
published in 1947, and the full English transla- cal reconstruction in patients whose deformity
tion of “The Marrow Nailing Method” in 2006 could not be accommodated in a load sharing
[4]. This text was previously unknown until 2004 orthosis. They also advocated that the skin should
and gives a remarkable account of his treatment be free of ulceration at the time of the
of World War II injuries from the perspective procedure.
of a German surgeon. Similar to AO principles A systematic review on the surgical manage-
and the methods of Ilizarov, intramedullary fixa- ment of Charcot neuroarthropathy was published
tion of long bone injuries was initially viewed in 2012 [12]. The authors searched databases
with skepticism in the USA. Over the past four from 1960 until 2009 and identified 96 articles
decades, intramedullary fixation has been univer- that met the inclusion criteria of surgical manage-
sally adopted as the treatment of choice for lower ment of Charcot neuroarthropathy. Forty-two of
extremity long bone fractures. This technique has the 96 articles were expert opinion or case reports
been translated to use in CN) reconstruction, and (44%) and 54 articles were retrospective case
retrograde intramedullary fixation is widely used series without a control group (56%). The level
for complex reconstructions of the ankle and of evidence for the surgical management of
hindfoot. Originally implants designed for the Charcot neuroarthropathy was therefore based on
femur were inserted, but now multiple specially level IV and level V evidence, and there were no
designed retrograde ankle arthrodesis nails are controlled retrospective studies or prospective
available [5]. randomized studies. Interestingly, four centers
An early study from the Mayo Clinic (1990) accounted for 51% of all patients reported in this
reported on ankle fusion in diabetic neuropathic systematic review. The authors offered several
joints, citing complication rate of 62% including conclusions from their study: (1) the evidence for
non-union, amputation, and death [6]. The performing or not performing surgery during the
authors cautioned that neuropathic arthropathy acute phase of Charcot neuroarthropathy was
contributed to the inordinate complication and inconclusive, (2) the most common locations
failure rates, and ankle arthrodesis should be con- requiring surgical intervention were the midfoot
sidered with caution in the diabetic patient. It is followed by the ankle, (3) exostectomy was
now well recognized that patients with CN) may found to be useful to relieve bony pressure that
have peripheral artery disease; however, it rarely could not be accommodated with orthotics and
results in critical limb ischemia. Using noninva- prosthetics means, (4) Achilles tendon lengthen-
sive arterial testing, approximately 13% of ing or gastrocnemius recession reduced forefoot
patients with CN have ischemia as defined by a pressure and improved alignment of the ankle
great toe pressure of less than 60 mmHg, and and hindfoot relative to the midfoot and forefoot,
only 2.4% of patients had critical limb ischemia (5) arthrodesis was indicated for instability, pain,
defined as a toe pressure of less than 30 mmHg or recurrent ulceration that failed nonsurgical
[7]. While adequate perfusion is necessary for treatment, (6) there was inconclusive evidence to
successful surgical outcomes, we now recognize recommend one type of fixation over another
the neuropathy and poorly controlled diabetes (internal versus external fixation).
19 Charcot Foot: Surgical Management and Reconstruction 239
The same group updated their systematic care team (MDFT) [16]. They have reported their
review searching articles from 2009 until 2014 experience in the management of complex mid-
[13]. An additional 30 manuscripts met the crite- foot, hind foot, and ankle Charcot neuroarthropa-
ria for inclusion, demonstrating that 6.6% of thy as well as their protocol for dealing with
studies were level II prospective comparative infected Charcot joints [17–19]. Both the
studies, 13.3% were level III retrospective case- Georgetown and King’s College Programs have a
control study, and 80% were level IV retrospec- collaborative service that includes specialists in
tive case series. This updated review demonstrated reconstructive surgery, vascular surgery, wound
that the ankle (38.4%) and hindfoot (41.6%) were care, and internal medicine (diabetologists) with
the most common locations reported for surgery a mission of providing outstanding patient care
followed by the midfoot (29.6%). The conclusion and service.
of this updated systematic review suggested that
the published surgical data for Charcot neuroar-
thropathy was improving as evidenced by higher Controversies of Surgical
level studies during the preceding 5 years. The Management
authors also reported that despite improved meth-
ods of fixation and improved patient selection, Many questions regarding the surgical manage-
approximately 9% of patients with Charcot neu- ment of Charcot neuroarthropathy remain unan-
roarthropathy who underwent surgery required a swered or debated. The decision to proceed with
major amputation. surgical intervention is often debated, and often
In 2017 Safavi et al. [14] also performed a sys- the anatomic location of Charcot determines
tematic review on the outcomes of surgical treat- whether or not surgery will be done. For exam-
ment of midfoot CN. Nine studies were identified, ple, nonsurgical treatment of midfoot Charcot
and the authors reported a fusion rate of 91%, has been reported to be as high as 60% in a large
amputation rate of 6%, and hardware complica- series [20]. Success was defined as being able to
tion rate of 16%. wear standard, commercially available therapeu-
One of the most important determinants of a tic depth inlay shoes and custom fabricated
successful Charcot surgical team is to be part of a accommodative foot orthosis. Deformities at the
multidisciplinary program. Cates et al. [15] ankle are less well tolerated and more prone to
reported on outcomes of Charcot reconstruction ulceration, particularly when deformity in the
in patients with and without diabetes. The authors coronal plane is present. A consensus document
are a part of the Georgetown University Diabetic recommended that for severe Charcot deformity
Limb Salvage Program, globally viewed as an of the ankle, surgical management should be con-
excellent multidisciplinary program. Despite sidered a primary treatment because coronal
their large experience, Charcot reconstruction in deformity of the ankle is poorly tolerated [21].
diabetic patients was associated with high rates Traditionally, surgical intervention was not
of wound dehiscence (16%), delayed healing recommended until the acute inflammatory
(34%), and major lower extremity amputation response had subsided and consolidation
(26%). When they evaluated their cohort of dia- occurred. There is little evidence to support this,
betic patients who were deemed to be well con- but the dogma was that surgical intervention dur-
trolled (hemoglobin A1c ≤6.5), the rate of major ing the hyperemic phase was associated with
lower extremity amputation was only 10%. There higher complication rates. In 2000 Simon et al.
was little difference in the rate of wound dehis- [22] reported on a series of 14 patients with mid-
cence (15%) or delayed healing (30%) in well- foot Charcot who underwent early operative
controlled patients. treatment during Eichenholtz stage I. All 14
The King’s College Hospital Program in arthrodesis procedures were successful and the
London UK is also widely globally recognized as meantime to return to assisted weight-bearing
an outstanding multidisciplinary diabetic foot was approximately 10 weeks. In 2010,
Mittlemeier et al. [23] reported on the outcomes required major amputation. Procedures on the
in 22 patients (26 ft) that underwent primary sur- foot achieved a higher rate of success than the
gical reconstruction. The indications for realign- ankle (93% vs. 84%). In contrast, external fixa-
ment arthrodesis were instability, non-plantigrade tion was associated with successful outcomes in
foot, and deformity with ulcer or impending 93% of patients and the major amputation rate
ulceration. They experienced nine complications, was 3.5%. Procedures on the foot achieved a
five hematomas, and four with postoperative higher rate of success than the ankle (90% vs.
instability. Despite this, all patients achieved a 88%).
stable and plantigrade foot and no recurrent Additional data demonstrated from Dayton’s
ulcerations occurred. The authors suggested that review included the fact that internal fixation was
surgical reconstruction of the Charcot foot should used in patients with uncomplicated wounds or
not be limited to salvage procedures, but early osteomyelitis. Screws were preferred for the foot
surgical intervention in high-risk patients should and intramedullary fixation for the ankle. Dayton
be considered. One of the potential limitations of also acknowledged that external fixation was
this retrospective study is that only four of 22 used primarily in more complicated cases with
patients (18%) were treated during Eichenholtz infection. Pooling of data from the 23 studies
stage 1. Five years later the same center reported found that the odds ratio of successful outcome
that 19 of 21 patients (90%) who underwent late using internal fixation was significantly less
corrective arthrodesis experienced at least one likely than when external fixation was used (OR
complication [24]. 0.52, 95% CI 0.30–0.90, p < 0.05). The conclu-
The choice of fixation (i.e., internal or external sions drawn from this study must be viewed in
fixation) depends on several factors, not the least the context of selective bias.
of which is surgeon preference. One of the major
determinants is the presence or absence of active
bone or soft tissue infection. Most authors agree Radiographic Evaluation
that internal fixation is not recommended in the
setting of active infection. Some surgeons utilize Standing X-rays of the ankle and foot should be
internal fixation in patients with clinically unin- obtained in all patients to include three views.
fected wounds, while others prefer to achieve Hindfoot alignment views are also essential to
ulcer healing prior to operative reconstruction. identify subtle varus and valgus deformities.
Our general approach is to use internal fixation in Contralateral radiographs can be especially help-
patients without active infection. In patients with ful to assess the normal anatomy. In some cases,
open wounds associated with active infection we osseous anatomy can be so distorted that radio-
prefer external fixation, as a primary procedure graphs are not optimal for preoperative planning
or staged. Patients with active infection are also in which case advanced imaging is beneficial.
treated with culture directed antibiotics and nega- Malalignment of the ankle is typically obvious;
tive pressure wound therapy if indicated. In select however deformities of the hindfoot and midfoot
cases, a hybrid type of construct is utilized com- can be less obvious. Measurement of certain
bining both internal and external fixation, partic- angles of the foot can be helpful in preoperative
ularly in patients with poor bone quality. While planning and predicting the potential for ulcer-
external fixation is an invaluable tool in CN, its ation. In 2008, Bevan and Tomlinson [27]
use can be associated with a high complication reported that lateral talar-first metatarsal angle
rate in patients with diabetes [25]. measured on weight-bearing radiographs was a
Dayton et al. [26] published a systematic simple means of monitoring patients’ risk of
review comparing the outcomes of CN using development of midfoot ulceration. Another
internal or external fixation. Procedures using radiographic study found that sagittal plane
internal fixation achieved an overall successful deformities are more likely to be associated with
outcome rate of 87% of patients and 6.5% foot ulcerations than transverse plane deformities
[28]. Lateral column involvement was identified assessment is commenced during their visit to a
by a decrease in the cuboid height, decreased cal- dedicated “Foot School Clinic” (see figure). The
caneal pitch, and decreased lateral calcaneal fifth group of patients undergoing Charcot reconstruc-
metatarsal angle. Meyr and Sebag [29] recom- tion procedures are seen along with their personal
mended against using a single radiographic care providers or family members in the clinic.
parameter to predict midfoot ulceration because Detailed and interactive audio-visual presenta-
of significant positive and negative correlations tions are made to the attendees by the members
among various angles that could be measured. of the MDFT (physician, surgeon, podiatrist,
Given that limitation, excellent reliability for physiotherapist, and occupational therapist), cov-
radiographic measurement of cuboid height on ering the generic information on their periopera-
subjects with midfoot Charcot neuroarthropathy tive care. This is followed by individual
has been reported [30]. assessment and counseling of each patient, sepa-
CT scans provide improved osseous visualiza- rately, by each member of the MDFT. The phys-
tion and can identify bone loss and dislocations iotherapist provides the information on the
not seen on radiographs. MRI can identify bone prehabilitation regime (PREHAB) whereas the
injury beyond the suspected area of Charcot as occupational therapist goes through the microen-
evidenced by increased signal. MRI can also be vironment setup at the patient’s residence and the
useful in cases of suspected osteomyelitis in regimens used for postoperative mobilization due
patients with active or healed wounds as well as to the limitation of weight-bearing. All routine
following the course of CN. perioperative assessments and investigations are
Nuclear medicine can also be helpful in the completed at this stage.
evaluation of suspected for infected CN by label- Routine blood investigations, including CBC,
ing Leukocytes with either (99m)Tc-HMPAO or renal and liver profiles, and inflammatory mark-
(111)In-oxine [31]. In experienced centers accu- ers (C-reactive protein, ESR, procalcitonin) will
racy in detecting bone infection can be greater provide adequate assessment of surgical fitness.
than 95%. Another benefit is that white cell Blood vitamin D levels are often low in this group
labeled scans may be able to differentiate soft tis- of patients and it is recommended to routinely
sue infection versus aseptic inflammation. provide vitamin D replacement. In the presence
Single-photon emission computed tomography/ of raised inflammatory markers, radiological fea-
computed tomography (SPECT/CT) and bone tures of osteomyelitis or a history of previous
marrow scanning can also improve anatomic res- infection in the Charcot affected region, it is
olution of the foot and ankle [31]. advisable to perform bone biopsies for a defini-
tive diagnosis and microbiological sensitivities.
Bone biopsy can be performed as an outpa-
Preoperative Evaluation tient procedure in most patients. The patient
should be off antibiotics for at least 2 weeks prior
Patients with CN often have multiple comorbidi- to the biopsy procedure. The location of the bone
ties that can increase the perioperative risks of biopsy target material is determined based on the
surgery to include cardiovascular disease (hyper- imaging studies. Local anesthetic infiltration can
tension, coronary artery disease, compensated or be applied to the area of skin penetration if the
uncompensated heart failure), diabetic nephropa- skin sensation is intact. Using aseptic technique,
thy or autonomic neuropathy, poorly controlled the assembled trocar and cannula of the biopsy
diabetes, and tobacco use. A thorough preopera- instrument is pierced into adequate depth and in
tive evaluation can predict the risk [32]. the direction based on imaging studies. If an ulcer
Patients undergoing Charcot reconstruction is present, the biopsy entry point is chosen about
benefit from a structured multidisciplinary evalu- 1 cm away from the edge of the ulcer, avoiding
ation prior to the procedure. At King’s College areas of active inflammation. Using a standard
Hospital diabetic foot unit, the preoperative bone core biopsy technique, the specimen is har-
vested and sent for microbiology (culture and fracture rather than dislocation was 9.5.
sensitivities) and histological studies. Dislocations and fracture dislocations had nor-
Vascular studies are routinely considered prior mal bone mineral density as measured in their
to Charcot reconstruction, to rule out any signifi- study. The fracture pattern was more likely to be
cant vascular compromise. If identified, this is seen in the ankle and foot, while the midfoot
best addressed by performing the revasculariza- mostly involved dislocations. The hindfoot was
tion procedure about 4–6 weeks prior to the represented by fractures, dislocations, and frac-
deformity correction. The method of ture dislocations. The authors opined that the
revascularization is beyond the scope of this
osteopenia seen in the fracture group was not a
chapter and will be discussed in other chapters. result of regional Charcot neuroarthropathy,
because the decreased bone mineral density was
observed in the contralateral extremities. They
Charcot Bone further stated that the success of midfoot recon-
struction may be related to the fact that the dislo-
Surgeons should recognize that bone is a dynamic cation pattern has more of a normal bone mineral
organ, and in normal homeostasis, bone resorp- density compared to the fracture pattern.
tion and bone formation are in relative balance. It Limitations of this article included few patients
is well recognized that during the active phase of in the combination fracture dislocation group and
Charcot neuroarthropathy, circulating osteoclasts inclusion of patients presenting at different
are significantly elevated and metabolically Eichenholtz stages of the disease. Nonetheless
active resulting in a net loss of bone. Osteoclasts this study highlights an important point, namely
also express inflammatory cytokines such as that identification of peripheral osteopenia may
interleukin-1 beta, interleukin-6, and TNF alpha be a potentially modifiable systemic risk factor in
which facilitate the recruitment, proliferation, patients with diabetes and neuropathy.
and differentiation of osteoclasts. A histopatho- Petrova at al. [35] studied 36 consecutive
logical and immunohistochemistry study of bone patients who were treated for acute Charcot neu-
retrieved from patients undergoing Charcot roarthropathy. They measured bone mineral den-
reconstruction demonstrated that even though sity of the calcaneus from the involved foot and
patients were beyond Eichenholtz stage 1 (active) compared it to bone mineral density from the
and in the remodeling phase, expression of proin- contralateral uninvolved foot. The authors found
flammatory cytokines was still present on patho- that the bone mineral density of the involved foot
logical examination [33]. This finding has was significantly decreased when compared to
implications in planning surgical reconstruction. the contralateral foot at presentation, after
Surgeons planning to reconstruct Charcot 3 months of casting and at clinical resolution.
neuroarthropathy should have an understanding There was a significant decrease in bone mineral
of the quality of the involved bone. Herbst at al. density from the time of presentation until the
[34] classified the bone injury pattern as either a time of casting at 3 months. After 3 months no
fracture, dislocation, or fracture dislocation. significant further decrease in bone mineral den-
Bone mineral density was measured in the con- sity occurred. Contrary to the opinions of Herbst
tralateral femoral neck or contralateral distal et al. [34], the authors felt that this reduced ipsi-
radius, and not measured in the involved foot. lateral bone mineral density was secondary to
The authors found that patients who presented proinflammatory induced osteolysis.
with a fracture pattern had significantly lowered Greenhagen et al. [36] prospectively studied
T-scores in bone mineral density compared to the central (core) and peripheral bone mineral den-
dislocation group. In fact, the age adjusted odds sity in a cohort of diabetic and non-patients.
ratio of a patient with osteopenia according to the Peripheral bone density was measured in the cal-
World Health Organization criteria as having a caneus of the extremity affected by CN, while the
core bone density was measured in the lumbar Indications for Surgery
spine. The diabetic cohort was comprised of two
groups, one who had Charcot neuroarthropathy Traditionally the indications for surgical inter-
and a control of diabetes patients without vention include:
Charcot. The bone mineral density of the Charcot
group was significantly lower in the calcaneus • Non-braceable deformities
compared to the control group, and there was a • Instability
strong trend that the Charcot group bone quality • Impending ulceration of the skin
was lower than the diabetic control group • Non-healing ulcers
(p = 0.08). Interestingly the core bone mineral • Recurrent ulcers
density as measured in the lumbar spine was not • Osteomyelitis of the midfoot, hindfoot, and
significantly different between the three groups. ankle
It is important to recognize that tools that • Pain
measure BMD are quantitative in nature and do
not measure the qualitative aspect of bone. Although symptomatic pain is relatively
Patients with diabetes are at risk for fragility frac- uncommon, a subset of patients with Charcot
tures due to decreased bone material strength neuroarthropathy will complain of significant
even in the setting of normal BMD [37]. This pain due to instability and deformity. Some
increased risk of fracture is secondary to greater patients complain of difficulty ambulating with a
cortical porosity, smaller cortical area, and rocker bottom deformity. Patients whose foot is
decreased bone strength. The implication in non-plantigrade are at high risk of ulceration. For
Charcot patients is the obvious potential for stress the purposes of this chapter, a non-plantigrade
fractures even without observed trauma. Given foot/ankle is defined as one in which the patient
the alteration in bone remodeling and turnover is bearing weight on skin that is not meant to bear
seen in diabetic bone, healing after arthrodesis weight. For example, the plantar arch, lateral and
could be impacted as well due to decreased bone medial borders of the foot dorsal to glabrous skin
quality and reduced biomechanical properties. and skin over the medial and lateral malleoli are
It has also been demonstrated that inflamma- not designed to bear weight. Midfoot CN com-
tory and bone turnover markers and acute Charcot monly results in collapse of the arch with poten-
neuroarthropathy are elevated in peripheral tial skin compromise medially or laterally on the
serum [38]. Inflammatory markers such as plantar surface. Collapse of the medial column
C-reactive protein, TNF alpha, and interleukin-6 can involve subluxation/dislocation of the talona-
were found to be significantly higher in patients vicular, naviculocuneiform, or tarsometatarsal
with Charcot neuroarthropathy when compared joints. Laterally, the prominence is typically a
to diabetic patients without Charcot neuroar- result of subluxation or dislocation of the
thropathy. Markers of bone turnover such as calcaneo-cuboid joint. Hindfoot and ankle defor-
C-terminal telopeptide, bone alkaline phospha- mities can result in significant varus or valgus
tase, and osteoprotegerin were also significantly malalignment that jeopardizes non-plantar skin
elevated at presentation. TNF alpha and interleu- (see figure). Final surgical planning and goals of
kin-
6 declined significantly after 3 months of surgery are best discussed by the multidisci-
casting but did not change during the resolution plinary team, taking into consideration the fac-
phase. Markers of bone turnover did not decline tors that have been previously reviewed. While
significantly after 3 months of casting or at final each Charcot case is unique, reconstruction
resolution. Surgeons should recognize that the should follow a logical and reproducible plan.
potential for ongoing bone remodeling can occur We recognize that customization of the approach
regardless of the timing of surgical intervention, may be necessary, but in general the following
even after resolution of Eichenholtz Stage 1. principles guide reconstruction.
1. Perioperative medical optimization mea- 8. The fixation devices: Due to the presence
sures. A high portion of patients are on anti- of significant bone loss, Charcot foot recon-
coagulation treatment and it is often not safe struction procedures often require a com-
to stop this medication preoperatively. bination of fixation devices to achieve a
2. The choice of anesthesia: Peripheral nerve long-segment and rigid fixation construct.
block for pain relief is not considered in most Hindfoot nail fixation may require additional
patients, due to the degree of sensory neu- cannulated screw fixation across the hind-
ropathy. Tranexamic acid administration dur- foot, and midfoot beams may require supple-
ing induction is usually considered in most mentary locking plate fixation, to enhance
patients. the rotational rigidity to the construct.
3. Decision on the usage of tourniquet: This 9. Wound closure: On occasions, it may not
is based on the vascular status and previous be possible to achieve tension-free pri-
revascularization procedures. It should be mary wound closure, particularly when the
recognized that many patients have medial degree of the deformity is severe or if con-
artery calcinosis that can prevent occlu- comitant ulcer debridement was done. The
sion with a tourniquet, resulting in a venous need for performing a local rotational flap
tourniquet. or other appropriate plastic surgical proce-
4. Prophylactic antibiotics administration: This dure or usage of NWPT is anticipated. Soft
is delayed until the intraoperative bone and tissue complications are common, and one
deep tissue samples are harvested. method of minimizing these complications
5. Surgical approaches: The location of the is to approach the deformity from the con-
surgical approaches and their effect on the vex side. Once the deformity is corrected, the
vascular supply to the soft tissue envelope convex side is no longer under tension while
and bones is discussed. It is preferred to the concave side is subjected to tension.
perform the reconstruction using one main 10. Antibiotic regimen: In the presence of an
surgical approach, supplemented with addi- ulcer or previous history of infection, a bio-
tional small approaches as required. Foot and degradable, osseoconductive and local anti-
ankle surgeons must be comfortable with a biotic eluting calcium sulfate preparation can
360-degree approach to the pathology, as be used to fill the bone voids and achieve high
many patients have compromised skin from concentrations of the antibiotic. The postop-
previous surgery. erative antibiotic regimen can be based on
6. Soft tissue releases: The associated soft tis- the preoperative bone biopsy microbiology
sue contractures are assessed, and plans are sensitivities and modified according to the
made for lengthening or release for defor- sensitivities of intraoperative specimens.
mity correction. Commonly performed 11. Mobility: Postoperative weight-bearing sta-
soft tissue lengthenings in Charcot surgery tus and the duration is determined based on
include Achilles (sagittal plane), posterior the complexity of the reconstruction proce-
tibial (varus deformities), and peroneal (val- dure. Consideration is given on the status of
gus deformities). the opposite foot, as excessive load bearing
7. Bone corrections: The location of the bone carries a risk of activation or re-activation of
osteotomies and the size of the bone wedge/ Charcot changes in this foot.
rhomboid resections are discussed based on
the assessment of clinical deformity (shape
and flexibility) and imaging studies. CT Exostectomy
imaging with 3D reconstruction, weight-
bearing CT, and 3D printed model of the Several retrospective case series have described
bone deformity of the foot are useful tools medial or lateral exostectomy to decompress
used for this assessment. bony deformities of CN and promote healing of
recalcitrant ulcers [39–44]. Advocates of exos- inactive phase. Despite adequate offloading some
tectomy cite high healing rates of ulcers; how- Charcot deformities continue to progress second-
ever, Catanzariti et al. [40] reported higher ary to the degree of bone fragmentation or joint
success with medial column exostectomy versus dislocations. Progressive deformities make the
lateral column exostectomy. Molines-Barroso foot and ankle vulnerable to friction and shear
et al. [42] found that sagittal plane radiographic forces which can lead to ulceration. If the foot is
measures worsened after lateral column exostec- at risk of ulceration, and consequently infection
tomy as manifested by a significantly decreased due to the presence of marked deformity and or
calcaneal inclination angle and significantly instability, it is advisable to perform surgical
increased talar declination angle. reconstruction in the active phase of the disease.
Plantar ulcers due to bone prominence that do Although ideally performed after resolution of
not respond to surgical debridement can be con- foot swelling and normalization of local warmth,
sidered for exostectomy. The infected ulcer is the degree and location of deformity may accel-
excised, removing all infected and necrotic tissue, erate the surgical plan despite the presence of
down to the bone prominence. Any associated active inflammation. The use of a preoperative
tendon contractures, particularly of the Achilles compression dressing incorporating cast padding
tendon is released or lengthened. The area of in conjunction with elevation can result in sub-
bone resection is identified by careful palpation stantial reduction in edema. The reconstruction is
and under the guidance of fluoroscopy. All bone performed using internal or external fixation,
prominence is excised completely using an oscil- using the principles described later in this
lating saw or a sharp osteotome. If there are any chapter.
areas of residual bone necrosis or bone changes
consistent with osteomyelitis, the resection is
continued until all these areas are removed. Care Reconstruction of Inactive
is taken not to leave any bone projections or loose Charcot foot
bone fragments as this will interfere with ulcer
healing. Where available, antibiotic loaded cal- Severe Charcot deformity carries a high risk of
cium sulfate preparation can be inserted into drill developing ulceration even with adequate
hole channels created in the exposed bone as an offloading. Associated instability, often noticed
injectable form or applied on the bone surface as in severely affected feet due to non-union of bone
beads (see figure). Local elution of high concen- fragments effected by the Charcot process, pro-
trations of antibiotic can potentially eradicate any vides additional challenge in preventing a skin
residual infection. The foot is examined after com- breakdown. Ulceration often progresses to devel-
pletion exostectomy for the presence of instability oping infection and a chain of events resulting in
due to bone resection. This requires a temporary a major amputation. An ulcerated Charcot foot is
stabilization of this area with threaded wires or an 12 times more vulnerable to undergo a major
external fixator for the duration of bone healing. lower limb amputation [45]. Due to the high rate
The open wound is managed either with a local of mortality following a major lower limb ampu-
rotation flap, free flap, or negative pressure wound tation in the diabetic population, a functional
therapy and appropriate offloading. limb salvage of Charcot foot can potentially save
the life of some of these patients.
The aim of Charcot foot reconstruction is to
Reconstruction of Active achieve a plantigrade and stable foot that is infec-
Charcot Foot tion and ulcer free and allows full weight-bearing
in a modified shoe or a brace. The incidence of non-
Acute (active) CN of foot normally responds to union following Charcot foot reconstructions is
immediate offloading in a total contact cast high, and in general a stable non-union or pseudo-
(TCC) or a well-fitting brace until it reaches an arthrosis has been considered as an acceptable out-
come. Some fibrous non-unions achieve adequate fixation devices in a novel position that maxi-
stability and are still desirable; however, mobile and mizes its mechanical function. Subsequent stud-
unstable non-unions should be avoided in a neuro- ies identified the additional need for the fixation
pathic foot, as this can result in recurrence of defor- construct to provide rigidity against axial, bend-
mity over a period of time. Ideally, the surgical aim ing, and rotational forces to improve the fixation
should be to achieve a full bone fusion or a stable outcomes. The current established principle of
fibrous union in every procedure. internal fixation for Charcot reconstruction is
“durable long-segment rigid fixation with opti-
mal bone opposition.”
Deformity Correction
Charcot foot and ankle deformity correction is Hindfoot Internal Fixation

achieved by achieving adequate soft tissue balance,
through release or lengthening of contracted ten- An intramedullary hindfoot nail (IMHN) is
dons and other soft tissues, and performing wedge the most accepted method of internal fixa-
or rhomboid bone resections on the convexity of tion for Charcot hindfoot reconstruction.
the deformity, based on surgical planning. The Biomechanically, IMHN is a load sharing device,
choice of incision and surgical approach depends provides better mechanical environment, and
on the location of the deformity and the vascular has higher bending and torsional stiffness com-
status of the angiosomes. Multiple major surgical pared to other forms of internal fixation. It can
incisions should be avoided as they carry a sig- also provide intraoperative compression of the
nificant risk of wound breakdown and infection. bone fragments over the nail and that results in
Careful deep dissection of the incisions develop- optimal bone opposition. The torsional rigidity of
ing thick and deep soft tissue flaps and protecting the construct may be suboptimal in the presence
vascular structures is critical. All joints intended of marked bone loss and may require additional
for bone fusion are exposed and thoroughly pre- fixation (see figure) [18].
pared. Following the desired deformity correction, A trans-fibular lateral approach provides good
stabilization of the correction is achieved by using access to the ankle and subtalar joints for prepa-
either internal or external fixation methods. Recent ration and wedge resections and is the most com-
systematic review studies revealed no significant mon surgical approach. Alternative approaches
advantage of one method over the other (see fig- may be considered for severe valgus deformities
ure) [46]. With the recent introduction of Charcot- or those with compromised lateral soft tissues.
specific internal fixation devices, there has been a Following the soft tissue releases and bone resec-
recent increase in the usage of this internal fixation tions, the hindfoot is stabilized temporarily with
method for reconstructions. 2 mm Kirshner wires, to maintain correction. The
entry point for the hindfoot nail is determined
under fluoroscopy guidance and care is taken to
indfoot and Midfoot Stabilization
H make sure that guide wire goes through the mid-
Using Internal Fixation portion of calcaneus. The intramedullary ream-
ing to adequate diameter and depth is performed.
The surgical principles for Charcot foot and ankle The Kirshner wires are then removed and the
internal fixation method have evolved since chosen length and diameter hindfoot nail is
Sammarco et al. [47] described a decade ago, inserted, using the recommended standard surgi-
when the term “Super-construct” was introduced cal technique. Correct length and diameter of the
for this fixation. This advocated extension of nail should be chosen to achieve a good isthmal
bone fixation beyond the zone of injury, the usage fit of the nail is the tibial diaphysis. There are
of the strongest fixation device that is tolerated varying opinions on whether to use short or long
by the soft tissue envelope and application of the retrograde nails, and IMHN sizes range from 150
to 300 mm in length. Axial compression of the wedge and permits the application of tension
bone fragments over the nail is attained before band plating principle for the medial column fix-
inserting both proximal and distal locking screws. ation (see figure). The deformity correction can
In the presence of significant bone loss or during be provisionally held with two or more 2 mm
severe hindfoot correction that utilizes large bone Kirschner wires.
resections, optimal rotational rigidity cannot be The deformity correction can be stabilized
achieved with a standard hindfoot nail construct with a medial column beam or locking plate or a
alone. To enhance the rotational rigidity in such combination of these. For locking plate fixation
constructs, an additional cannulated screw can be technique, initial lag screw fixation with one or
inserted from calcaneum into distal tibia (see fig- two cannulated lag screws across the osteotomy
ure). Supplemental fixation can also be achieved is done before using a strong and low profile con-
with a locking plate spanning distal tibial and toured locking plate spanning across the medial
talus. column for neutralization. More recently an
intramedullary medial column beam spanning
the first metatarsal and talus, inserted either retro-
Midfoot Internal Fixation grade through the metatarsal head or antegrade
through the posterior body of talus, is favored as
Charcot midfoot deformities generally fall into it provides excellent compressive fixation and
one of three patterns: requires smaller surgical approach. If any resid-
ual rotational instability is noted, this can be
1. rocker bottom forefoot abduction enhanced by supplementing the fixation with a
2. dorsal subluxation/dislocation locking plate across the medial column (see fig-
3. forefoot adduction (see figure). ure). Most midfoot deformities, involving the
medial column, do not require a lateral column
The rocker bottom forefoot abduction defor- fixation, if the lateral cortex of cuboid is left
mity is the commonest pattern and results from intact. However, for complex deformities, as
the involvement of the medical column collapse. noted in some dorsal subluxation patterns and
Significant deformity often results in marked those that involve medial and lateral column
reduction of calcaneal pitch and contracture of rocker bottom deformity, additional lateral col-
Achilles tendon. Sagittal plane deformity can be umn fixation is required. This can be achieved by
quite significant. using additional lateral beams inserted from the
Midfoot deformity correction often requires third and fourth metatarsal into calcaneus, along
posterior muscle group lengthening to achieve with an additional plate fixation spanning the
soft tissue balance in the sagittal plane. This can base of fourth metatarsal to the anterior part of
be accomplished with required percutaneous calcaneum, if required.
tendo Achilles lengthening, open Achilles tendon
lengthening, or gastrocnemius recession. This is
performed in conjunction with anatomic restora- Two-Stage Reconstruction
tion by performing bone wedge resections on the
convex side. Most deformities are associated Charcot foot reconstruction is typically carried out
with rocker bottom and forefoot abduction comas a one-stage procedure, even in the presence of a
ponents. A medial midfoot approach allows per- non-infected ulcer. In the presence of an ulcer, thor-
forming a plantar and medial based bone wedge ough surgical debridement is performed at the
resection, with the apex of the wedge placed in beginning of the procedure, followed by the recon-
the lateral part of the cuboid bone, thereby pre- struction using the principles enumerated above.
serving the cuboid’s lateral cortex. This intact Multiple bone and soft tissue specimens are col-
lateral cortex of the cuboid allows controlled cor- lected during the procedure for microbiological
rection of the forefoot deformity by closing the analysis and empirical antibiotic therapy is com-
menced until the microbiological sensitivity results with internal fixation methods using the princi-
are obtained. The wound from ulcer debridement is ples described above (see figure). Repeat debride-
managed with primary closure, a local rotation flap, ment of the previously infected areas and further
or NPWT. In some cases, the ulcer wound can be harvesting of deep tissue and bone samples are
left open and healing occurs rapidly once the osse- done during the second stage, followed by soft
ous deformity has been corrected. tissue releases if required, wedge bone resec-
Charcot foot deformity associated with an tions, joint preparations, and internal fixation
infected ulcer or deep infection is best managed using the principle of “long segment and rigid
as a two-stage procedure (to achieve functional internal fixation with optimal bone opposition,”
limb salvage) [48]. The first stage of this treat- as described above. Gentamycin or Vancomycin
ment consists of surgical debridement of all impregnated injectable calcium sulfate prepara-
infected and necrotic tissues using the principles tion (Cerament® G or V, Bonesupport, Lund,
described above. It is critical that multiple deep Sweden) is applied to the bone voids and around
tissue and bone specimens from the infected the osteotomy sites for local antibiotic elution.
areas are harvested for microbiological culture Targeted intravenous antibiotics are continued
and sensitivities. Infected bone and prominences for 2–6 weeks based on the improvements noted
are thoroughly excised. In the presence of marked clinically and serologically. The postoperative
deformity, osteotomy or wedge resection is done care is similar to the one-stage reconstruction.
to reduce deformity and decompress the soft tis-
sues. The bone voids that are created from
debridement and osteotomy are filled with an Postoperative Care
antibiotic impregnated calcium sulfate prepara- of Reconstructed Charcot Foot
tion, for local antibiotic elution in high concen-
tration to eliminate any residual infection. The The leg is elevated postoperatively to reduce
choice of the antibiotic used in this preparation is swelling and the patient mobilized non-weight-
based on the previous microbiological sensitivi- bearing in a well-padded below-knee splint.
ties. If an osteotomy is done, the associated foot Closed surveillance of the surgical wound is
instability is addressed with the application of undertaken, and once the wound is stabilized, a
threaded guidewires or an external fixator tempo- total contact cast is applied. Bivalving of the
rarily. The open wounds created from ulcer TCC is especially helpful to facilitate regular
debridement or surgical wounds are managed wound inspections. The patient is discharged
with negative pressure wound therapy (NPWT). home, when safe mobility levels are reached,
Infection eradication is achieved by adminis- non-weight-bearing in a TCC. Postoperative
tering empirical intravenous antibiotics that are radiographs are taken at 6 and 12 weeks and reg-
changed to targeted antimicrobials once the intra- ularly then after as required. The non-weight-
operative specimen microbiology results become bearing TCC is continued for at least 3 months
available. The duration of antibiotic administra- post-surgery. Progression to partial weight-
tion is based on the improvement noted clinically bearing in the cast can be initiated once radio-
and serologically. After a period of 6–10 weeks graphs demonstrate signs of osseous healing.
of interval treatment that includes advanced Ultimately, progression to custom-made orthot-
wound care and foot offloading, the second stage ics and/or shoes is fabricated to assist in inde-
of treatment is delivered. pendent ambulation. Some patients may benefit
The second stage of the reconstruction is typi- from additional stability by using a cane to help
cally done using the external fixation option; mitigate the consequences of peripheral
however, recent reports have shown good results neuropathy.
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34. Herbst SA, Jones KB, Saltzman CL. Pattern of dia- 44. Sato T, Ichioka S. Ostectomy and medial plantar artery
betic neuropathic arthropathy associated with the flap reconstruction for Charcot foot ulceration involv-
peripheral bone mineral density. J Bone Joint Surg ing the midfoot. J Foot Ankle Surg. 2016;55:628.
(Br). 2004;86:378. 45. Sohn MW, Stuck RM, Pinzur M, Lee TA, Budiman-
35. Petrova NL, Edmonds ME. A prospective study of Mak E. Lower-extremity amputation risk after
calcaneal bone mineral density in acute Charcot Charcot arthropathy and diabetic foot ulcer. Diabetes
osteoarthropathy. Diabetes Care. 2010;33:2254. Care. 2010;33:98.
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Assoc. 2012;102:213. 47. Sammarco VJ, Sammarco GJ, Walker EW Jr, Guiao
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lowering agents: basic biology. Diabetologia. midfoot arthropathy. Surgical technique. J Bone Joint
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and bone turnover markers in a cross-sectional and without foot wounds. Foot Ankle Int. 2017;38:140.
Diagnostic Evaluation of Arterial
Disease in Limb Salvage
20
Michael Siah and Cameron M. Akbari
Introduction cinosis [3]. Below the ankle, the infra-malleolar

and pedal arch vessels may be impacted by non-
Many studies have established the association enzymatic glycation due to elevated blood sugar
between diabetes mellitus and peripheral arterial [4]. Disease in any vascular bed may impact
disease (PAD). Although atherosclerosis is a gen- wound healing. For example, even an incomplete
eralized process that can occur in diabetics and pedal arch is associated with recurrent ulceration
non-diabetics alike, the prevalence of PAD is within 1 year after primary ulcer healing [5].
more common in diabetic patients. In patients These implications highlight the importance of
with diabetes, for every 1% increase in hemoglo- vigilant perfusion screening in both symptomatic
bin A1c, there is a 26% associated increase in the and asymptomatic diabetic patients to improve
risk of PAD [1]. In fact, PAD in conjunction with the healing of and prevent new and recurrent
diabetic neuropathy contributes to 50% of dia- ulcerations.
betic foot ulcerations [2].
The predominant arterial beds impacted by
PAD in the diabetic patient are typically infra- History and Physical Examination
geniculate, or below the knee. The pathophysio-
logic mechanism of disease of the anterior tibial, Perfusion assessment of the diabetic patient
posterior tibial, peroneal, dorsalis pedis, and begins with a complete history and careful physi-
geniculate arteries is most frequently medial cal- cal examination. It should include gross exami-
nation of the patient for the stigmata of peripheral
vascular disease. Broadly classified, this bedside
M. Siah (*) assessment includes the healing potential of the
Surgery, University of Texas Southwestern Medical foot, the details of the foot problem (e.g., ulcer,
Center, Dallas, TX, USA gangrene, infection, osteomyelitis, etc.), the sys-
Clements University Hospital, Dallas, TX, USA temic consequences of diabetes, and any immedi-
Parkland Memorial Hospital, Dallas, TX, USA ate threats to life and/or limb. By carefully
e-mail: [email protected] following these considerations, the astute sur-
C. M. Akbari geon can usually make an accurate diagnosis and
Surgery, Georgetown University Medical School, reliably start a comprehensive treatment plan
Washington, DC, USA without the need for further costly and time-
Vascular Surgery, Medstar Georgetown University consuming diagnostic tests.
Hospital, Washington, DC, USA

252 M. Siah and C. M. Akbari
The history of the foot problem itself can give important clue as to underlying arterial insuffi-
valuable insight as to the potential for healing, ciency. Other cardiovascular risk factors, such as
the presence of coexisting infection or arterial cigarette smoking or hyperlipidemia, should also
occlusive disease, and the need for further treat- be considered, as their presence increases the
ment. Any patient presenting with a foot ulcer- likelihood that ischemia is contributing to the
ation or gangrene should immediately arouse present foot problem.
suspicion of underlying arterial insufficiency, Although claudication or rest pain has tradi-
even if neuropathy or infection is present. In the tionally been associated with vascular disease,
patient with diabetes and arterial insufficiency, diabetic neuropathy may obscure those symp-
the inciting event for a nonhealing foot ulcer may toms, and their absence in the diabetic patient
be a seemingly benign event such as cutting a certainly does not rule out ischemia. Because
toenail, soaking the foot in a warm bath, or a even moderate ischemia will preclude healing in
heating pad. the diabetic foot, the absence of rest pain is not a
The duration of the ulcer also provides impor- reliable indicator of adequate arterial blood sup-
tant clues, insofar as a long-standing, nonhealing ply; moreover, many patients may not ambulate a
ulcer is strongly suggestive of ischemia. sufficient distance to develop true vasculogenic
Certainly, an ulcer or gangrenous area that has claudication. Conversely, some patients with true
been present for several months is unlikely to ischemic rest pain are dismissed for years as hav-
heal without some type of further additional ing “painful neuropathy.”
treatment, whether it be off-loading of weight- Because unrecognized infection in the dia-
bearing areas, treatment of infection, or, most betic patient may rapidly progress to a life-
commonly, correction of arterial insufficiency. threatening condition, attention should be
Did the present ulcer heal previously, and is the directed toward detecting the subtle manifesta-
present episode a relapsing problem? A history of tions of an infected foot ulcer. Worsening hyper-
intermittent healing followed by relapse should glycemia, recent erratic blood glucose control,
raise suspicion of underlying untreated infection, and higher insulin requirements all suggest
such as recurrent osteomyelitis, or uncorrected untreated infection. Due to the microvascular and
architectural abnormality, such as a bony pres- neuropathic abnormalities in the diabetic foot,
sure point or varux deformity. classical symptoms of infection such as chills or
It is helpful to consider past opinions and pain are often absent, and hyperglycemia is often
treatments, while still formulating an objective the sole presenting symptom of undrained infec-
treatment plan based on presenting data. Many tion. With ongoing infection and hyperglycemia,
diabetic patients with correctable foot ulceration impending ketoacidosis or nonketotic hypergly-
and limb ischemia have been told that the only cemic hyperosmolar coma may develop, with
option is limb amputation, usually due to “inher- symptoms of weakness, confusion, and altered
ited pessimism” and inadequate knowledge of mental status.
the advances made in limb and foot salvage. In The history should also include a comprehen-
these circumstances, when sought for an addi- sive assessment of the patient’s overall health, to
tional treatment opinion, it is best to “start at the help stratify perioperative risk should some type
beginning” rather than blindly concur with previ- of operative intervention be needed. Knowledge
ous actions. of previous cardiac events, such as myocardial
The past history should be first directed to pre- infarction or revascularization, and present car-
vious foot and limb problems. Recent ipsilateral diac status, anginal severity, and heart failure
ulceration or foot surgery that healed in a timely symptoms are all mandatory components of the
and uncomplicated course may suggest adequate history taking. Similarly, in the patient with sus-
arterial supply; with a more remote history, how- pected infection and ischemia, a history of wors-
ever, such information becomes less useful. A ening renal function or impending need for
history of previous leg revascularization (includ- hemodialysis will help determine the dose and
ing percutaneous therapies) also provides an choice of antibiotics and may alter plans for stan-
20 Diagnostic Evaluation of Arterial Disease in Limb Salvage 253
dard contrast arteriography. Functional status Great attention should be directed toward the
also becomes an important consideration at this foot pulses, which requires a knowledge of the
point, and the history should carefully determine usual location of the native arteries. The dorsalis
the ambulatory and rehabilitative potential of the pedis artery is located between the first and sec-
patient, so that appropriate decisions may be ond metatarsal bones, just lateral to the extensor
made for limb salvage or amputation. hallucis longus tendon, and its pulse is palpated
Examination of each limb should identify by the pads of the fingers as the hand is partially
scars indicating healed arterial or venous ulcers, wrapped around the foot (Fig. 20.2).
prior surgical interventions such as saphenous If the pulse cannot be palpated, the fingers
vein harvesting or distal bypass, and biomechani- may be moved a few millimeters in each direc-
cal callous formation. Trophic skin lesions such tion, as the artery may have an occasional slight
as pale, cool skin or shiny, thickened nail beds aberrant course. A common mistake is to place a
may be visible. Hair loss is an unreliable sign of
ischemia and is of little clinical value [6].
Capillary refill in the soft tissue or under the nail
bed should be assessed. Atrophy, pallor, and
asymmetric peripheral temperatures should be
noted. Ulcerations and areas of necrosis or gan-
grene should be described, measured, and
photographed.
The pulse examination, including the status of
the foot pulses, is the single, most important
component of the physical exam and remains as a
cornerstone in the treatment algorithm. As has
been emphasized, ischemia is always presumed
to be present in the absence of a palpable pulse.
Identification of diminished or absent pedal
pulses provides a general indication as to the
presence and level of atherosclerotic disease bur-
den. For example, a palpable popliteal pulse in
the setting of absent pedal pulses suggests iso-
lated tibial disease whereas an absent popliteal
pulse may suggest a more proximal disease bur-
Fig. 20.1 Proper technique for the palpation of a popli-
den. Regardless of the level of disease, the UK teal pulse
NICE National Guidelines for the diabetic foot
suggest that the absence of palpable pedal pulses
is sufficient for the identification of vascular
impairment [7]. Any atherosclerotic disease
resulting in the loss of a pulse may cause inade-
quate perfusion for wound healing [3].
Although not difficult, an accurate pulse
examination of the lower extremities is an
acquired skill, and time should be devoted to
practicing and perfecting the technique. The fem-
oral pulse is palpated midway between the supe-
rior iliac spine and the pubic tubercle, just below
the inguinal ligament. The popliteal pulse should
be palpated with both hands and with the knee
flexed no more than 15° (Fig. 20.1). Fig. 20.2 Palpation of the right dorsalis pedis artery
single finger at one location on the dorsum of the limbs. The presence of infection and involvement
foot. The posterior tibial artery is typically of deeper structures increases the metabolic
located in the hollow just behind the medial mal- requirement of ulcer healing [8]. To account for
leolus, approximately halfway between the mal- this, the Society for Vascular Surgery devised the
leolus and the Achilles tendon. The examiner’s WIfi System to better predict a mputation risk and
hand should be contralateral to the examined foot better evaluate outcomes in the treatment of
(i.e., the right hand should be used to palpate the peripheral vascular disease. By integrating the
left foot and vice versa), so as to allow the hand key factors associated with tissue loss, the WIfi
curvature to follow the ankle (Fig. 20.3). classification system is able to combine perfusion
There are many published scales that may aid and tissue assessment to better predict clinical
in the standardization of physical exam reporting. outcomes than previous scoring systems.
Consistent use allows for the clinician to track Ultimately, the use of any of these scoring sys-
patient improvement or decline. The Fontaine and tems allows for objective assessment of patients
Rutherford classifications, as well as the that can guide care and monitor outcomes.
University of Texas system, have historically been
used to guide wound assessments; however each
do not incorporate all the etiologies of threatened Noninvasive Perfusion Assessment
Noninvasive testing is beneficial in both the diag-

nosis of existing peripheral vascular disease and
in screening patients for advancing atherosclerotic
disease. The simplest of noninvasive exam that can
be performed is the ankle-brachial index (ABI)
(Fig. 20.4). It is a critical extension of the vascular
physical exam and can be performed by the clini-
cian at the bedside. The ABI is a ratio of the ankle
and brachial systolic blood pressures. A normal
ABI can range from 0.9 to 1.2 [10]. Generally,
an ABI of >0.8 is not associated with impaired
wound healing [11]. Given the ease with which
an ABI can be performed, the American Diabetes
Association recommends PAD screening with an
ABI every 5 years in patients with diabetes [12].
Unfortunately, ABI values can often be unreli-
Fig. 20.3 Palpation of the right posterior tibial artery able in the diabetic patient due to the extensive
a b
Fig. 20.4 Bedside technique for performed ankle pressure measurement using a Doppler probe at the (a) posterior
tibial artery and (b) dorsalis pedis artery [9]
calcification, or medial calcinosis, of the infra- as with all noninvasive tests, the PVR has several
popliteal blood vessels. This extensive calcifica- limitations. Although there are some semiquan-
tion prevents proper compression of the tibial titative criteria, these have not been correlated
arteries and results in either a falsely elevated ABI clinically, and the test is essentially qualitative.
or a value that is unattainable due to the inability Therefore, a completely normal study is help-
to achieve a vessel compression at a supra-sys- ful, but it is difficult to quantitate the degree of
tolic cuff pressure. Therefore, any abnormal, be ischemia with any abnormal study. Indeed, one
it diminished or falsely elevated (non-compress- major shortcoming of the PVR test is that it fre-
ible), ABI indicates the presence of arterial dis- quently underestimates the severity of proximal
ease that should be further evaluated. arterial disease (due to the presence of collateral
When ABIs are impaired or unattainable, a vessels). Additionally, the test is affected by sev-
vascular lab can provide other useful diagnostic eral variables, including room temperature (since
tests to assess perfusion in the diabetic patient. temperature differences in the air cuff can change
Pulse volume recording (PVR), also known the pressure measured by the air-filled plethys-
as plethysmography, is a noninvasive method mograph). Peripheral edema and obesity will also
to evaluate the arteries of the lower extremity. affect the quality of the waveforms.
The pulsed volume recorder (PVR) is a form of Toe systolic pressure measurements (TSP)
volume plethysmography, which measures the and transcutaneous partial oxygen pressure mea-
pulsatile volume changes that occur in the limb surements (TcPO2) are useful modalities to attain
with each heartbeat. A pneumatic cuff is placed a better understanding of tissue perfusion. Trans-
around a specific level of the limb (thigh, calf, cutaneous oxygen tension measurements reflect
and ankle) and inflated with air to a preset pres- the resting oxygen tension (and the metabolic
sure between 10 and 65 mmHg. During systole, state) of the underlying tissue. The test involves
blood enters the limb, the limb expands, this the placement of a probe (with a sensitized elec-
expansion presses upon the cuff, and the pressure trode) on the dorsum of the proximal foot, and
within the cuff increases. During diastole, limb the local tissue is heated to about 40–42 °C. Fol-
volume is reduced and cuff pressure falls. There- lowing an equilibration period of 20–25 min,
fore, volume changes within a specific level of the local resting oxygen tension of the skin is
the limb beneath the cuff are indirectly studied by recorded in mm Hg. The measurement of toe
measuring pulsatile pressure changes within the pressures allows for an accurate assessment of
cuff. These changes are converted into a wave- pedal perfusion as digital vessels are often free
form by a strip recorder. of atherosclerotic disease burden. Toe pressures
The normal PVR waveform displays a brisk are usually 30 mmHg less than ankle pressures
rise during systole, a sharp systolic peak, a and an abnormal toe-brachial index (TBI) is
dicrotic notch, and a rapid downslope to baseline. <0.70 [14]. However, digital ulceration or prior
Segmental pressures and waveforms are ana- amputation may limit the usefulness of the TBI
lyzed to identify the level and degree of potential examination.
stenosis. Pressure cuffs are used to measure the Transcutaneous measurement (TcPO2) of
pulsatile change in blood pressure at various lev- the partial oxygen pressure is performed at the
els of a limb (Fig. 20.5). Abnormal PVR findings back of the foot and between the first and second
include decreased amplitude, a flattened peak, toe space. Normal TcPO2 for a diabetic patient
and an absent dicrotic notch. Amplitudes of less is 50 mmHg [15]. Because hemodynamics are
than 5 mm from trough to peak have been used as not measured, the test is immune to many of
a criterion for the diagnosis of peripheral vascu- the problems facing other noninvasive tests
lar disease [13]. in the presence of diabetes, such as noncom-
Because the PVR measures volume change pressible vessels. However, due to the unique
and not pressure, it is also unaffected by noncom- considerations of the diabetic foot, TcPO2
pressible arteries and may be a valuable adjunct measurements are not entirely reliable in the
in the evaluation of the diabetic foot. However, diabetic patient with foot ulceration. Lockhart
Doppler
R) Femoral L) Femoral
Segmental BP
Segment/Brachial Index
Gain: 18% R L Gain: 24%
R) Sup Femoral 148 Brachial 150 L) Sup Femoral
Gain: 18% Gain: 24%
R) Popliteal L) Popliteal
Gain: 24% Gain: 24%
R) Post Tibial L) Post Tibial
Gain: 24% Gain: 24%

100 (PT) (PT) 96
0.67 0.64
R) Dors: Pedis L) Dors: Pedis
99 (DP) (DP) 99
0.66 0.66
30 80
0.20 TBI 0.53
Gain: 24% Gain: 85%
R) Digit L) Digit
0.67 Ankle/Brachial Index 0.66
Gain: 85% Amp; 1mm Gain: 85% Amp; 3mm
Fig. 20.5 Physiologic study demonstrating segmental pulse volume recording associated with an aortic occlusion
et al. demonstrated pressures <30 mmHg to be with pressures <25 mmHg [18]. Therefore, the
associated with severe ischemia, while pressures likelihood of wound healing increases with skin
>40 mmHg are associated with wound healing perfusion pressures of >40 mmHg, toe pressures
with conservative therapy [16, 17]. Addition- >30 mmHg, or TcPO2 >25 mmHg [19]. Values
ally, Kalani et al. demonstrated that TcPO2 can below these levels suggest a role for invasive
be a better predictor for ulcer healing than toe diagnostic and therapeutic measures. It should
pressures in diabetics with foot ulcerations and be noted, though, that despite the documented
confirmed a low likelihood of wound healing utility of skin perfusion pressure measurements
and TcPO2, they are not typically performed. Hyperspectral Imaging (HSI) has emerged
Even in the patient with a “normal” TcPO2 value, as an additional noninvasive way to assess tis-
the measurement may not accurately reflect the sue perfusion and may have a role in predict-
healing potential at the target area. TcPO2 mea- ing wound healing in diabetic patients with
surements may be influenced by many technical tissue loss. HSI identifies tissue oxygenation
features, including the type of equipment used, on a microvascular level and anatomically
monitor placement, and surface temperature of demonstrates changes in the microcirculation
the measured area. (Fig. 20.6). Unlike TpCO2, HSI measurements
Fig. 20.6 Visual hyperspectral images of pedal perfusion in a foot with no peripheral vascular disease (left) and a foot
with peripheral vascular disease (right) [20]
can be performed quickly in the clinic. Addi- velocity increase in the stenosis with spectral
tionally, HSI can directly evaluate perfusion broadening.
in the ulcer bed. One of the major barriers to Despite the invaluable role of Duplex ultra-
widespread application of the technology is sound in the diagnosis of carotid arterial disease
cost, as the devices are generally very expen- and for postoperative graft surveillance, there are
sive. Additionally, at present time, there is a lack multiple limitations in its use for the diagnosis of
of evidence demonstrating the reliability of HIS lower extremity arterial disease. There is a large
measurements in diabetics with tissue loss. variation in the range of “normal” velocities for
the leg arteries, and therefore a significant steno-
sis may be misinterpreted. Although the femoral
Noninvasive Diagnostic Imaging and popliteal vessels may be visualized relatively
easily, the tibial vessels are more cumbersome to
Of the many modalities available to assess the scan, and the velocities in the tibial arteries may
arterial supply of the lower extremity, the most be even more difficult to interpret. When one
commonly utilized are duplex ultrasound, com- considers the usual pattern of vascular disease in
puted tomography angiography (CTA), and mag- diabetes (with a predilection toward atheroscle-
netic resonance angiography (MRA). In general, rotic involvement of the tibial vessels), the limita-
these imaging tests should be reserved for tions of Duplex in the diagnosis of arterial
patients prior to or after endovascular or surgical insufficiency in the diabetic patient are realized.
therapy. Ultrasound may be considered as the Because the study depends on accurate sono-
first-line study given its low cost and the lack of graphic localization of the vessel, Duplex is quite
potentially adverse side effects. “operator dependent.” Finally, multiple other
Duplex scanning employs the dual modali- variables can influence the quality of the image,
ties of B-mode (gray scale) imaging and pulsed including medial arterial calcification (which can
wave Doppler spectral frequency analysis. In cause artifactual shadowing), obesity, and periph-
addition, most Duplex scanners are actually eral edema (which can preclude imaging of the
“triplex,” with the third modality being color tibial vessels).
flow imaging. The vessel being insonated may In patients in whom ultrasound is unlikely to
be localized by B-mode imaging, and the pulsed be successful, particularly patients that have mor-
wave Doppler allows for range specificity. Color bid obesity or extensive dressings or tissue loss,
flow imaging evaluates the Doppler information CTA and MRA are reasonable second-line
and determines whether flow is toward or away imaging modalities. Both CTA and MRA allow
from the transducer as well as frequency for visualization of supra-inguinal blood vessels,
content. for the localization of infra-inguinal disease bur-
The information obtained from Duplex arte- den and the characterization of stenotic or occlu-
rial scanning includes the gray scale ultrasound sive lesions. Most importantly, they can show the
structural characteristics of the artery (such as quality of tibial runoff, which is vital for deciding
wall thickness or type of plaque), as well as between different interventional strategies. A
Doppler waveform, velocities, and direction of CTA can be performed rapidly and allows for
flow. Analysis of the Doppler waveform charac- easy evaluation of previously placed stents and
teristics is similar to the preceding discussion on bypasses. However, in the setting of severe calci-
segmental waveform analysis (considered as tri- fication, CTA may overestimate the degree of ste-
phasic, biphasic, or monophasic), but the princi- nosis and lack accuracy of flow assessment of the
pal advantage of Duplex is that the vessel may be tibial arteries. Additionally, CTA requires radia-
localized by the gray scale ultrasound. Duplex tion exposure and the use of iodinated contrast
also allows for an estimation of the degree of ste- agents for vasculature visualization. Such agents
nosis based on velocities and degree of spectral are contraindicated in patients with underlying
broadening: as an artery narrows, there will be a renal dysfunction due to the risk of contrast-
induced nephropathy. However, they can be used

in patients with end-stage renal disease (ESRD).
MRA is useful in patients with mild renal dys-
function, as unlike CTA, MRA does not require
iodinated contrast. MRA uses a gadolinium-
based contrast agent to provide better visualiza-
tion of the arterial system in the lower extremity.
Gadolinium contrast, however, has been associ-
ated with the development of nephrogenic sys-
temic fibrosis in patients with impaired creatinine
clearance and is contraindicated in patients with
ESRD. MRA utilization may be limited in
patients with claustrophobia or metallic implants
and long acquisition times are associated with
more patient-generated motion artifact.
Ultimately, the selection between the use of
duplex, CTA, or MRA depends upon patient-
specific factors, local expertise, and safety profile
and is up to the discretion of the clinician.
Invasive Diagnostic Imaging
Invasive diagnostic imaging in diabetics with

signs of tissue loss and ischemia should be lim-
ited to those patients who would not benefit from
primary amputation. Arteriography is the best
means of identifying the distribution and extent
of PAD. Angiography allows for real-time flow
Fig. 20.7 Diagnostic arteriogram revealing an occlusion
assessment using either carbon dioxide, iodin- of the anterior tibial artery and a patent peroneal and pos-
ated contrast, or gadolinium contrast to visualize terior tibial artery
arterial flow under fluoroscopy. Arterial stenosis,
occlusive lesions, and named-vessel collateral
reconstitution may all be assessed (Fig. 20.7). regarding the angiosome in diabetic patients with
Diagnostic imaging may then translate into endo- PAD is less conclusive.
vascular intervention or become the basis for The clinical application of the angiosome con-
open surgical intervention. cept requires an understanding of perfusion
Angiography also allows for angiosome char- sources of the foot and to consider these as thera-
acterization. Introduced nearly 30 years ago, an peutic targets for intervention. Interventionalists
angiosome refers to a 3-dimensional unit of tis- can perform angiosome-directed revasculariza-
sue comprised of skin, subcutaneous tissue, mus- tion procedures, which focus on intervening on
cle, and bone, supplied by a clear arterial source. the source vessel/angiosome of ulceration, as
In the lower leg and foot, there are six angio- opposed to indirect revascularization procedures.
somes: three fed by the posterior tibial artery, one Some studies have demonstrated more rapid
fed by the anterior tibial artery, and two supplied times to healing with angiosome-directed revas-
by the peroneal artery. Attinger et al. have cularization procedures; however there is no dif-
demonstrated the validity of the angiosome conference in amputation rates. Ultimately,
cept in free flap procedures; however the data considering the option of angiosome-directed
revascularization should be performed, however modality in patients with diabetes. The BASIL
revascularization should still be pursued indi- trial, a randomized controlled trial, compared the
rectly if no direct revascularization targets are results of angioplasty versus bypass and exam-
available. ined amputation rates and survival for the two
Given the challenge of correlating angiosome methods. There was no significant difference
and non-angiosome-based perfusion assessment between the two techniques, but there was a
with clinical outcomes, the use of indocyanine marked advantage of endovascular techniques in
green angiography (ICGA) has also emerged as a patients with elevated surgical risk, and better
perfusion assessment tool. ICGA has been stud- results than prosthetic bypasses. Additionally, the
ied extensively in free flap creation and has been trial suggested that bypass outcomes following
shown to provide perfusion information that pre- failed endovascular interventions were worse
dicts tissue survival in assessing flap viability than those performed prior to endovascular ther-
[21–23]. ICG is administered intravascularly apy. Since BASIL, there has been little random-
where it binds to serum proteins. The uptake of ized controlled data to guide clinical decision
ICG can be quantified in tissue bed of interest making in the management of critical limb isch-
and this value may serve as a surrogate for tissue emia, but there has been a marked proliferation in
perfusion. Ongoing studies are being performed the endovascular tools available to the interven-
to determine the role of IGCA in determining the tionalists. Newer wires, catheters, sheaths, and
optimal treatment of peripheral vascular disease, other devices like drug eluting stents (DESs),
as well as assessing the success of revasculariza- drug-coated balloons (DCBs), and atherectomy
tion procedures [24, 25]. devices have become readily available and have
made treating TASC C and D lesions much easier
than before [27–29]. These newer techniques are
Therapeutic Options frequently used to treat PAD despite an absence
of level one data. To address the lack of treatment
There are two modalities to address perfusion consensus in PAD management, the BEST-CLI
deficits in diabetic patients with tissue loss: open (Best Endovascular versus Best Surgical Therapy
and endovascular surgery. Open techniques, for Patients With Critical Limb Ischemia) trial is
namely surgical bypass, historically have been currently being conducted. This trial will com-
the mainstay of treatment. Bypass with autoge- pare outcomes of the best endovascular and open
nous conduit, most commonly the greater saphe- surgical revascularization strategies in patients
nous vein, represents the gold standard for with tissue loss and infrainguinal PAD.
revascularization techniques, as it is associated
with better patency and increased amputation
free survival compared to bypass using prosthetic Conclusion
conduits [26]. However, endovascular therapies
have emerged as an acceptable first line in the Peripheral arterial disease in the diabetic patient
surgical management of ischemic diabetic foot is a growing problem and will continue to repre-
ulcerations. This is likely due to the ease with sent a tremendous economic and social burden
which diagnostic and therapeutic procedures can facing modern societies in the twenty-first cen-
now be performed, as well as the wide variety of tury. Early recognition of perfusion deficits is
interventionalists who are capable of performing critical in curtailing the extent of this problem,
them. and there are a variety of noninvasive tests that
Coming to a decision between bypass first allow for the objective identification of
versus an endovascular first strategy is challeng- PAD. Once diagnosed, referral to a vascular spe-
ing due to the absence of randomized controlled cialist allows for the restoration of arterial perfu-
data demonstrating the superiority of either sion either by open or endovascular techniques.
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U.S. National Library of Medicine, Bethesda, MD
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Arterial Disease Management
in the Limb Salvage Patient:
21
Endovascular and Open Bypass
Michael C. Siah, Roberto Ferraresi,

Alessandro Ucci, Andrea Casini, Giacomo Clerici,
and Cameron Akbari
Introduction tion strategies such as smoking cessation, lipid

lowering and cardioprotective medications,
Chronic limb-threatening ischemia (CLTI) repre- which are known to decrease adverse cardiac
sents the most severe manifestation of peripheral events and mortality in patients with CLTI.
arterial disease (PAD) and is defined by the pres- In addition to medical therapy, both open sur-
ence of ischemic rest pain, ulceration, or gan- gery and endovascular therapies are frequently
grene. It affects over two million Americans and utilized in restoring perfusion in patients with
is a global problem of increasing prevalence. The CLTI. Over the course of the last 25 years, inva-
natural history of CLTI is associated with signifi- sive therapies for the treatment of PAD have
cant morbidity, mortality, and rising health care changed dramatically. The frequency of bypass
costs approaching $200 billion annually (1–3). surgery has decreased by 42%, and endovascular
Without revascularization, 20–40% of patients therapeutic utilization has increased more than 3
will require amputation and 6-month mortality is times (6). As a result of the increase in overall
greater than 20% (4, 5). As a result, the financial procedures performed for PAD, amputation rates
burden posed by patients with CLTI is massive, have decreased by 29% (6). Ultimately, the
representing a $3 billion cost to the American choice of procedure should be individualized
health care system annually. based on the patient’s anatomy, comorbidities,
The mainstay of therapy for the management and preoperative assessment, with the goal being
of CLTI is revascularization in an attempt to to provide the most durable procedure with the
improve perfusion to an affected limb. Medical least risk.
therapy is supportive, utilizing lifestyle modifica-
pen Surgery General

O
M. C. Siah (*) Considerations
Vascular Surgery, UT Southwestern,
Dallas, TX, USA
e-mail: [email protected] The approach to the patient with CLTI and the
R. Ferraresi · A. Ucci · A. Casini · G. Clerici decision as to the type of surgical revasculariza-
Diabetic Foot Unit, Clinica San Carlo, Paderno tion depend on the patient presentation and the
Dugnano, Milano, Italy CLTI classification. The goal of treatment of
C. Akbari ischemia in the CLTI patient is to restore maxi-
Georgetown University Hospital, mal perfusion to the foot and ideally restore a
Washington, DC, USA palpable foot pulse (7). For example, the patient

264 M. C. Siah et al.
with extensive foot ulceration and/or gangrene Autogenous vein grafting to the dorsalis pedis,
will require normal perfusion to the foot for limb distal posterior tibial, and plantar arteries incor-
salvage, with the goal being to restore a normal porates knowledge of the anatomic pattern of dia-
foot pulse; in order to maximize the chances of betic vascular disease, satisfies the fundamental
successful limb salvage, targeted revasculariza- goal of restoration of the foot pulse, and provides
tion to the specific angiosome should always be durable and effective limb salvage (7, 8). Indeed,
the first choice. As the majority of these patients extensive experience with arterial reconstruction
will have diabetes, and because of the pattern of to the pedal vessels has established the efficacy,
diabetic vascular disease, this will almost always durability, and safety of these procedures, and
require infrainguinal surgical bypass to the target improved limb salvage rates in the diabetic
vessel. Proximal bypass to the popliteal or tibio- patient may be directly attributed to the increas-
peroneal arteries may restore foot pulses; how- ing use of pedal bypass (8). Ultimately, the choice
ever, the characteristic pattern of occlusive of outflow artery should be based on availability
disease in the diabetic patient usually requires of conduit, the location of the foot ulcer, and the
more distal bypass grafting, often to the dorsalis quality of the outflow vessel. For example, in the
pedis artery, distal posterior tibial, or plantar patient with an ischemic heel ulcer, first consider-
arteries. ation should be given to the posterior tibial or
In contrast, the patient presenting with isch- plantar arteries if they are patent by preoperative
emic rest pain without tissue loss may be signifi- imaging. However, absence of a posterior tibial
cantly ameliorated with more proximal artery should not rule against a dorsalis pedis
revascularization. This may include femoral end- bypass, as comparable rates of healing and limb
arterectomy with profundaplasty alone in the salvage for heel ulcers have been reported with
patient with concomitant superficial femoral the dorsalis pedis artery bypass.
artery occlusion, or bypass to an isolated popli- Clinical experience has shown a variety of
teal segment. adjunctive techniques to be of advantage in
In most patients, restoration of the foot pulse infrainguinal revascularization among diabetic
usually mandates infrainguinal arterial bypass patients. For example, due to the pattern of lower
grafting. The primary goal of infrainguinal arte- extremity diabetic atherosclerotic disease, the
rial reconstruction in the ischemic foot is to popliteal or distal superficial femoral artery may
bypass to an outflow artery that is in direct conti- be used as an inflow site, thereby allowing for a
nuity with the foot, thereby restoring normal arte- shorter length of vein to be used and avoiding
rial pressure to the target area. Although proximal dissection in the groin and upper thigh, a com-
bypass to the popliteal or proximal tibioperoneal mon location for wound complications. In addi-
arteries may restore foot pulses, more distal tion, the shorter length of saphenous vein obviates
revascularization is often needed to achieve this the need for foot extension of the vein harvest
goal, again owing to the pattern of occlusive dis- incision, which is parallel to the one required to
ease in the diabetic patient. Similarly, although expose the paramalleolar and inframalleolar
excellent results have been reported with pero- arteries; this avoids the resultant skin bridge
neal artery bypass, the peroneal artery is not in which may occasionally become ischemic from
continuity with the foot vessels and may not undue tension.
achieve the maximal flow required for healing, Although the vein graft may be prepared as in
particularly at the forefoot level. Therefore, the situ, reversed, or nonreversed graft, without any
authors believe that peroneal artery bypass should significant difference in outcome, the authors
be reserved for those rare circumstances in which believe that size mismatch may best be mini-
there is no dorsalis pedis or posterior tibial artery mized with either an in situ or nonreversed tech-
in continuity with the foot, or when limited nique, particularly for grafts originating from the
venous conduit length mitigates against more common femoral artery. Although the valves in
distal bypass. the vein graft may be lysed blindly, some sur-
21 Arterial Disease Management in the Limb Salvage Patient: Endovascular and Open Bypass 265
geons prefer to cut the valves under direct angio- the plaque. Results of bypasses to calcified ves-
scopic guidance using a flexible valvulotome. sels are comparable to noncalcified vessels
This also allows for assessment of the saphenous (9–11).
vein to detect intraluminal abnormalities, and can Several reports have summarized the results of
help direct endoluminal interventions that the dorsalis pedis artery bypass, of which the
upgrade the quality of the conduit and improve most recent summarizes a decade-long experi-
patency. ence of more than 1000 cases (11, 12). In that
Absence of ipsilateral greater saphenous vein series, 5-year primary patency rates were 57%
is not a contraindication for bypass; although with a limb salvage rate of almost 80%, confirm-
prosthetic material may occasionally be used for ing the efficacy and durability of these proce-
more proximal reconstructions, it should seldom, dures. Additionally, concern regarding
if ever, be used for extreme distal bypass grafting. perioperative morbidity and long-term outcome
When ipsilateral saphenous vein is not available, in diabetic patients has also been dispelled (12,
several alternatives exist for autogenous conduit. 13).
Although the contralateral saphenous vein is
an obvious alternative, several considerations
limit its use in the diabetic patient. Contralateral
leg vein may not always be present in this popu- Preoperative Surgical
lation of patients who often require multiple Considerations
cardiovascular interventions. More importantly,
diabetes is a strong risk factor for subsequent Essential to the success of surgical revascular-
contralateral limb bypass, with almost 60% of ization is appropriate and accurate preoperative
patients requiring contralateral bypass at planning. High-quality arteriography should
3 years. Therefore, the authors’ approach has include visualization of planned target vessels,
been to use arm vein grafts as the first alterna- localization and extent of disease in the proxi-
tive in the absence of ipsilateral saphenous vein mal vessels (including aorta and iliac arteries),
(9). The cephalic, basilic, or upper arm basilic- and, if needed, pressure measurements across
cephalic loop vein grafts may be harvested. suspected inflow lesions. Based on the pattern
Once the vein has been harvested, angioscopic of vascular disease in the diabetic patient, with
evaluation is crucial, as many of these patients sparing of the pedal vessels, the arteriogram
have undergone multiple venipunctures and must include the foot vessels in both the lateral
cannulations with resultant scarring and web- and anterior views for a complete assessment
like synechiae. Angioscopy allows for detection (Fig. 21.1).
and correction of many of these areas, and Although others have performed distal revas-
allows for precise valve lysis within these thin- cularization based on Duplex ultrasound or CT
walled veins (9). angiography alone, the author’s preference is to
Active infection in the foot is not a contraindi- always have a high-quality arteriography prior to
cation to paramalleolar bypass grafting, as long any infrainguinal bypass.
as the infectious process is controlled (10). Autogenous ipsilateral saphenous vein is the
Adequate control implies resolution of cellulitis, preferred conduit for all infrainguinal bypass
lymphangitis, and edema, especially in areas of grafts. High-quality conduit is central to success-
proposed incisions required to expose the distal ful bypass and has direct implications for both
artery or saphenous vein. Occasionally, severe short-term and long-term patency results.
circumferential calcification of the distal artery Preoperative bilateral saphenous vein mapping
may also be encountered. Strategies include the with Duplex ultrasound should always be per-
use of special intraluminal bulb-tipped vessel formed, assessing for caliber and size, phlebitic
occluders or tourniquet occlusion, with no changes, wall thickening, and accessory branch-
attempts made at endarterectomy or “cracking” ing (Fig. 21.2a, b).
Fig. 21.1 Lateral and AP arteriogram of the foot. Note projection confirms only lateral tarsal runoff (yellow
that on the lateral projection, a vessel which resembles the arrow), and no true dorsalis pedis artery is present
dorsalis pedis artery is seen (red arrow). However, the AP
a b
Fig. 21.2 Adequate sized great saphenous vein by Duplex (a) in contrast to a nonusable small sized vein (b). Duplex
can also demonstrate previous phlebitic changes or thrombus within the saphenous vein
A minimum diameter should be 2 mm; experience into the femoral segment. These include aorto-
has shown that smaller veins will yield poor results. If bifemoral bypass, iliac-femoral bypass, com-
the great saphenous vein is inadequate, consideration mon femoral endarterectomy, and
may be given to either arm vein or prosthetic graft; if profundaplasty, as well as extra-anatomic
the former is chosen, Duplex scanning should be per- bypasses such as axillo-femoral and femoral-
formed in the upper extremities as well. femoral bypass. Because they are performed on
As with any major operation, appropriate medi- larger vessels with expected higher patency
cal stabilization and optimization of the patient rates, prosthetic grafts are utilized for almost all
should be performed prior to proceeding with sur- inflow bypasses. With greater success and appli-
gical revascularization. This may involve cardiac cation of endovascular procedures, especially in
stress testing, coronary angiography, and echocar- the aorto-iliac segment, these procedures are
diography. Many patients with longstanding foot being performed with marked less frequency.
ulceration may be nutritionally depleted, and pre- Nevertheless, they continue to be an important
operative assessment and intervention may prevent component of the treatment plan for revascular-
postoperative wound and systemic complications. ization, especially for endovascular failures and
As noted previously, many patients with CLTI infections.
will present with foot ulceration or gangrene, Aorto-bifemoral bypass represents the “gold
with concomitant foot infection. Control of infec- standard” for patency and durability for inflow
tion is mandatory prior to surgical revasculariza- operations, with 5-year primary patency surpass-
tion, to prevent the risk of systemic sepsis, ing 90%. The aorta is exposed via a midline inci-
wound, and graft infection. In the patient with sion or retroperitoneal incision, and the proximal
diabetes, classical signs of infection may not anastomosis may be performed to the infrarenal
always be present in the infected diabetic foot aorta in almost all cases. Even if there is occlu-
due to the consequences of neuropathy, altera- sive disease present, endarterectomy of the infra-
tions in the foot microcirculation, and leukocyte renal aorta may be performed, followed by the
abnormalities. Fever, chills, and leukocytosis proximal anastomosis to the endarterectomized
may be absent in up to two-thirds of diabetic aorta (Fig. 21.3).
patients with extensive foot infections, and Each limb of the graft is tunneled anatomi-
hyperglycemia is often the sole presenting sign. cally to the respective groin and the distal
Infections should be adequately drained, as dia- anastomosis is performed to the common fem-
betic patients simply cannot tolerate undrained oral artery. The author’s preference is to extend
pus or infection. Because most infections are the anastomosis onto the profunda, so as to
polymicrobic, cultures should be obtained from prevent late thrombosis of the limb secondary
the base or depths of the wound after debride- to unrecognized stenoses at the profunda or
ment so that appropriate antibiotic treatment may superficial femoral artery origin. In instances
ensue. If adequately controlled with antibiotics of redo operations or groin infection, the anas-
and surgical drainage (if necessary), the infec- tomosis may be performed onto the profunda
tious process can be controlled within 5–7 days, directly, with a lateral approach to the pro-
even in patients with systemic sepsis, and subse- funda, which avoids the femoral region alto-
quent prompt revascularization may ensue. gether (Fig. 21.4).
Because of the challenges associated with per-
cutaneous endovascular treatment of common
urgical Considerations: Inflow
S femoral artery disease, common femoral endar-
Operations terectomy and profundaplasty are utilized com-
monly, and may be combined with concomitant
The term inflow operation refers to any proce- iliac or superficial femoral-popliteal-tibial angio-
dure performed on a vessel at or proximal to the plasty. The femoral vessels are exposed, and as
inguinal ligament, which restores normal flow the occlusive process often extends proximally to
Fig. 21.3 Proximal anastomosis of an aortobifemoral Fig. 21.4 Distal anastomosis of an aortobifemoral graft
graft sewn to endarterectomized infrarenal aorta. The yel- sewn to the second profunda segment, approached later-
low arrow points to the left renal vein ally, in a patient with an infected heavily scarred groin
from a previous femoral-femoral graft. Note the vein
patch onto the profunda (yellow arrow), with the Dacron
the external iliac artery, the distal external iliac graft sewn onto the patch
artery above the circumflex branches is also
exposed (Fig. 21.5).
Arteriotomy is made extending onto the pro- Although axillo-femoral and femoral-femo-
funda and all plaque is removed (Figs. 21.6 and ral bypasses are associated with lower patency
21.7), followed by patch closure with vein, pros- rates as compared to the aortobifemoral bypass,
thetic patch, or bovine pericardium (Fig. 21.8). their principal advantages lie in the fact that
If concomitant iliac or distal endovascular they are markedly less invasive. By avoiding an
intervention is planned, a sheath may be placed abdominal incision and aortic cross-clamping,
directly through the patch after restoration of these operations may be performed in high-risk
flow (Fig. 21.9), and a simple suture used to close patients with poor cardiopulmonary reserve; in
the hole after the sheath is removed. some cases, the operation may be performed
In some cases, the occlusive process within under local anesthesia in those patients in whom
the profunda may be too bulky for endarterec- general anesthetic is contraindicated. In addi-
tomy, or may result in extensive thinning of the tion, by virtue of their extra-anatomic location,
artery. In these instances, a short bypass from the they may be utilized in instances of groin sepsis
common femoral to the profunda may be per- when placement of a prosthetic graft is
formed, with excellent results (Fig. 21.10). undesirable.
Fig. 21.7 Following complete thromboendarterectomy.

Note widely patent orifice of both the superficial femoral
and profunda arteries
Fig. 21.5 The femoral vessels as well as the distal exter-

nal iliac artery proximal to the circumflex branches (white
arrows) are dissected free prior to femoral
endarterectomy Fig. 21.8 The arteriotomy is closed with a bovine peri-
cardial patch
Fig. 21.9 After completion of the patch closure (top

panel), a sheath may be inserted for iliac or more distal
Fig. 21.6 Standard endarterectomy of the common fem-
intervention
oral, proximal superficial femoral, and profunda femoris
arteries, with inset showing plaque removed
The type of configuration utilized—reversed,

nonreversed translocated, or in situ—has no
effect on patency, and multiple series have con-
firmed that all yield virtually identical results
when performed correctly. Ultimately the deci-
sion as to the type of configuration should depend
on the surgeon’s experience with each technique
and vein graft size. Our preference is either a
reversed graft when the vein is of a uniformly
large caliber and for shorter bypasses, or nonre-
Fig. 21.10 Vein bypass from the common femoral to the versed translocated for smaller veins and for long
profunda (white arrow) bypasses (such as femoral-tibial). If a nonre-
versed configuration is used, we prefer to inspect
the vein with an angioscope and cut all the valves
Surgical Considerations: under direct angioscopic guidance, which allows
Infrainguinal Bypass for precise valve lysis without any risk of intimal
injury or retained valve, both of which can have
Infrainguinal bypass represents the most com- an adverse effect on patency and outcome
monly performed surgical revascularization (Fig. 21.11).
among patients with CLI. Several principles are The vein may be harvested through continu-
noteworthy. Autogenous saphenous vein is the ous incision, small “skip” incisions, or endoscop-
preferred conduit for all infrainguinal bypass ically. There has been increasing enthusiasm for
operations, even to the above-knee popliteal endoscopic, minimally invasive techniques for
artery. In addition to its superior primary patency harvest, as it may decrease postoperative recov-
compared to prosthetic, autogenous vein does not ery time, edema, and wound complications.
have the disadvantages of associated with pros- However, this should be tempered against the risk
thetic graft infection, which can be devastating. of occult vein injury during harvest, including
The saphenous vein graft can be prepared in sev- vein spasm, which can have implications for
eral ways. The simplest is a reversed configura- patency. Our preference continues to be harvest
tion, in which the vein is harvested off its bed, by a continuous incision which is meticulously
reversed, and then placed either subcutaneously created to avoid any skin flaps (Fig. 21.12). This
or deep to the muscle and fascia after the proxi- allows for careful vein harvest. Periadventitial
mal anastomosis is performed. Because of the papaverine or nitroglycerine injection overcomes
inherent disadvantage of the size discrepancy vein spasm and the vein is gently distended with
between the smaller distal portion of the vein and solution, then harvested off its bed. With careful
the larger proximal artery, the nonreversed and in incision placement, avoiding skin flaps, and with
situ techniques may be employed, in which the layered accurate closure, we have found the risk
valves are rendered incompetent by cutting them of significant wound complications to be mini-
with an atraumatic valvulotome. The nonreversed mal. Additionally, we prefer to place all grafts
translocated technique is identical to the reversed deep to surgical incisions, such that grafts origi-
technique except that the valves are cut, whereas nating from the femoral artery are tunneled deep
the in situ technique leaves the vein in the bed, to the muscle and fascia down to the below-knee
with mobilization only of the proximal and distal popliteal space. This obviates the risk of graft
portions and tributary ligation without harvesting infection or exposure should a wound complica-
the vein. In both of these, the larger proximal tion occur, which is discussed in more detail later
vein is utilized for the proximal anastomosis, in this chapter.
allowing for an easier anastomosis both proxi- The proximal and distal anastomoses are
mally and distally. almost always performed end to side. All adven-
Fig. 21.11 Angioscopic evaluation and angioscopic guided valve lysis (labeled)
the anterior aspect, so as to minimize twisting of

the graft (Fig. 21.13).
Recognizing the pattern of vascular disease in
diabetes, in which the femoral-popliteal segment
is often spared of the atherosclerotic occlusive
process, shorter bypass grafts to the tibial vessels
with origin from the popliteal or distal superficial
femoral artery may be performed. Extensive
experience has shown that, in the absence of
more proximal occlusive disease, such grafts
yield the same patency results as grafts taken
Fig. 21.12 Exposure and harvest of the saphenous vein from the common femoral artery. This allows for
through a continuous incision without flaps. Note the vein reconstruction in those patients with limited
is fully exposed, allowing for meticulous harvest and pre-
vention of spasm. The incision is created directly overly- saphenous vein, shortens operative time and inci-
ing the vein, and no thin flaps are created, which sion length, and avoids potentially troublesome
maximizes the chance for successful wound healing groin wound complications.
As an example of a short bypass graft from the
titia should be removed from the vein at the site popliteal artery, a typical popliteal to dorsalis
of proposed anastomosis to avoid kinking at the pedis bypass graft is illustrated in Figs. 21.14,
“heel” of the graft, which can be a cause of sub- 21.15, and 21.16. The saphenous vein is har-
sequent graft stenosis or failure. Redundancy at vested from the upper leg and will be translocated
the proximal and distal anastomoses should also subcutaneously in the lower leg, where no inci-
be avoided. The graft should have a natural curve sion has been made, which minimizes the risk of
with the native artery, with the anastomosis on graft infection with any wound complication
Fig. 21.16 Same patient as Fig. 21.14. The graft has

been tunneled subcutaneously to the dorsalis pedis artery
and the distal anastomosis has been performed
(Fig. 21.14). After preparation of the graft with

angioscopy, the proximal anastomosis is per-
formed in an end vein to side artery fashion to the
popliteal artery (Fig. 21.15). After completion of
the anastomosis, the graft is placed in the previ-
ously created tunnel to the dorsalis pedis incision
Fig. 21.13 Proximal (top panel) and distal (bottom
under arterial pressure (to avoid kinking or twist-
panel) anastomoses of a femoral-tibial graft. Note absence
of kinking or “pull” on the anastomosis, with no ing of the graft) and the distal anastomosis is then
redundancy performed (Fig. 21.16). A handheld continuous
wave Doppler is used to insonate the distal anas-
tomosis and distal artery. We rarely perform com-
pletion arteriography, though some surgeons
utilize it routinely. Estimated blood loss is usu-
ally 150 mL or less.
In many patients with CLI, the only suitable
target for revascularization is a distal inframal-
leolar vessel, such as the plantar or tarsal artery.
Bypass to these vessels, though technically chal-
Fig. 21.14 Popliteal to dorsalis pedis bypass, with trans- lenging, can be performed successfully through
located vein harvested from the upper thigh (solid dark accurate angiographic visualization preopera-
arrow). Note the vein graft is translocated to a subcutane- tively, anatomic knowledge of the plantar and
ous position where no incision has been made in the calf
and lower leg (dashed dark arrow) tarsal vessels, and by incorporating meticulous
surgical and vein harvest techniques (Figs. 21.17,
21.18, and 21.19). Increasing experience has
shown excellent short-term and long-term
patency and limb salvage rates, which is highly
encouraging in this particular subset of patients
who are often advised to undergo limb
amputation.
When ipsilateral saphenous vein is not avail-
able, the decision for an alternative source of
conduit should be made with consideration of
the patient’s comorbidities. Contralateral saphe-
Fig. 21.15 Same patient as Fig. 21.14, demonstrating the nous vein may be used, though up to 60% of
proximal anastomosis to the below-knee popliteal artery patients will require contralateral revasculariza-
Fig. 21.17 Arteriogram of the foot in a 60-year-old

patient with a gangrenous hallux, demonstrating only a
plantar vessel in the foot
Fig. 21.18 Same patient as Fig. 21.17. The plantar ves-
sels have been exposed and the vein graft is prepared for
distal anastomosis (top panel). Distal anastomosis per-
tion within 2 years. Several reports also have formed to the junction of the medial and lateral plantar
attested to the success of arm vein grafts; how- arteries (solid and dashed arrows) (bottom panel)
ever, enthusiasm is tempered by their limited
length. In addition, an increasing number of
patients with CLI will have either chronic renal Our preference is to use the contralateral
insufficiency or end-stage renal disease, and the saphenous vein only in those patients who have
arm vein should not be sacrificed in these patients a palpable foot pulse or near-normal noninva-
in whom optimal angioaccess is essential for sive arterial studies. Our second preference is a
survival. prosthetic PTFE graft which I modify by per-
Based on these limitations, prosthetic grafts forming a vein patch at both the proximal and
have been increasingly used in the tibial location distal anastomosis. The patch is sewn widely
for patients with limited autogenous conduit, onto the recipient vessel, with a generous PTFE
with encouraging results. Newer developments anastomosis on the top of the patch (Fig. 21.20).
and advancing techniques, such as heparin- By performing this at the proximal anastomo-
bonded polyfluorotetraethylene (PTFE) and vein sis, we have not encountered a patient who
cuffs/patches at the distal anastomosis, have presents with severe limb ischemia from proxi-
resulted in improved patency rates in some mal propagation of thrombus should the graft
series. occlude.
Fig. 21.19 Angiogram 1 year postoperative and Duplex 2 years postoperative of the patient from Fig. 21.17, demon-
strating a widely patent graft
Complications
Both systemic and local complications may occur

after surgical revascularization. Perioperative
cardiac complications are the most common sys-
temic complication, occurring in up to 5% of
patients, and include arrhythmias, congestive
heart failure, and myocardial infarction.
Perioperative use of beta-blockers may reduce
this risk. Judicious use of fluids, intraoperative
monitoring with liberal use of nitrates, and a high
index of suspicion for myocardial ischemia
Fig. 21.20 Distal anastomosis of a PTFE graft with dis- remain as important tenets of postoperative care.
tal vein patch to the peroneal artery. Note the wide vein The incidence of early (immediate) postopera-
patch on the native artery with the PTFE graft anasto-
tive graft occlusion varies according to the loca-
mosed to the patch
Fig. 21.21 Four weeks following left femoral to tibial (top panel) with a large infected pseudoaneurysm by CT
bypass, complicated by a superficial wound dehiscence, scan. This necessitated emergent groin exploration with
this patient presented with bleeding in the groin incision debridement and graft removal (bottom panel)
tion and obviously varies among individual leaks, and clean dressings all can help prevent
surgeons; most series report a rate of approxi- wound complications. Additionally, as stated pre-
mately 2–5%. Unless otherwise dictated at the viously, we will avoid placing grafts in the subcu-
time of the original operation, or otherwise miti- taneous space of a surgically created incision. In
gating circumstances, all patients with early graft the femoral location, use of a rotational sartorius
occlusion should be re-explored and graft muscle flap is quite helpful to cover the graft
thrombectomy performed. Most importantly, an prophylactically.
underlying cause (such as an anastomotic flap or
clamp injury) should be sought and addressed, as
the outcome is more favorable when the cause is Results
corrected.
Wound complications are often under- Patency rates and limb salvage after surgical
reported, and probably the most frequent compli- revascularization vary widely, principally accord-
cation after infrainguinal bypass surgery. The ing to the anatomic location, though other factors
spectrum ranges from simple cellulitis which (such as re-do procedures, type of conduit, and
may be treated with antibiotics alone, to exten- indication) also are important determinants. The
sive soft tissue infection with graft involvement. highest patency rates are seen with in-line (ana-
Most often, the sequence is that of an indolent tomic) inflow operations, with 5-year and 10-year
infection which results in a small area of wound patency for aortobifemoral bypass being 90% and
dehiscence and fibrinous exudates. Unfortunately, 80% respectively. Similar rates are seen following
this can mask deeper involvement, which can isolated profundaplasty or femoral endarterec-
result in a catastrophic outcome if the graft is tomy. For extra-anatomic bypass, the results are
involved (Fig. 21.21). The most important treat- obviously lower, with 5-year patency for femoral-
ment is prevention. Accurate and precise tissue femoral bypass averaging 65%. Among axillo-
approximation and closure, avoidance of flaps, bifemoral grafts, the patency rates are even lower,
judicious use of antibiotics, prevention of lymph averaging between 40% and 60% at 3 years.
Bypass grafts with saphenous vein provide the A suggested approach to the patient with limb
highest patency rates among infrainguinal revas- ischemia may be guided by the results of the
cularization. In situ and reversed vein graft pri- BASIL trial, which was the first and only inten-
mary patency at 1 year and 4 years averages tion to treat randomized controlled trial compar-
approximately 85% and 65% respectively, again ing endovascular intervention to surgical bypass
with no difference based on vein configuration. as “first treatment” among patients with severe
For paramalleolar bypass grafts, secondary limb ischemia. At follow-up of 7.7 years, 56% of
patency is approximately 60% at 5 years, with patients had died, emphasizing the precarious
limb salvage rates in excess of 80% at 5 years. medical condition of these patients. At 2 years,
The reported patency data for prosthetic grafts there was no difference in amputation free sur-
vary widely, with expected 1 year patency vival or overall survival among the two treated
between 35% and 75%. Multiple factors may groups, with a slight increase in overall survival
explain this wide variation. At least some of the and amputation free survival favoring bypass sur-
reports are 20 years or older; additionally, vari- gery at 3 years. Hospital costs were significantly
ables such as use of a distal vein cuff, anticoagu- higher for bypass surgery, but this had equalized
lation, and outflow are widely discrepant or not at 3 years among the two groups. Finally, in the
even reported. More recent data are more encour- analysis of quality of life, the worse outcome was
aging, and certainly support the use of prosthetic seen among patients undergoing major limb
grafts to the popliteal or tibial location when amputation, again emphasizing an aggressive
good quality autogenous vein is not available. approach to limb salvage in these patients.
In addition to patency, quality of life scores The results of these and other smaller nonran-
need be considered after any intervention, but domized series suggest that an endovascular-first
especially after infrainguinal bypass among approach is warranted in almost all patients, pro-
patients with foot ulceration. In this subset of vided that it may be performed without “burning
patients, time for healing can take up to a bridge” for future surgical revascularization.
3–6 months, with only 50% reporting “back to This is especially applicable for patients who are
normal” at 6 months. Significantly, approxi- expected to live less than 2 years, based on the
mately 15% of patients who were independent BASIL results. Conclusively, it can be stated that
preoperatively require some level of dependence limb amputation should be avoided, and surgical
at 6 months postoperatively. Finally, the best revascularization plays an integral part of that
measure of quality of life is freedom from major goal.
amputation, as amputation is uniformly associ-
ated with the lowest quality of life score.
General Considerations
in Endovascular Revascularization
hoice of Surgical Revascularization
C
or Endovascular Procedure In 2000, the TransAtlantic Inter-Society
Consensus on the management of PAD, authored
The decision for surgical revascularization or by vascular surgeons, cardiologists, angiologists,
percutaneous endovascular intervention is depen- and interventional radiologists aimed to address
dent on multiple variables, including both patient the variation in therapy among individual patients
variables and the skill of the interventionalist/sur- with identical conditions, with an aim to promote
geon. Notwithstanding the debates on which uniform high-level care across different coun-
should be performed first, it is axiomatic that the tries. The document stated that “in general, if
patient with CLI is best served by an aggressive there is a balanced choice between an endovascu-
approach to limb salvage, which, by definition, lar and a surgical procedure for a particular
incorporates both endovascular and surgical lesion, then the former is preferred because it
approaches. usually avoids a general anaesthesia, poses a
lesser systemic stress, and has fewer serious loss, nearly always requires restoration of pul-
complications” (14). Encouraged by this vision, satile in-line flow to the foot (27). In presence
in the next 20 years we observed a widespread of diffuse BTK disease, typical of CLTI, the
increase of endovascular procedures in patients first step is to identify the target arterial path
with CLTI, with many authors advocating an (TAP) in each patient by high-quality imaging,
“angioplasty first” revascularization strategy selecting a preferred infrapopliteal artery. The
(15–20). TAP is generally based on the least diseased
Interventional physicians rode this endovascu- crural artery providing runoff to the foot and
lar wave, developing new technical approaches, other relevant factors, such as angiosome pref-
such as endoluminal and subintimal crossing of erence or avoidance of a previously instru-
long occlusion and retrograde approaches able to mented vessel (27).
increase procedural success. Manufacturers of In the last years multiple studies have sup-
medical devices followed them, producing new ported the concept that direct revasculariza-
dedicated tools, able to ablate and dilate long and tion (DR) of the angiosome affected by tissue
often calcified lesions, to scaffold vessel wall lesion leads to improved healing and limb sal-
preventing recoil and dissection, and to deliver vage rates in patients with CLTI (28–35). In
antiproliferative drugs to avoid restenosis. line with the angiosome concepts, the endo-
Despite this huge effort, even in high-income vascular treatment of patients with CLTI has
countries with advanced health care systems, evolved toward extreme approaches, and BTA
such as Germany and the United States, many interventions are proposed as a new strategy to
patients with CLTI do not always undergo angi- improve the clinical outcomes of revascular-
ography or any attempt at revascularization (21, ization (36, 37).
22). For this reason, it is important to keep in In summary, the key point in our revascular-
mind that a low-cost balloon angioplasty with ization strategy is to identify the proper TAP in
uncoated balloons and bailout stenting has been each patient with CLTI, considering many fac-
demonstrated from the beginning to be effective tors such as anatomy, obstructive disease pat-
in preventing amputation in the majority of tern, and technical hurdles that must be
patients with CLTI (15, 23–26). overcome to achieve, if possible, a successful
Instead of pursuing a high-cost and high-tech recanalization.
angioplasty in few fortunate patients our duty
should be to promote and guarantee a wide-
spread access to basic endovascular revascular- Anatomic Considerations
ization to the vast majority of patients with in Endovascular Revascularization
CLTI, independently from census and country.
In line with this assumption, the purpose of this The TAP must be evaluated by high-quality
chapter is not to describe the newest and most imaging, applying standard foot projections
advanced devices and techniques, but to over- and digital post-processing methods. About
view the basic technical strategy that should be 7% of the patients present some type of ana-
used everywhere by skilled physicians for chang- tomical abnormality in the distribution of BTK
ing the fate of CLTI at a reasonable cost. vessels at the ankle: anterior or posterior domi-
nance of peroneal artery or a single peroneal
artery (38). Moreover about 20% of the patients
Targets of Endovascular have some variations in the foot vessel anat-
Revascularization omy with dominant dorsalis pedis or plantar
artery or a tarsal loop. Every patient is differ-
According to the new Global Vascular ent and to recognize the true underlying anat-
Guidelines (GVGs) a successful revasculariza- omy is of fundamental importance in guiding
tion in CLTI, particularly in patients with tissue our procedure (38).
Evaluation of the Collateral Vessel angiosome in 24.2% legs, two angiosomes in

Network 46.6%, three angiosomes in 26.1%, four angio-
somes in 2.5%, and five angiosomes in 0.6% legs
Angiosomes are interconnected by a collateral (45). They concluded that the tissue lesion of
vessel network which guarantees blood flow to CLTI affects several angiosomes in majority of
the entire foot in case of occlusion of one or the cases, suggesting that consensus needs to be
more arteries (39, 40). In cases when diffuse dis- achieved for the accurate definition of angiosome-
ease prevents the DR of the injured angiosome, targeted revascularization when more than one
some authors suggest to seek a collateral-vessel- angiosome is clinically involved. Some authors
guided revascularization (41, 42). Other authors suggest to pursue a multiple BTK vessel recana-
demonstrated that indirect revascularization lization, because this approach can obtain a better
through collaterals can effectively promote the wound perfusion, improving healing speed and
healing of ulcers and decrease the amputation compensating for restenosis of one of the treated
rate (34, 35, 43). vessels. On the other hand, it is suspected that the
The evaluation of collateral vessels is a key procedure may carry a higher risk due to greater
point in guiding our revascularization strategy in contrast volume, longer procedure time, radiation
patients with CLTI. The value of an angiosome- exposure, and potential complications (46–48).
oriented revascularization is directly correlated to The GVGs assert that multivessel (tibial) revas-
the degree of SAD affecting the foot distribution cularization may be reasonable in selected
system, and inversely correlated with the expan- patients with advanced limb-threatening lesions
sion of the collateral vessel network (38). (e.g., WIfI stages 3 and 4) undergoing endovas-
cular therapy if it can be safely accomplished
without risking loss of a bypass target or compro-
Metabolic Demands of Tissue Loss mising runoff to the foot (27).
According to the GVGs, angiosome-guided

revascularization may be of importance in the Technical Approaches
setting of endovascular intervention in patients in Endovascular Revascularization
with significant wounds (e.g., WIfI wound grades
3 and 4), particularly those involving the midfoot This is not meant to be a treatise on the endovas-
or hindfoot, but is likely to be irrelevant for isch- cular treatment of inferior limb vessels; it merely
emic rest pain and of marginal value for most highlights the key technical elements to consider
forefoot lesions and minor ulcers (27). Wounds when facing patients with CLTI.
have a different blood flow requirement for heal-
ing. The value of revascularization, and particu-
larly an angiosome-targeted revascularization, hronic Total Occlusions (CTOs)
C
varies according to the type of wound (38). Crossing Strategy
CTOs represent the majority of the obstructive

Multivessel Versus Single-Vessel lesions encountered in patients with CLTI (49).
Revascularization Crossing the lesion is the first step of endovascu-
lar recanalization. Independently of the site of the
Every lesion starts generally well localized; how- lesion (above-the-groin inflow, femoro-popliteal
ever delayed referral and infection lead to its or infra-popliteal) we recommend a step-by-step
enlargement, invading surrounding tissues and approach. The first attempt is endoluminal cross-
adjacent angiosomes (44). Spillerova et al., eval- ing. In many cases a soft tip, hydrophilic wire can
uating patients with CLTI and foot lesions, cross the occluded lumen, also in very long
observed that the wound interfered with one occlusion, finding easily the true distal lumen.
The explanation of this success resides in a softer sufficient to keep the skill of the operators at a
core of the occluding material, surrounded by high level.
stiffer and often calcified walls: the wire slides
inside the core, supported by dedicated low pro-
file catheters or balloons. In case of resistant ndovascular Strategy in the Vascular
E
fibrous cap or focal calcification, the soft tip wire Territories of the Lower Leg
can be exchanged with a CTOs dedicated wire.
The stiffer and often tapered tip can pierce the The concept of target arterial path implies that a
tough material, oriented by the operator in the partial revascularization, limited to the arterial
correct direction. inflow or the femoro-popliteal segment, leaving
In case of failure of the endoluminal approach, an untreated diffuse BTK vessel disease, is gen-
the subintimal approach offers an effective alter- erally insufficient to obtain healing; a successful
native. The wire is typically advanced in a looped revascularization in CLTI requires restoration of
shape, and instead of crossing the lumen, the pulsatile in-line flow to the foot. While in bypass
operator dissects the subintimal space. The dis- surgery this is generally an achievable target due
covery of the subintimal space by Bolia was a to the size and low resistance of the bypass con-
major development in angioplasty technique (51, duit, in the endovascular treatment of multivessel
52). At the end of the CTO, reentry inside the true diffuse disease this target is more difficult to
distal lumen can be achieved by pushing the wire; obtain. Every segment of the vascular tree of the
however, due to the risk of damaging the distal inferior limb requires a different and specific
vessel, especially in case of a diseased target, ret- approach.
rograde approaches are preferred.
The retrograde approaches have demonstrated
to be safe and effective, and to increase by 20% reatment of Inflow Disease:
T
the success rate of peripheral endovascular pro- The Aortoiliac System
cedures (53, 54). Every vessel below the CTO
can be used for a retrograde approach, from the The endovascular treatment of iliac obstructive
metatarsal arteries to pedal, tibial, and peroneal disease represents the first choice of revascular-
artery. The retrograde puncture of tibioperoneal, ization if done by an experienced team and if it
popliteal, and superficial femoral artery can be does not compromise subsequent surgical options.
performed without changing the supine position A recent metanalysis compared endovascular and
of the patient on the radiological table. In the open surgical approaches in iliac obstructive dis-
majority of the cases it is possible to use a sheath- ease: the endovascular approach reduced the
less approach, supporting the wire with low pro- length of hospital stay and the postoperative mor-
file catheters or balloons. Rendezvous with the bidity, while, in the long-term follow-up, open
antegrade approach can be accomplished in the surgical approach demonstrated a better primary
endoluminal or subintimal space, sometimes patency and lower reintervention rate (54).
with the help of balloons dilatation. The procedure must be planned according to
Other approaches were described, trans- the characteristic of the obstructive lesion: site of
collateral, pedal-plantar loop, and can be used in lesion (common or external iliac artery), type of
particular cases with the advice to respect what is lesion (stenosis or occlusion), length of lesion,
functioning and to preserve the potential landing calcium burden, soft plaque. Whenever possible,
zone of bypass. the internal iliac artery should be preserved. The
Endoluminal, subintimal, and retrograde involvement of common iliac ostium often
approaches in CTOs crossing are key elements of requires a bilateral kissing stenting technique, in
a successful percutaneous revascularization. order to avoid plaque prolapse and contralateral
Every center treating CLTI must be familiarized ostium stenosis, and to optimize blood flow in the
with these techniques and must have a workload aortic bifurcation (55–57).
Simple balloon angioplasty is now abandoned a lower complication rate (72). Another meta-
in favor of primary stenting, which represents the nalysis involving more than 3000 patients con-
gold standard in iliac treatment, due to better firmed these positive 1 year results; however,
results in terms of patency and complications after this duration, the patency of the endovas-
(58–63). Different types of stents are available on cular treatment was significantly lower than
the market: bare metal stents and covered stents, open repair and the overall rate of stent fracture
both in the balloon expandable and self- was 3.6% (73).
expandable configuration. Drug elution has a Waiting for further studies, dedicated materi-
marginal role in iliac arteries, limited to reste- als and a broader consensus, endovascular treat-
notic lesions (64). ment of CFA should be considered in selected
Balloon expandable stents offer a higher radial patients with contraindication for surgery and a
force, able to scaffold calcified lesions, and pre- favorable anatomy.
cise deployment; self-expandable stents have
lower radial force and less precise deployment;
however the adaptable geometry and the higher Treatment of Femoro-Popliteal (FP)
flexibility facilitate the treatment of longer Segment
lesions and maintain the natural movements of
external iliac artery (65–67). The new GVGs affirm that, “individual lesion-
Covered stents reduce the risk of distal embo- based schemes correlate poorly with effective
lization and repair arterial wall ruptures, demon- revascularization in CLTI, vascular specialists
strating safety and good long-term results in must integrate approaches for arterial segments
comparison with uncovered stents (68–71). into a management strategy for the whole limb.”
According to this global strategy, complex FP
lesions should be considered for a surgical
Treatment of Inflow Disease: approach; however the final decision relies on the
The CFA surgical patient’s risk, type of foot lesion, autolo-
gous vein availability, and the evaluation of BTK
Open endarterectomy is considered the standard and BTA vessel disease.
of care for treatment of atherosclerotic stenosis In the last 20 years, the endovascular strategy
of the CFA due to the scarce invasiveness of the for the FP segment is radically improved, with
procedure, durable results, and possibility to outcomes approaching that of surgical bypass.
spare the bifurcation. The endovascular approach After initial experiences with balloon angio-
is limited to patients at high surgical risk or with plasty, the introduction of the “drug delivery”
hostile groin because the CFA is a hyperdynamic technology, drug coated balloons (DCB) and
region with risk of stent fracture; obstructive drug eluting stents (DES), and covered stents has
plaque is often heavily calcified and difficult to significantly improved the outcomes of the endo-
dilate, and in case of bifurcation involvement vascular treatment of the FP segment in terms of
stenting can jeopardize the ostium of one main primary patency and freedom from target lesion
femoral branch (27). revascularization (TLR), becoming the first treat-
Nevertheless, there is significant morbidity ment option in the FP segment (74–78).
and mortality resulting from open surgery in A recent meta-analysis comparing drug-
CFA, and in recent times the endovascular coated devices versus saphenous vein graft
approach has demonstrated to compete with sur- bypass in FP arterial occlusive disease concluded
gery. In a recent systematic review and meta- that there is no significant difference in short-
analysis of 28 studies, endovascular treatment term efficacy, short- and long-term mortality
with routine stenting has demonstrated compa- (79). Despite traditional saphenous vein bypass
rable 1-year primary patency and target lesion remaining the gold standard, drug coated devices
revascularization as CFA endarterectomy, with provide a reasonable alternative therapy with
lower short-term morbidity associated with the and stent fractures, both responsible for resteno-
procedure (79). sis and occlusion and, consequently, affecting the
Despite the evolution of materials and tech- long-term success of the procedure (82, 85–87).
niques, there are still several critical issues To overcome these problems, in the last years
regarding the endovascular treatment of the FP different technical approaches have been pro-
segment, essentially represented by calcium and posed. Atherectomy, with or without DCB, does
motion. not seem to confer any significant additional clin-
Heavily calcified lesions are a barrier for every ical benefit compared with balloon angioplasty or
step of endovascular revascularization: crossing, stenting (88–92). However, several authors dis-
dilatation, scaffolding, and drug elution. New agree with this conclusion (93, 94).
devices are available to overcome calcium resis- A self-expandable nitinol stent (Supera™,
tance to dilatation, starting with high pressure Abbott), with a peculiar geometry that allows
balloons, cutting and scoring balloons. Orbital conformability to the FP segment during flexion,
atherectomy has demonstrated to be effective in showed good results in terms of patency, freedom
modifying the calcified lesions facilitating easier from TLR and stent fracture rate (95–99).
balloon inflation and intravascular drug elution.
A new approach of intravascular lithotripsy to
treat severely calcified lesions in a real-world reatment of Below the Knee (BTK)
T
study demonstrated low residual stenosis, high Arteries
acute gain, and a low rate of complications
despite the complexity of disease. A different BTK arteries are extensively diseased in patients
solution is represented by the “pave and crack with CLTI, so to be considered the most chal-
technique” which requires stent-graft lenging field. The first line of treatment is plain
implantation and aggressive dilatation of the arte- old balloon angioplasty with uncoated balloon
rial segment (80). with optional bailout stenting. Balloons now are
The second issue is represented by the available in tapered shape and length up to 30 cm,
dynamic properties of popliteal artery. The whole allowing a homogeneous dilatation of the vessel.
FP segment is affected by torsion, compression, Calcification is a common problem in BTK ves-
and bending forces during the walking movement sels and non-compliant high-pressure balloons,
or sitting position. Furthermore, from cadaveric able to support 25 atm, represent an important
studies, these forces seem to be lower in the prox- tool in BTK treatment. Cutting, scoring balloons,
imal and mid-superficial femoral artery and and atherectomy could play a role in optimal ves-
higher in the distal portion in the abductor chan- sel dilatation. Long dissection after balloon
nel and in the popliteal artery (81). Individual angioplasty can be corrected by the focal implan-
characteristics regarding the muscle modeling, tation of dedicated stent.
different for each patient, modify the bending Also in the BTK district, after initial experi-
forces acting on the popliteal artery, and the pres- ences with balloon angioplasty, DESs and DCBs
ence of arterial wall calcification influences its were proposed in order to improve the outcomes
curvature. Moreover, the endovascular treatment, of the endovascular treatment in terms of primary
both with angioplasty and stenting, modifies the patency and freedom from TLR; however the
dynamic characteristics of the FP segment (82). results were promising but also conflicting. The
The choice of the treatment method is a key reasons for this situation of uncertainty are essen-
point: while angioplasty results in a more flexible tially two. First, while studies on FP segment
artery, suggesting priority to a “leaving nothing were predominantly done on claudicants, studies
behind” strategy, stents interfere more with FP on BTK vessels were done on patients with CLTI,
dynamic properties (83, 84). Depending on the resulting in a higher complexity of the clinical
anatomical position of the stents, the axial stiff- scenario and confounding factors such as wound
ening of the arteries may lead to chronic kinking severity and comorbidities. Secondly the popula-
tions enrolled in BTK angioplasty studies present loon angioplasty with uncoated balloons and
a selection bias based on matching the target DCBs, and stenting. We lack data on restenosis
lesion length on the type of studied device. rate and long-term follow-up and no randomized
Studies on stenting, evaluating balloon control trials are available. In conclusion BTA
expandable and self-expandable stents, bare angioplasty is still in an artisanal era, and we can
metal and DESs, were focused on short and prox- share only anecdotal advice based on our
imal BTK lesions, while studies on uncoated and experience.
DCBs enrolled longer BTK lesions extended to In line with the GVGs, the first advice is to
the distal third of the tibial vessels. study BTA vessel disease with high-quality imag-
In summary, for short (<5 cm) and proximal ing. BTA vessels represent the main obstructive
BTK lesions DCBs have demonstrated better target of SAD, which is strongly associated with
results in terms of patency, TLR, and amputa- diabetes, hemodialysis, and CLTI (104). To eval-
tions and improved wound healing compared to uate the presence and the degree of SAD is a key
uncoated balloon angioplasty and bare metal point in defining the prognosis and the strategy of
stent (100–102). any revascularization procedure in patients with
CLTI. Due to the difficulty of obtaining a high-
quality imaging of the BTA vessels and quantify-
reatment of Below the Ankle (BTA)
T ing SAD (repeated contrast dye injection,
Arteries movement artifacts), we proposed a calcium
score on the plain radiographs of the foot, which
If the best strategy in revascularizing patients has demonstrated a high sensitivity and specific-
with CLTI is restoration of pulsatile in-line flow ity for SAD (105). SAD and MAC scores are
to the foot vessel, possibly a DR to the wounded both strong predictors of major adverse limb
angiosome, BTA vessel disease represents the events in patients with CLTI.
final obstacle. Many authors proposed BTA inter- The second advice is to respect what is, more
vention as a new strategy to improve clinical suc- or less, function. After treating big artery disease
cess of revascularization. to the ankle level, before going BTA, consider the
A recent systematic review and meta-analysis disease extension and the collateral vessel func-
concluded that the currently available evidence tion. We suppose that SAD is not a yes or no phe-
suggests that additional BTA angioplasty is a safe nomenon; it should take months or years to
and feasible procedure, and there is a potential slowly progress in the vascular tree. The quanti-
benefit in wound healing (103). tative evaluation of SAD is an open question, for
Despite these positive findings, before going which we lack standardized angiographic sys-
aggressively into BTA vessels, we believe it tems, and we rely on peripheral perfusion tests
extremely important to consider a critical such as transcutaneous oxygen tension and toe
appraisal of this literature. pressure. In case of doubts, stop the procedure
Studies on FP and BTK endovascular treat- and wait days or weeks for the clinical response
ment include thousands of patients, many ran- to big artery disease treatment, looking at wound
domized control trials, and long-term follow-up. evolution and tissue perfusion indexes. Go BTA
The amount of data on BTA vessel angioplasty is only with clear clinical indications and angio-
much lower: the only metanalysis by Huinzig graphic targets.
et al. included 10 studies of moderate quality,
reporting a total of 478 patients with BTA angio-
plasty performed in 524 legs (103). Moreover, “No-Option” Patients with CLTI
these studies are heterogeneous, the authors
applied different techniques such as endoluminal Not every patient with CLTI can be revascular-
or subintimal approaches, antegrade, retrograde ized due to vascular and clinical factors. The fate
and pedal-plantar loop technique, plain old bal- of these no-option patients with CLTI is poor,
with rates of limb loss up to 46% at 1 year (106– series, treated with off-label devices (111–113).
111). Moreover, these patients suffer from a low These are quite complex and difficult maneuvers,
quality of life and higher rates of mortality in whose reproducibility is as yet unknown.
comparison to other patients with CLTI (106, The main attempt in developing a totally per-
110). cutaneous deep vein arterialization was realized
Kim et al. proposed a new classification of no- by the LimFlow company through a series of
option patients with CLTI in five types: type I— dedicated tools designed to perform an arteriove-
severe and pedal occlusive disease (desert foot nous fistula at the tibial artery level, diverting
anatomy) for which there is no accepted method blood flow to the deep venous plantar system
of repair; type II—lack of suitable venous con- through dedicated covered stents. The prelimi-
duit for bypass in the setting of an acceptable tar- nary studies showed >96% technical success rate
get for bypass; type III—extensive tissue loss and 70% amputation-free survival at 1 year and
with exposure of vital structures that renders sal- multicentric studies are ongoing. In the near
vage impossible; type IV—advanced medical future, FVA could be proposed as a standard pro-
comorbidities for which available revasculariza- cedure in no-option patients with CLTI, before
tion options would pose a prohibitive risk; and proceeding with a major amputation (114–117).
type V—presence of a nonfunctional limb (106).
Type I no-option patients are characterized by
the desert foot anatomy, which is the final expres- Conclusion
sion of SAD-MAC. Their prevalence in patients
with CLTI varies from 20% to 45% and is associ- The management of a CLTI patient is exceed-
ated with aging, diabetes, and ESRD (110). In ingly challenging. Interventionalists are armed
these patients, alternative therapies should be con- with a host of medical, open surgical, and endo-
sidered such as primary major amputation, pallia- vascular tools to treat this complex disease pro-
tive care, or foot vein arterialization (FVA). FVA cess. The decision between open and endovascular
was proposed as the last attempt, obtaining a limb therapy delivery is nuanced, and even in the best
salvage rate between 55% and 75% at 1 year, with interventionalists hands, avoiding major amputa-
very with few complications. tion and cardiovascular morbidity remains a chal-
In recent years, following the evolution of the lenge. Continued developments and
therapy toward less invasive approaches, some advancements may provide new options for the
authors proposed totally percutaneous techniques treatment of CLTI, in the hopes of achieving
of FVA, describing positive single center case effective and durable therapies for patients.
Venous Disease Management
in the Limb Salvage Patient:
22
Diagnostics, Compression,
and Ablation
Bianca Cutler, Nikita Patel, and Misaki Kiguchi
Introduction
Chronic venous disease (CVD) of the lower

extremities encompasses a wide range of disease
pathologies. Venous hypertension generally
occurs as a result of either a structural or obstruc-
tive pathophysiology, or a combination of both.
Structural obstruction of venous outflow is seen
in various disease states including May-
Thurner’s, deep vein thrombosis (DVT), and ret-
roperitoneal fibrosis, whereas CVD related to
functional reflux occurs due to a dysfunction of NORMAL VEIN DISEASED VEIN
vein valves. Healthy veins carry blood towards Valves ensure blood Valves that cannot close
the heart, and competent valves prevent retro- flows in one direction allow blood to drain and pool
grade venous flow. However, the failure of vein Fig. 22.1 Valves in a normal vein and diseased vein.
valves to close appropriately allows backflow (Reprinted with permission from Medtronic, Inc.)
(e.g., reflux) of blood, preventing the reduction in
venous pressure that normally occurs with walk-
ing or exercising. This reflux of venous blood described by the CEAP classification, ranging
ultimately results in venous hypertension [1] from asymptomatic to clinical findings of edema,
(Fig. 22.1). Excessive venous hypertension can skin changes, or venous ulcers to the legs [2].
produce a wide distribution of symptoms The progression and sequelae of venous
insufficiency in the setting of chronic venous
disease contributes significantly to the economic
healthcare burden and negatively impacts patient
B. Cutler · M. Kiguchi (*) quality of life [3]. Fortunately, the emergence of
Department of Vascular Surgery, MedStar
Washington Hospital Center, Washington, DC, USA minimally invasive, safe, and effective office-
e-mail: [email protected] based treatments has significantly improved out-
N. Patel comes in chronic venous disease progression
Piedmont Heart Institute, Division of Vascular and has largely improved patient satisfaction.
Surgery, Piedmont Atlanta Hospital,
Atlanta, GA, USA

286 B. Cutler et al.
Anatomy of the total lower extremity blood volume is

transported via the deep venous system [4].
The lower extremity venous system is divided Perforating veins are bridging channels that
into three major components: the superficial, link the superficial and deep venous systems
deep, and perforating systems. The superficial leg through the fascia (Fig. 22.3). Competent perfo-
veins are located between the dermis and muscle rator veins support unidirectional blood flow
fascia, while the deep veins run just below the from the superficial to the deep system. They are
muscle fascia. The deep and superficial systems
are connected by a network of perforating veins.
Superficial veins include major truncal veins:
Femoral Vein
the great saphenous vein (GSV) and the small
(Deep System)
(lesser) saphenous vein (SSV), accessory veins
Saphenofemoral
(anterior and posterior), and any tributaries or
Junction
branches that originate from the superficial (SFJ)
venous system [4]. Excluding any anatomical
variants, the GSV is a continuation of the dorsal Great
venous arch in the foot, traveling anteriorly along Saphenous
the medial malleolus and ascending along the Vein
(GSV)
medial aspect of the leg. It drains into the deep
system via the saphenofemoral junction (SFJ) and Popliteal Vein
(Deep System)
perforating veins. The SSV begins on the lateral
aspect of the foot and travels posteriorly along the Small
back of the calf, ultimately draining into the pop- Saphenous
Vein
liteal vein at the saphenopopliteal junction (SPJ). (SSV)
Anatomical variants include draining into a poste-
rior medial tributary of the GSV, femoral vein or a
vein of Giacomini [5] (Fig. 22.2).
Deep veins include the iliac, femoral, pro-
funda, popliteal, peroneal (fibular), soleal, tibial,
and plantar (foot) veins. These veins course from
Fig. 22.2 Superficial venous anatomy. (Reprinted with
the foot to the upper thigh. Approximately 85% permission from Medtronic, Inc.)
Fig. 22.3 Perforator

veins. (Reprinted with
permission from
Medtronic, Inc.)
Deep vein
Failed valve
ein
t or v
fora
Per
Superficial vein
22 Venous Disease Management in the Limb Salvage Patient: Diagnostics, Compression, and Ablation 287
integral in equilibrating blood flow during calf- Dysfunction of these critically important valves
muscle contraction (walking) by facilitating in any component of the lower extremity veins
venous outflow from superficial veins as the deep causes retrograde flow, ultimately resulting in
system pressure drops. However, it is important chronic venous insufficiency.
to note that perforators may have physiologic
bidirectional capabilities depending on the phase
of the calf-pump activity, and thus “reflux” of the Pathophysiology
perforator veins alone is not considered a cause
for venous hypertension [5]. There are approxi- The etiology of valvular incompetence resulting
mately 60 perforating veins in a lower extremity, in venous hypertension is generally classified as
excluding anatomical variants [6]. However, either venous reflux or venous obstruction, or a
there are four clinically important perforator combination of both derangements [4]. Venous
groups that have been identified, grouped by dis- disease from reflux results from progressive
tribution: upper thigh (Hunterian), lower thigh venous remodeling due to persistent hemody-
(Dodd’s), at knee level (Boyd’s), and in the calf namic stress. Obstructive incompetence occurs
region (Cockett’s) [5]. due to valve damage and limited venous recanali-
zation after deep venous thrombosis or due to
extrinsic compression [5]. Mechanical contribu-
Normal Venous Valves tions to venous hypertension include the failure
of an effective calf muscle pump, thus limiting
Venous valves are integral in maintaining uni- effective venous return [11].
directional venous circulation against gravity Inflammatory changes to the venous vessel
and intra-abdominal pressure [7]. Normal wall are thought to be largely involved in the
venous valves are bicuspid and promote blood development and progression of venous reflux
flow from peripheral superficial veins to the and related valve incompetence. There is evi-
central deep veins, preventing pathologic dence to suggest that inflammatory changes
reflux [5]. These valves are more frequent in precede the development of observable valvular
distal veins, located the farthest from central incompetence and varicose veins [5]. Low shear
venous circulation. There are approximately stress within the vein as a result of vein dilation
10–20 valves in the GSV and 10–12 valves in and venous reflux can promote release of
the SSV [8]. inflammatory markers, increased collagen, and
Valves in the deep system vary in number and decreased elastin content. The resulting chronic
location as well; both the tibial and the peroneal inflammation ultimately progresses to the clini-
veins have numerous valves, spaced apart at cal manifestations of chronic venous insuffi-
approximately 2 cm intervals. Most popliteal ciency (CVI) [4].
veins have one to two valves. The femoral veins Deep system valvular venous disease has mul-
may contain an average of five valves across the tiple etiologies, the most common of which
mid and distal femoral veins, though there are (approximately 30%) is primary valvular incom-
generally one or no valves in the common femo- petence. Deep venous reflux may also occur due
ral vein above the level of the saphenofemoral to post-thrombotic injury after DVT, extramural
junction. The inferior vena cava and the external compression (most commonly left common iliac
iliac veins may be absent of valves altogether [9, vein compression by the right common iliac
10]. Thus, the deep system relies heavily on ade- artery, e.g., May-Thurner’s syndrome), and more
quate use of the calf-pump muscle contraction rarely, congenital valve agenesis or hypoplasia
that occurs with walking to promote venous [12–14].
return. Regardless of a reflux-related or obstructive
Perforating veins have been shown to have pathology, the resulting inflammation and dys-
between one to three venous valves [9]. function of vein walls and valves within both the
superficial and deep venous systems cause underlying pathophysiology (P) (Fig. 22.4)
chronic venous hypertension and dilation, result- [17].
ing in a repeating cycle of pathologies that poten- The linchpin of appropriate diagnosis and
tiate one another (abnormal venous flow, subsequent management of CVD is establishing
increased local venous pressure, damaged venous the accurate clinical class of the disease. Clinical
valves, and continued inflammatory response to class describes the full spectrum of venous disor-
the venous endothelial cells), ultimately contrib- ders, ranging from no physical signs of venous
uting to CVD progression [15]. disease to venous ulceration, which represents
the most severe form of venous disease. The clin-
ical classification stratifications are as follows:
Epidemiology no signs of visible or palpable venous disease
(C0), telangiectasia or reticular veins (C1), vari-
CVD is a common condition, although its over- cose veins (C2), edema (C3), skin changes,
all reported prevalence is difficult to capture as including hyperpigmentation or eczema (C4a),
the disease clearly remains underdiagnosed. lipodermatosclerosis, atrophie blanche (C4b) or
The European Society of Vascular Surgery esti- corona phlebectatica (C4c), presence of healed
mates the prevalence of CVD in the adult popu- ulceration (C5), or presence of active ulceration
lation to be as high as 60%, particularly among (C6). The presence or absence of symptoms is
populations in developed countries [16]. There documented as S (symptomatic) or A (asymp-
is great variability depending on the study popu- tomatic). Etiology is either congenital (Ec), pri-
lation and demographics, and the condition mary (Ep), secondary (Es), or no cause identified
itself is thought to be largely underreported due (En). Anatomic classification refers to the super-
to variability of symptoms. To better detect and ficial system (As), perforator involvement (Ap),
stratify an accurate diagnosis, venous disease is deep system (Ad), or no location identified (An).
stratified according to severity using the CEAP Pathophysiology is classified under reflux (Pr),
classification system, which is recommended obstruction (Po), or both [16].
for clinical practice. The CEAP classification With standardized clinical reporting (using the
was introduced in 1994 by the American Venous C of the CEAP scale), it is possible to provide
Forum (AVF) (later revised in 2020). The clas- more accurate reports of disease prevalence for
sification is based on clinical signs of venous each clinical class, as well as progression rates
disease (C), etiology (E), anatomy (A), and the though clinical classes over time and the relation-
C class Description
C0 No visible or palpable signs of venous disease
C1 Telangiectasias or reticular veins
C2 Varicose veins
C2r Recurrent varicose veins
C3 Edema
C4 Changes in skin and subcutaneous tissue secondary to CVD
C4a Pigmentation or eczema
C4b Corona phlebectatica
C4c Lipodermatosclerosis or atrophie blanche
C5 Healed
C6 Active venous ulcer
Recurrent active venous ulcer
CVD, Chronic venuous disease.
Each clinical class subcharacterized by a subscript indicating the presence (symptomatic, s) or absence (asymptomatic, a) of symptoms attributable
to venous disease.
Fig. 22.4 CEAP classification system. (Reprinted with permission from the Journal of Vascular Surgery: Venous and
Lymphatic Disorders. License Number 502659091955 [18])
ship to risk factors, which impacts the develop- among both men and women who have not been
ment of CVD. The European Society for Vascular pregnant, which suggests that pregnancy is an
Surgery published the most recent and compre- influential risk factor in development of C2 dis-
hensive data in 2015 from updated epidemiologic ease [21]. However, existing literature remains
studies: telangiectasia and spider veins (C1) have conflicted in gender influence: the notable
been reported to affect up to 80% of the popula- Edinburg Vein study reports that C2 disease may
tion. Varicose veins (C2) are common, with a vari- be even more common among male subjects in
able reported incidence ranging from 20% to 64%. the general population. While there is no obvious
C3-C6 affects approximately 5% of the popula- gender influence concerning development of
tion, with the prevalence of severe symptoms (C5- venous disease, the gender influence diminishes
6) estimated at approximately 1–2% [16]. with age [16].
Obesity is known to have a damaging effect on
venous return. A body mass index greater than
Causes and Risk Factors 25 kg/m2 significantly increases the risk for
CVI. Excess weight, particularly around the
While the development of primary CVI of the abdominal area, increases intra-abdominal pres-
superficial or deep venous system can be idio- sure and thus alters the hemodynamics of the
pathic, there are many known risk factors that lower extremity veins that are already under
contribute to its progression. stress to counteract gravity [22]. Additionally, a
Obstructive disease affecting the deep system positive family history also increases the preva-
is generally due to the aforementioned post- lence of CVI among individuals. Many studies
thrombotic disease and/or extramural compres- have revealed a correlation between positive fam-
sion of the iliac vein. After development of DVT, ily history and the risk of developing venous dis-
spontaneous lysis occurs in the acute period, ease; however, a responsible specific genetic
while venous recanalization occurs over months disturbance has not been identified to explain the
to years after sustaining the thrombus [19]. heredity [16].
Although the extent of recanalization depends on Ethnicity is thought to play a role in CVI, but
a myriad of factors (including extent of original most studies are based on figures from developed
thrombus, location, inflammation and inflamma- countries in the western world. More studies are
tory mediators), the process itself generates rela- needed to evaluate evidence from other geo-
tive obstruction and reflux in the deep and graphical locations. Existing data reveals preva-
superficial systems. Incomplete recanalization lence of C1-C6 disease in all demographics, with
may lead to outflow obstruction, further potenti- unequal distributions of C5-C6 by region [16].
ating venous hypertension [20]. Some recent studies on the impact of race on CVI
Primary valvular incompetence that occurs in demonstrate that African-American patients
the superficial system is thought to be due to a present with more advanced venous disease at a
variety of factors. The European Society for younger age, compared to Caucasians [23]. In
Vascular Surgery’s 2015 updated clinical practice addition, lower socioeconomic status portended
guidelines report older age as the most important to a more advanced venous disease presentation,
risk factor for both symptomatic and asymptom- reflecting a possible delay in diagnosis and inter-
atic varicose veins and CVI [16]. Historically, vention [24]. Other risk factors for CVI include
gender was thought to be a significant risk factor, damage to the deep veins (secondary to DVT or
although more recent studies demonstrate incon- trauma), and poor function of the calf muscle
clusive gender influence. While several studies pump through inactivity, immobility, or abnor-
have highlighted that women have a higher risk mal gait [1]. Thus, lifestyles or careers that
for development of varicose veins (approximately include prolonged periods of standing or sitting,
2–3 times higher risk) than men, a similar preva- with limited use of the calf-muscle pump,
lence of varicose veins has been documented increase the risk for vein damage.
linical Presentation of Venous

C describe symptoms of pruritus and pain to the
Hypertension affected area [4].
CEAP C6 patients may present with a combi-
The clinical presentation of CVI and resulting nation of any of the subjective and objective
CVD runs the gamut from asymptomatic to findings from previous CEAP classifications;
lifestyle-
limiting subjective symptoms. While however, criteria for this category is presence of
objective manifestations of CVD are encom- an ulceration. CEAP C5 classification is reserved
passed in the CEAP classification system, the for those with successful healing of venous
subjective symptoms often correlate to disease ulcers; however, the patient may continue to
severity. have subjective symptoms consistent with CVI/
CEAP C0-C2 patients may often be asymp- CVD [4].
tomatic. Symptom presentation becomes preva-
lent in CEAP C1-C2 with spider veins,
telangiectasias, and development of small vari- Diagnostic Workup
cosities <3 mm [4]. Varicosities are manifesta-
tions of CVD, defined as dilated subcutaneous The Society of Vascular Surgery (SVS) guide-
veins (arising from superficial veins: GSV, SSV, lines recommend a comprehensive workup of
or tributaries) measuring >3 mm in the upright venous disease including a thorough review of
position. While often a result of primary venous HPI and clinical exam, in combination with non-
disease, varicosities can also manifest due to sec- invasive diagnostic imaging techniques.
ondary causes including venous obstruction, pre- Symptoms that suggest CVD may include throb-
vious DVT, superficial thrombophlebitis, or bing, heaviness, edema, fatigue, restlessness of
arteriovenous fistula [17]. Varicosities may be the lower extremities, often exacerbated with
tender or nontender. standing and sitting for prolonged periods of time
Subjectively, patients with CVI at the CEAP and relieved with elevation. Venous claudication
C3 score often report lower extremity heaviness, symptoms occur in both primary and secondary
achiness, fatigue, and edema that is progressive venous diseases. Pertinent medical history
throughout the day or with prolonged leg exer- includes a review of DVT or thrombophlebitis
tion, with improvement of symptoms with leg history, self or family history of thrombophilia
elevation [16]. There is a tendency for these and hypercoagulable disorders, tobacco or hor-
patients to report pruritus, pain, and/or nocturnal mone use (including pregnancy), and family his-
leg cramps. As venous disease progresses to the tory of venous diseases. Physical exam should be
CEAP C4 level, the increased truncal vein diam- comprehensive for varicosities, discoloration
eter in conjunction with erythrocyte extravasa- (including atrophie blanche, lipodermatosclero-
tion and dermal hemosiderin deposition result in sis, pigmentation), edema, telangiectasias, ulcer
hyperpigmentation [4]. These trophic skin (active or healed), and ankle mobility. Pedal
changes are generally seen in the gaiter distribu- pulses and sensory/motor function of the leg and
tion of the lower leg, defined as the circumferen- foot should be evaluated to rule out any arterial
tial region between the medial malleolus and insufficiency and neuropathy etiologies, respec-
upper part of the calf [7]. Severe CEAP C4 mani- tively. The patient should also be evaluated for
festations include lipodermatosclerosis, atrophie compressive abdominal masses or lymphadenop-
blanche, and stasis dermatitis, often presenting as athy for consideration of extrinsic venous
erythema, fibrosis, and induration. Patients often compression.
The SVS recommends using the CEAP clas- in the United States [17]. A systematic review
sification system to evaluate CVD severity on published in the European Journal of
clinical exam. If CVD is suspected, a duplex scan Endovascular Surgery suggests that venous
should be completed. Venous duplex is the gold ulcers alone contribute to 2% of the total health-
standard, first-line diagnostic imaging test to care budget in developed countries [26]. This fig-
evaluate for valvular incompetence and obstruc- ure is expected to increase with the rising
tive disease, with or without the presence of acute population of older adults and the growing preva-
venous thrombosis. A comprehensive duplex lence of obesity [27]. Symptomatic varicosities
scan includes visibility, compressibility, venous alone can be a source of chronic pain, discomfort,
flow, and augmentation of the venous vessels. loss of working days, disability, and decreased
The SVS defines venous reflux in the superficial quality of life. Infrequently, severe CVD can lead
system veins as >500 ms, which aligns with pre- to loss of limb or life [17]. An increased aware-
vious international consensus recommendations ness among healthcare providers of venous dis-
of 0.5 s as a cutoff value for lower extremity vein ease, early detection, lifestyle coaching, and
incompetence. The iliac, femoral, and popliteal prompt referral to vein specialists will aid in pre-
veins of the deep system cutoff are slightly longer venting the progression of venous disease and
at 1 s. Perforating veins have previously sug- curb treatment expenditure [27].
gested cutoff values of 350 and 500 ms, and thus, Recognizing the quality of life burden of
perforator vein diameter is included in defining severe venous insufficiency and disease, numer-
pathologic reflux. The SVS and AVF Guideline ous standardized outcomes of patient reported
Committee defines pathologic perforating veins quality of life measures are used to quantify the
as those with an outward flow of ≥500 ms, with a degree of venous disease disability. The Venous
diameter of ≥3.5 mm, with presence of a current Clinical Severity Score (VCSS), for example, is a
or previous ulceration (CEAP class C5-C6). scoring tool that standardizes the clinical assess-
CT venography is recommended for patients ment of venous-specific disease severity. The tool
in which deep venous obstruction, iliac vein uses ten gradable symptom categories that may
compression, or post-thrombotic syndrome is change in response to treatment, rendering the
suspected, as well as for patients planning to VCSS an ideal instrument for longitudinal sur-
undergo endovenous or surgical treatment of veillance and evaluation of venous disease. The
deep system veins [17]. ten clinical descriptors include: pain, varicose
veins, venous edema, skin pigmentation, inflam-
mation, induration, number of active ulcers,
conomic Burden and Quality
E duration of active ulcers, ulcer size, and compres-
of Life sion use. Each category is scored from 0 to 3 with
a total possible score of 30 (Fig. 22.5). With the
Although a condition of low mortality, venous introduction of the VCSS and other venous dis-
insufficiency and its complications significantly ease specific quality of life measures, both venous
impact patient quality of life and the overall eco- clinical severity and its impact on quality of life
nomic healthcare burden. Varicose veins affect up can be quantified, allowing for an outcomes eval-
to 40% of the population, with up to 4% of uation that cannot be captured by a CEAP score
patients older than 65 suffering from venous alone. The venous disease specific quality of life
ulcers [26]. It is estimated that the direct medical measures are being increasingly studied and used
cost of CVD may exceed over $1 billion annually in the clinical setting [28].
Clinical descriptor Absent (0) Mild (1) Moderate (2) Severe (3)
Pain None Occasional Daily not limiting Daily limiting
Varicose veins None Few Calf or thigh Calf and thigh
Venous oedema None Foot and ankle Below knee Knee and above
Skin pigmentation None Limited perimalleolar Diffuse lower 1/3 calf Wider above lower 1/3 calf
Inflammation None Limited perimalleolar Diffuse lower 1/3 calf Wider above lower 1/3 calf
Induration None Limited perimalleolar Diffuse lower 1/3 calf Wider above lower 1/3 calf
Number of active ulcers None 1 2 ≥3
Ulcer duration None < 3 month 3-12 month > 1 year
Active ulcer size None < 2 cm 2-6 cm > 6 cm
Compression therapy None Intermittent Most days Fully comply
Fig. 22.5 Venous Clinical Severity Score (VCSS) Tool. License Number: 5444480868116
Conservative Management ing in CVD patients. Leg elevation in patients

with C3-C6 disease has been shown to reduce leg
All treatment and management strategies for swelling and venous pressures [16, 31]. While
venous disease have a common aim of achieving there is no correlation between elevation and
reduced venous hydrostatic pressure. When compression use regarding ulcer size reduction,
supine, and not counteracting effects of gravity, elevation remains recommended for patients
lower extremity venous pressure is around unable to tolerate compressive therapy alone.
10–20 mmHg. Hydrostatic pressure changes dra- Some studies suggest that patients who elevate
matically during postural changes from supine to their legs throughout the day have reduced ulcer
erect, as the body must now counteract an healing times [32, 33]. Additionally, elevation
increased gravitational column. Thus, the lower can help reduce lower extremity edema prior to
extremity veins are subject to a pressure increase donning compressive garments or bandages,
as high as 90–100 mmHg. In the absence of any allowing for easier application and compliance.
functional venous pathology, utilization of the
calf muscle pump of the leg can reduce hydrostatic
pressure in the lower legs to as low as 22 mmHg, Compression Therapy
after an average of only 7–12 steps [29, 30].
Compression therapy remains the gold standard
in the conservative management of CVD and has
Elevation been shown to improve the healing rate of ulcers.
Compression modalities include elastic stock-
Leg elevation is recommended to mitigate venous ings, non-elastic bandages, non-elastic compres-
stasis, provide symptomatic relief, reduce edema sion systems (self-adjusted Velcro devices), and
and inflammation, and promote ulceration heal- intermittent pneumatic compression pumps
Fig. 22.6 Effect of compression on venous macrocirculation. (Reprinted with permission: http://creativecommons.org/
licenses/by/4.0/ [34, 66])
(IPC). However, elastic graduated compression is exerting a higher pressure on the calf versus the
the hallmark of conservative management for ankle demonstrate a greater efficacy in increasing
C0-C4 disease, which improves calf muscle the venous ejection fraction from the leg [35–37].
pump function and thus reduces venous pressures The SVS and the AVF recommend a minimum
and edema (Fig. 22.6) [16, 31]. Most importantly, pressure of 20–30 mmHg for C2 disease and
the degree of compression must be medical-grade above [17].
to be considered clinically significant in the treat- Compression stockings are the most common
ment of venous hypertension. While further form of compression. The main disadvantage of
research is needed to evaluate the benefit of elas- stockings is that they produce less extrinsic pres-
tic compression directly on venous valve func- sure increases compared to compression ban-
tion, what is well established in the literature is dages when standing up and walking and,
the improvement in venous hemodynamics with therefore, are less effective with respect to their
compression use. Venous hemodynamics can be hemodynamic effects. However, compression
directly evaluated via air plethysmography stockings have been shown to be effective in
(APG), which measures volume changes in the reducing edema and pain versus no stockings and
leg and calf-pump effectiveness with ambulation. are thought to have anti-inflammatory properties
The residual volume fraction (RVF), a direct [31]. Patients should be advised of the
reflection of ambulatory venous pressure, is sig- recommendation to replace compression stock-
nificantly reduced in patients with CVI with the ings at 3–4 month intervals to promote optimal
use of graduated elastic compression. APG has pressure and avoid overstretching the elastic
also demonstrated that compression garments compression gradient [16].
If elastic medical-grade compression socks Adherence to treatment recommendations is

(Fig. 22.7) cannot be tolerated due to difficulty particularly low in patients requiring long-term
donning or discomfort, non-elastic compression management. Compression therapy is essential
(such as bandages and adjustable Velcro bands) to prevent the recurrence of ulcers, and the most
can be considered, although non-elastic compres- benefit is derived from high-grade compression.
sion is not as clinically effective as elastic com- The main concerns reported by patients include
pression systems. Compression bandages are difficulties donning and doffing stockings,
multilayer and have been shown to promote the improper fitting bandages that are loose, and
wound healing rates of ulcers when compared to concerns for hygiene, as dressings are often
standard wound care without the utilization of worn for extended periods of time. Hence, the
compressive therapy [16]. technical ability for patients to don and doff
Common compression bandages include the must be considered in compression treatment
Unna boot, Profor, Comprifore, and Coban. An choice.
important consideration with bandage compres- Significant peripheral arterial disease is a con-
sion is to avoid applying the dressing too loosely, traindication to compression therapy use, but
which results in an ill-fitting, non-effective unfortunately may be concomitant in many
dressing. patients with venous ulcers or venous disease.
Another non-elastic compression system con- Compression can compromise arterial perfusion
sists of Velcro bands, which facilitate higher to limbs, and it is recommended to limit com-
compression levels during ambulation, thus pression use in patients with an ankle brachial
reducing venous stasis and edema. Compliance is index of less than 0.5 or if absolute ankle pres-
improved with Velcro wraps due to ease of don- sure is <60 mmHg [31].
ning and can be easily adjusted as leg edema is
reduced or loosened as discomfort occurs.
Fig. 22.7 Medical grade compression. (Reprinted with permission: Lim CS, Davies AH. Graduated compression
stockings. CMAJ. 2014;186(10):E391–E398. doi:10.1503/cmaj.131281 [38])
reatment of Superficial Refluxing

T FDA in 2001, but as it gained popularity through
Veins its minimally invasive convenience, safety, and
efficacy; its technology and procedural modifica-
The era of open ligation and stripping of reflux- tions to power, linear endovenous energy density,
ing superficial saphenous veins has been replaced wavelength, and fiber type have resulted in
by more minimally invasive safe and effective improvements in treatment success. The
endovenous closure techniques to decrease International Endovenous Laser Working Group
venous hypertension. These endovenous closure evaluated long-term outcomes of endovenous
techniques can be done without general anesthe- treatment. Failure rates were 7.7% at 1 year and
sia and are often performed in the office. Although 5.4% at 2 years [39].
open ligation and stripping continues to be appro- Radiofrequency ablation (RFA) of refluxing
priate for superficial saphenous veins (>1 cm) superficial veins was introduced in the early
from the skin, dilated >2.5 cm, etc., regular 1990s (Fig. 22.8). The alternating electrical cur-
advancements in endovenous closure techniques rent emits heat due to its electrical resistance. The
have broadened indications for venous newest iterations can automatically adjust the
treatment. power output to ensure consistent treatment
throughout the treating section by maintaining a
target temperature of 120 °C. Several studies
Thermal Endovenous Closure have shown success rates >90% [40–42].
Not surprisingly, comparisons between RFA
Either laser or radiofrequency can accomplish and high open ligation with stripping have dem-
thermal closure of refluxing superficial veins. onstrated RFA to be less painful, require less time
Both techniques require access to the vein under off work, and increase quality of life, without any
ultrasound guidance after local anesthetic is difference in efficacy [41, 43, 44]. Across all
administered. With regard to the GSV, access is modalities, including thermal and nonthermal
performed slightly below the knee to avoid ther- endovenous closure, a meta-analysis demon-
mal injury to the saphenous nerve in the distal strated RFA and EVLA to consistently be more
calf. Similarly with the small saphenous vein, durable than sclerotherapy at 36 months to close
precautions should be taken to avoid the sural refluxing saphenous veins [45]. A pivotal ran-
nerve. A microwire is used to gain access into the domized control trial by Rasmussen et al. demon-
vein through the access needle. Once confirmed strated low procedural failure at 1 year with RFA
to be intraluminal by ultrasound, the catheter is and EVLA compared to sclerotherapy [46].
introduced, often through a sheath, into the vein Comparison studies between EVLA and RFA
and advanced to a point of 2 cm away from the groups confirmed that post-procedural discom-
sapheno-femoral/popliteal junction. Tumescent fort is higher in the EVLA group [40].
anesthesia is then administered around the peri-
venous tissue, mitigating risks of thermal injury.
Thermal energy is then initiated. For laser abla- Mechanochemical Endovenous
tion, the fiber and sheath are withdrawn simulta- Closure (MOCA)
neously and continuously, treating the entire
length of the vein in a pull-back fashion. For The need for tumescent anesthesia to mitigate
radiofrequency ablation, the catheter treats a seg- periprocedural pain and thermal injury with RFA
ment (3 or 7 cm) at a time. The heat causes irre- and EVLA techniques has catapulted nonthermal
versible cellular damage of the refluxing vein, techniques for endovenous saphenous vein closure
collagen contraction, fibrosis, and ultimately, to the forefront of emerging techniques for treat-
induces collapse of the vein. ment of chronic venous insufficiency since tumes-
With regard to endovenous laser ablation cent anesthesia prolongs procedural time and adds
(EVLA), the treatment was first approved by the to patient discomfort. Furthermore, thermal tech-
Disposable catheter Controlled heat Catheter withdrawn,

inserted into vein collapses vein closing vein
Fig. 22.8 RFA catheter. (Reprinted with permission from Medtronic, Inc.)
niques avoid treatment of reflux in the distal et al. published 1-year results of MOCA with
saphenous veins due to risk of thermal injury. 88.2% closure rate [47]. Despite consistent
MOCA, on the other hand, produces inflammatory higher recanalization rates compared to thermal
changes to endothelial wall, fibrosis, and subse- endovenous closure, MOCA can treat the entire
quent closure by utilizing mechanical injury with length of the refluxing vein without risk of ther-
chemical irritation with typical sclerosant without mal nerve injury and does not require tumescent
the need for tumescent anesthesia and can treat the anesthesia, lending to a more favorable patient
entire length of the saphenous vein. Furthermore, experience. The venous clinical severity score
sclerosant tends to dissipate into the superficial (VCSS) post-procedure also significantly
varicosities of the vein being treated, maximizing improved, even at 1 year.
treatment efficacy. In a randomized trial comparing MOCA with
Access for MOCA treatment with a micronee- RFA, the MOCA cohort experienced signifi-
dle and microwire can be at the ankle. The cantly less post-procedural pain compared to
MOCA device is introduced through the sheath RFA, and thus, an earlier return to activity [48].
to the saphenojunction, 1 cm away. The first The Maradona trial compared MOCA with
2–3 cm is treated with the mechanical ablation to RFA. MOCA was reported to be less painful of a
induce vasospasm and closure of the junction to procedure than RFA with a faster improvement in
limit dispersion of sclerosant into the deep sys- venous clinical severity scores. However, more
tem. The delivery catheter is activated with the anatomic failures were reported with MOCA due
rotating mechanical tip to withdraw at a constant to recanalization, but similar clinical success
speed while delivering sclerosant. rates at 1 and 2 years between the two techniques
MOCA, compared to thermal techniques, [49]. The LAMA trial compared MOCA to
have lower long-term closure rates. Van Eekeren EVLA. As predicted, the MOCA procedure was
a less painful procedure, though degree of post- tion of the cyanoacrylate adhesive closure sys-
procedural pain was similar between both groups tem reported a 97.2% closure rate of the great
[50, 51]. saphenous vein at 1 year, compared to the nearly
identical closure rate of 97% with RFA. Other
trial studies using cyanoacrylate adhesive have
Adhesive Endovenous Closure also demonstrated similar closure efficacy with-
out the need for post-procedural compression.
Given the efficacy and safety of cyanoacrylates in Mean return to work time was significantly
endovascular procedures for abdominal aortic shorter for cyanoacrylate adhesive closure [54,
aneurysms, arteriovenous malformations, and 55]. Additionally, a randomized trial comparing
pelvic congestion syndrome, this chemical adhe- adhesive to RFA showed treatment noninferior-
sive is delivered directly into the lumen of the ity in closure of incompetent GSV at 3 months
refluxing vein to incite an inflammatory response post-procedure. At 3-months post-procedure, the
and eventually leads to fibrosis. The access and closure rate for adhesive was 99% and RFA was
delivery are similar to MOCA, and as it is non- 96% [56].
thermal, the use of tumescent is not necessary
and the entire length of the vein can be treated
without risk of nerve injury. Post-procedural Care
A microwire is inserted into the access needle
and confirmed to be intraluminal under ultra- For thermal and MOCA endothermal closure
sound guidance. A 7Fr introducer sheath is placed techniques, patients are discharged from the
into the vein over the microwire. The 7Fr delivery office with 20–30 mmHg compression stockings
system is also introduced close to the sapheno- to wear continuously for approximately 48 h.
junction. The delivery catheter, primed with glue, Subsequently, patients are advised to wear day-
is inserted through the introducer sheath and is time compression for at least 2 weeks. Patients
positioned 5 cm away from the saphenojunction. are encouraged to walk immediately post-
While putting pressure on the junction, the trig- procedure and resume normal activities, includ-
ger of the dispensing gun is pulled to deliver the ing daily walking. Post-procedural ultrasounds
adhesive, squeezing once to deliver 0.10 mL of should be scheduled within 7–14 days.
adhesive, pulling back 1 cm, and the trigger is With cyanoacrylate adhesive closure, post-
squeezed again. Pressure is maintained at the procedural compression is not required. Patients
junction for 3 min. The catheter is then pulled should continue to walk immediately post-
back 3 cm for another delivery of 0.10 mL of procedurally and resume normal activities, includ-
adhesive with manual compression above the ing daily walking. Post-procedural ultrasounds
catheter for 30 s. This pull back and adhesive should be scheduled within 7–14 days [17].
delivery is continued until the entire length of the
target vein is treated.
The first clinical trial of cyanoacrylate adhe- Complications
sive closure involved 38 patients. The complete
occlusion rate immediately post-procedure was The advent of minimally invasive endovenous
100% and at 1 year, 92.1%. Using Kaplan-Meier closure techniques has allowed for superficial
life table analysis, the closure rate at 2 years was vein treatments to be performed in the outpatient
92% [52]. A multicentered European study setting. Though generally safe and well-toler-
treated refluxing GSVs with cyanoacrylate adhe- ated, superficial closure techniques carry inher-
sive. At 1 year, the complete venous closure rate ent risks.
was 92.9%. Venous Clinical Severity Score Endovenous thermal closure complications
improved significantly with acceptable safety include post-procedural pain, bruising, hematoma,
profile [53]. A more recent post-market evalua- phlebitis, and adjacent skin burn/discoloration.
Post-procedural duplex ensures diagnosis of pos- Furthermore, unique to thermal closure is

sible deep vein thrombosis or endothermal heat- nerve injury. For RFA, focal paresthesias were
induced thrombosis (EHIT) [57]. EHIT is unique noted in 12% of limbs in the first limb, improving
to thermal closure techniques and is referred to a over time. However, for below-knee GSV treated
thrombus that propagates more proximally than patients, the paresthesia rate was 7.7% at 5 years.
the treated segment, towards the junction. Taking Dermody et al. have showed a lower risk of nerve
extra care in treating a safe distance from the injury with RFA compared to EVLA (3.8% vs.
saphenojunction, including distal to the superficial 5.5%) [58]. Due to the proximity of the saphe-
epigastric vein for GSV t reatment, is imperative to nous vein to the saphenous nerve below the knee,
prevent post-procedural thrombus propagation. most physicians limit RFA treatment to the proxi-
In recent years, efforts have been made to mal third of the GSV below the knee and supply
standardize a classification system and guidelines sufficient tumescent fluid to separate the vein
for treatment of EHIT. Given that an acute throm- from the nerve [58].
bus of an EHIT behaves differently than a de MOCA complications include hyperpigmen-
novo DVT, there is some controversy surround- tation, bruising, hematoma, and phlebitis. The
ing the treatment algorithm for this complication, incidence of phlebitis is reported to be lower
and ongoing research is required for a consistent than endothermal techniques [46]. The risk of
consensus on treatment approach. The AVF and paresthesia is rare with MOCA as the technique
SVS published updated EHIT grading and rec- does not use heat. DVT and PE are also known
ommendation guidelines in 2020. The recom- complications to MOCA. Neurological side
mendations are summarized below [57] effects are unique to MOCA. The sclerosant may
(Fig. 22.9). travel systemically and can potentially cause
Fig. 22.9 Classification and treatment of endothermal heat-induced thrombosis. License #: 5447820045253
cerebrovascular accidents or transient ischemic Tumescent anesthesia is administered around the

attacks [59]. perivenous tissue. A spot-welding ablative tech-
Complications of endovenous adhesive clo- nique is recommended, treating all four quad-
sure include bruising and phlebitis. The phlebitis rants of the venous wall for 60 s each. The stylet
can sometimes be severe, requiring high dose is then withdrawn 3–5 mm and RF is performed
NSAIDs, compression, and warm compress ther- in all four quadrants. This is repeated throughout
apy. Care should also be taken to ensure there is the length of the perforator.
no allergy to adhesive, or history of autoimmune For laser, a 1470 nm, 400-mm laser fiber is
disease, prior to treatment as the cyanoacrylate is placed through a micropuncture needle, directly
considered an implant. Furthermore, endovenous into the vein, 2.0–3.0 mm away from the deep
glue-induced thrombus (EGIT) also can occur system. Perivenous tissue is infiltrated with
due to extension of thrombus into the deep sys- tumescence. The vein is treated in a pulsed tech-
tem [60]. nique at 6 W with 50–100 J per 2 mm through the
entire length of the perforator.
Ultrasound-guided sclerotherapy of perforator
Treatment of Incompetent veins involves a 25-gauge butterfly needle access-
Perforator Veins ing the perforator vein or a tributary off the perfo-
rator vein. Ultrasound-guided compression is
In addition to closure of refluxing superficial applied to the junction of the deep vein and the
saphenous veins, incompetent perforator vein perforator vein while the sclerosant is delivered.
closure has contributed to decreasing venous Lawrence et al. reported on a large series of
hypertension, directly near wounds. The Linton patients refractory to wound healing and eligible
procedure had severe wound complications and for perforator treatment. The study demonstrated
was largely replaced by subfascial endoscopic a subgroup of patients that may benefit from per-
perforator vein surgery (SEPS) when introduced forator ablation. Forty-five patients underwent
by Hauer in 1985 [61, 62]. SEPS became the pro- perforator ablation and healed in 71% of cases at
cedure of choice due to fewer incisions farther a mean of 193 days [63].
away from the already compromised area around
the ulcer. However, in recent years, thermal abla-
tions and US-guided sclerotherapy of refluxing Treatment of Deep Venous
perforators for associated venous ulcers have Obstruction
become the mainstay.
Societal guidelines have recommended treat- Patients with advanced venous disease presenta-
ment of pathologic perforators near the ulcer tion (e.g., CEAP C4-6) have a higher incidence
with a diameter of >3.5 mm and with a reflux of concomitant deep venous disease. The deep
time of >0.5 s. venous disease can either be reflux and/or
Percutaneous thermal ablation of incompetent obstruction. In symptomatic patients, both can
perforators involves placing the laser or RFA sty- occur simultaneously in up to 55% of patients
let directly into the offending vein under ultra- [16]. Thus, to optimize treatment of venous
sound guidance. The directed heat damages the hypertension, patients need to be evaluated and
endothelium, collapsing and fibrosing the vein. treated for both deep and superficial venous dis-
Under RFA, the stylet is directly placed into ease. Classification, based on signs and symp-
the vein 2 mm away from the deep system. toms, can be either “reflux dominant” or
Fig. 22.10 Pre- and post-treatment IVUS of occluded iliac vein
“obstructive dominant.” This separation can to reduce venous hypertension in the lower
guide treatment options to maximize outcomes. extremities rely heavily on preoperative planning
Deep venous thrombosis is the most common with CT venograms. Peri-procedurally, access is
cause of venous outflow obstruction causing often antegrade and retrograde. Crossing total
venous hypertension in the lower extremities. occlusion requires patience by the interventional-
However, other structural abnormalities such as ist and a myriad of different wires and supportive
May-Thurner’s and retroperitoneal fibrosis can catheters. The use of intravascular ultrasound
also impede venous outflow as well. Although (IVUS) to diagnose and guide sizing of stents is
collateralization may occur to mitigate outflow critical for optimizing chances of success in
obstruction, its compensation is often inadequate maintaining venous outflow (Fig. 22.10).
and can result in chronic venous hypertension. Commercially available venous stents are
Current endovascular techniques to recanalize self-expanding nitinol stents (Fig. 22.11). Each
the inferior vena cava and iliac vein obstruction venous stent varies in design to offer a balance
Fig. 22.11
Commercially available
a
self-expanding venous
stents. (a) Boston
Scientific Wallstent
Endoprosthesis. (b)
Cook Zilver Vena b
Venous Stent. (c) Boston
Scientific Vici Venous
Stent. (d) Bard Venovo
Venous Stent. (e)
Optimed sinus-Obliquis
Venous Stent. (f) c
Medtronic Abre Venous
Stent [64]. (Reprinted
with permission:
License Number
5026661464274)
d
between radial force, flexibility, and deployment strated a primary, assisted-primary, and second-
accuracy. Long-term clinical efficacy studies of ary cumulative patency rates of 79%, 100%, and
the various stents are still under investigation. 100%, respectively, at 72-months after ileocaval
Venous stenting, however, can be performed stenting with significant decreases in venous
with low morbidity and mortality with accept- clinical severity score [65]. In an additional
able patency rates. Furthermore, it results in study, sustained ulcer healing was achieved in
major symptomatic relief in patients with CVD, 60% of all limbs after ileocaval stenting
including ulcer healing. Neglen et al. demon- (Fig. 22.12) [66].
Fig. 22.12 Pre- and post-treatment venogram for ileocaval obstruction
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Science and Practicality of Tissue
Products in Limb Salvage
23
Alexandra N. Verzella, Allyson R. Alfonso,
and Ernest Chiu
Introduction way to better heal diabetic wounds and salvage

limbs in these individuals [4].
In 2017, the CDC estimated that the total direct
and indirect expenditure on diagnosed diabetes
in the USA was $327 billion, an increase of $56 Current Treatments
billion dollars since 2012 [1]. Globally, the esti-
mated cost in 2019 was 760 billion, and that is Diabetic wounds are precipitated by motor, sen-
projected to reach 825 billion in 2030 [2]. The sory, and autonomic neuropathy. Motor deficits
crude estimate of Americans with diabetes in include atrophy of intrinsic muscles of the foot
2018 was 34.1 million or 13.0%, and 7.3 million and dislocated metatarsophalangeal joints caused
(21.4%) of whom were not aware of the diagno- by unopposed power of the long flexors and
sis, with diabetic complications being the great- extensors of the foot [5]. Sensory neuropathy
est contributor to healthcare expenditure in these decreases the protective ability to sense pain and
patients [3, 4]. Some of these diabetes-related impairs proprioception, causing balancing defi-
complications include kidney disease, ocular dis- cits. Autonomic system dysregulation then fur-
ease, death, and hospitalizations secondary to ther contributes to the formation of diabetic foot
major cardiovascular disease, hyperglycemia, ulcers through decreased sweat and oil gland
hypoglycemia, and diabetic ulcers. Foot ulcers secretions, which predisposes patients to cracks
develop in up to 34% of patients with diabetes, and fissures in the skin barrier [5].
and failure of these ulcers to heal can lead to limb According to guidelines from the American
amputation [3, 4]. In fact, up to 5.6 out of 1000 Diabetes Association, there are 6 vital compo-
adults with diabetes underwent a lower-extremity nents to the treatment algorithm for a diabetic
amputation for a total of 130,000 people in 2016 wound which include: wound off-loading, surgi-
alone, underlining the importance of finding a cal debridement of the wound early and often,
maintenance of a moist wound bed, treatment of
active infections, vascular assessment with cor-
rection of ischemia, and strict glycemic control
A. N. Verzella · A. R. Alfonso · E. Chiu (*) [6–13]. Though there are a multitude of impera-
Hansjörg Wyss Department of Plastic Surgery, New
York University Grossman School of Medicine, tive components to healing a diabetic wound, the
New York, NY, USA standard of care (SOC) for these wounds is lim-
e-mail: [email protected]; ited to saline washes and vaseline gauze [14].
[email protected];
[email protected]

306 A. N. Verzella et al.
In addition to the standard practices of care, Science and Practicality

the clinical practice guidelines published by the of Allografts and Xenografts
Society for Vascular Surgery in collaboration
with the American Podiatric Medical Association Allografts and xenografts are skin substitutes that
and the Society for Vascular Medicine also rec- are harvested from human and animal sources,
ommend negative pressure therapy, hyperbaric respectively, that act as temporary skin grafts [19,
oxygen therapy, and biologics as adjunctive ther- 20].
apy for wounds recalcitrant to current SOC alone Allografts can be either cellular or acellular
[15, 16]. However, before biologics like tissue and are exclusively derived from human sources,
products can be considered for use, the wound most commonly from neonatal foreskin. Cellular
bed must be optimized through demonstrating allografts contain living cells like fibroblasts and
adequate perfusion, debridement, and edema keratinocytes that encourage wound healing
control. through secretion of growth factors and cytokines
that promote the ingrowth of native host cells and
neovascularization. Because these grafts retain
Tissue Product Definition non-autologous living cells, they can provoke an
immunologic response in the host.
In this chapter, tissue products are defined as Apligraf® (Organogenesis, Inc., Canton, MA),
anything that substitutes for skin and incorpo- previously called Graftskin, is a bilayer compos-
rates into the healing wound. The ideal tissue ite allograft that is indicated for full-thickness
product for a diabetic foot ulcer should resist neuropathic diabetic foot ulcers that have been
infection, prevent water loss, withstand the present for greater than 3 weeks and have not
shearing forces endured by native skin, conform responded to SOC [21, 22] (Fig. 23.1a, Table 23.1).
to irregular wound surfaces, lack significant anti- While Apligraf can be used in wounds that extend
genicity, and possess flexible thickness. It should through the dermis, it is not indicated for diabetic
also be cost-effective, widely available, easy to ulcers that involve tendon, muscle, joint, or bone
apply, durable and stable, and easy to store with [22]. Its epidermal layer is comprised of living
a long shelf-life. Unfortunately, the ideal tissue human neonatal foreskin- derived keratinocytes
product with all of these qualities does not cur- and stratum corneum, and its dermal layer con-
rently exist. tains bovine type I collagen and neonatal fibro-
Several systems of classification for tissue blasts that produce growth factors and cytokines
products have been proposed such as Kumar’s 3 like VEGF, IL-6, and IL-8. These components
classes that divide the products into temporary function to activate host keratinocytes at the edge
impervious dressing materials, single-layer of the wound, regulate growth factors signals,
durable substitutes, and composite skin substi- provide a barrier against further wound damage
tutes or Dieckman et al.’s 2 classes of biomate- and infection, control fibrosis and scar formation,
rial or cellular products with allogenic, and revitalize fibroblasts in the base of the
xenogenic, and autologous subcategories [17, wound—correcting ECM and matrix metallopro-
18]. Because there is a lack of consensus in teinase balance. Because of the impact on fibrosis
these classification systems, in this chapter, bio- and scar formation, Apligraf also has reports of
logic tissue products will be organized into their improved cosmesis and functional outcomes
individual brand product and will be placed into when used in chronic wounds [21, 23]. While
4 broader categories: (1) allografts/xenografts, Apligraf preserves many extracellular matrix
(2) dermal substitutes, (3) biosynthetic dress- (ECM) proteins and cytokines native to human
ings, and (4) cultured skin grafts. We will also skin, it does not contain Langerhans cells, mela-
highlight some of the currently commercially nocytes, macrophages, lymphocytes, blood ves-
available products and do not endorse one over sels, or hair follicles [22]. In addition, Apligraf’s
another. allogenic cells are not able to survive long-term in
23 Science and Practicality of Tissue Products in Limb Salvage 307
a Allografts
i) Apligraf® ii) Orcel®
Keratinocytes
Keratinocytes
and stem cells
Type I Collagen
Sponge
Fibroblasts
Fibroblasts
Collagen and growth factors
b Biosynthetic Dressings
i) Integra® DRT ii) Bibrane®
Silicon
Silicon
Nylon mesh
Bovine collagen
Chondroitin-6-sulfate Porcine collagen
glycosaminoglycans
c Cultured Skin Grafts

i) MySkin® ii) Epicel®
Petroleum
Keratinocyte cell gauze
suspension Keratinocytes
Murine
fibroblasts
d Dermal Substitutes
i) Promogran Prisma™ ii) GraftJacket®
Intact
basement
membrane
Bovine collagen
Type I
collagen
Oxidized regenerated
cellulose
Elastin and
aminoglycosides
Silver ORC
Adapted from Vig K, Chaudhari A, Tripathi S, et al. Advances in Skin Regeneration Using Tissue Engineering.
Int J Mol Sci. 2017;18(4):789. Published 2017 Apr 7. doi:10.3390/ijms18040789
Fig. 23.1 Biologic skin substitutes. (a) Allografts: (i) MySkin®, (ii) Epicel®. (d) Dermal substitutes: (i)
Apligraf®, (ii) Orcel®. (b) Biosynthetic dressings: (i) Promogran Prisma™, (ii) GraftJacket®
Integra® DRT, (ii) Biobrane®. (c) Cultured skin grafts: (i)
Table 23.1 Biologic skin substitutes
308
Intact Application Storage Difference

Manufacturer Source cells schedule Shelf-life temperature over SOC Indications
Allografts
Apligraf® Organogenesis, Neonatal foreskin-derived Yes Weekly 10 days Room Yes PMAa (1998)— Non-infected partial
Inc., Canton, MA keratinocytes with stratum temperature and full-thickness skin ulcers
corneum (epidermis) and secondary to venous insufficiency >1
bovine type-I collagen and month resistant to standard therapies
neonatal fibroblasts (dermis) PMA (2001)—full-thickness
neuropathic diabetic foot ulcers >3
weeks that have not responded to
SOC [95]
Off-label—epidermolysis bullosa
[96], recurrent hernia repair, pressure
sores, burn reconstruction [39]
Orcel® Forticell Neonatal foreskin-derived Yes One-time use 9 months Room No HDEb (2001)—burns (partial and full
Bioscience, Inc., epidermal keratinocytes and temperature thickness) and recessive dystrophic
NY, USA dermal fibroblasts cultured epidermolysis bullosa with hand
on bovine type-I collagen deformities
PMA—fresh, clean, split-thickness,
donor-site wounds in burn patients
Off-label—chronic wounds (venous
and diabetic ulcers) [20, 95]
Dermal substitutes
GraftJacket® Wright Medical Cadaveric allogenic acellular No As needed 2 years Room No PHS 361—full-thickness diabetic foot
Technologies, dermis with an intact temperature ulcers that have been present for >1
Inc., Memphis, basement membrane and week and extend through the dermis
TN dermal matrix with ECM [95, 97]
components Off-label—superficial wounds,
wounds with sinus tracts, and tendon
and osteal repairs [98]
DermACELL® LifeNet Health, Decellularized cadaveric No As needed 1.5–4 years Room No PHS 361—chronic non-healing
Virginia Beach, regenerative dermal matrix temperature wounds (diabetic and venous ulcers),
VA acute burns, breast reconstruction,
and other soft tissue trauma and can
be used on exposed joints, muscles,
bones, and tendons [97]
A. N. Verzella et al.
Amnioband® MFT Biologics, Dehydrated human amnion Non- Weekly 3 years Room Yes Partial and full-thickness neuropathic
Edison, NJ and chorion allograft viable temperature diabetic foot ulcers >6 weeks with no
capsule, tendon, or bone exposure
Internal and external tissue defects,
including acute, chronic, and surgical
wounds
Epifix® MiMedx, Dehydrated human amnion Non- Minimal 5 years Room Yes Neuropathic ulcers, venous stasis
Marietta, GA and chorion membrane with viable disruption is temperature ulcers, pressure ulcer, trauma wounds,
epithelial cells, basement ideal but and surgical wounds
membrane, and avascular change as
connective tissue needed
Allopatch MFT Biologics, Acellular human reticular No Weekly 3 years Room – Partial and full-thickness neuropathic
Pliable® Edison, NJ dermal tissue temperature diabetic foot ulcers >6 weeks without
exposed tendon or bone [97]
Epicord® MiMedx, Dehydrated human umbilical Non- As needed 5 years Room Yes Management of chronic and acute,
Marietta, GA cord allograft on an ECM of viable temperature including diabetic and other leg
hyaluronic acid and collagen ulcers; burns treatment and tendon
protection
Grafix® Smith + Nephew Cellular placental-based skin Yes Weekly 3 years No “Wound cover” for management of
23 Science and Practicality of Tissue Products in Limb Salvage
−75 to
Osiris substitute −85 °C chronic and acute wounds (diabetic
Therapeutics, Inc., foot ulcers, venous stasis ulcers,
Columbia, MD pressure ulcers), deep chronic
wounds, tendon repair, burns [97]
AmnioExcel® Integra Trilayered human allograft Non- Weekly 5 years Room No Management of complex chronic and
Lifesciences, membrane viable temperature acute wounds, including diabetic and
Plainsboro, NJ (chorion–amnion–chorion) venous/arterial ulcers, pressure ulcers,
trauma wounds, surgical wounds,
burns, and wounds with exposed
muscle, tendon, bone and vital
structures
(continued)
309
Table 23.1 (continued)
310

Oasis® Cook Biotech, Acellular ECM from porcine No Weekly 2 years Room No 510(k) (2006)—“management of
Lafayette, IN jejunal submucosa temperature wounds including: partial and
full-thickness wounds; pressure
ulcers; venous ulcers; diabetic ulcers;
chronic vascular ulcers; tunneled,
undermined wounds; surgical wounds
(donor sites/grafts, post-Mohs
surgery, post-laser surgery, podiatric,
wound dehiscence); trauma wounds
(abrasions, lacerations, second-degree
burns, and skin tears); draining
wounds” [95]
Promogran 3M, Saint Paul, Collagen, oxidized No Daily Use by date <25 °C No 510(k)—“intended for the
Prisma® MN regenerated cellulose, and printed on management of exuding wounds
silver on a sponge packaging including: diabetic ulcers, venous
ulcers, pressure ulcers, ulcers caused
by mixed vascular etiologies, full
thickness and partial thickness
wounds, donor sites and other
bleeding surface wounds, abrasions,
traumatic wounds healing by
secondary intention, dehisced surgical
wounds” [95, 99]
Kerecis® Kerecis, Decellularized Icelandic No When previous 3 years Room – 510(k) (2013)—“management of
Arlington, VA codfish skin that has been Kerecis is temperature partial and full-thickness wounds,
harvested, lyophilized, and absorbed and pressure ulcers, venous ulcers,
freeze-dried no longer chronic vascular ulcers, diabetic
visible ulcers, trauma wounds, surgical
wounds, and draining wounds” [95,
100]
Biosynthetic dressings
Biobrane® Smith and Porcine collagen in nylon No Typically one ~3 years (see Room – 510(k) (2009)—clean superficial burn
Nephew, St. mesh with semipermeable time use use by date temperature wounds, donor sites after hemostasis,
Petersburg, FL outer layer of silicone on protective covering for meshed
packaging) autografts [95]
Off-label—dermabrasions, skin-graft
harvesting, laser resurfacing, chronic
wounds, venous ulcers [20, 101]
Transcyte® Shire Neonatal foreskin fibroblasts Yes Typically one 18 months −70 to – PMA (1997)—temporary wound
Regenerative seeded on bioabsorbable time use −20 °C cover for surgically excised full-
Medicine, San nylon mesh and covered thickness and deep partial-thickness
Diego, CA with a layer of silicone thermal burn wounds [21]
Off-label—chronic legs ulcers,
diabetic foot ulcers lasting >6 weeks,
venous ulcers, pressure ulcers [21]
Integra® Integra Bilayer of bovine collagen No Minimal 6 months Room Yes 510(k) (2002)—“management of
Lifesciences, cross-linked with disruption is temperature wounds including: partial and
Plainsboro, NJ chondroitin-6-sulfate ideal but full-thickness wounds, pressure
glycosaminoglycans with a change as ulcers, venous ulcers, diabetic ulcers,
semipermeable silicone needed chronic and vascular ulcers, surgical
23 Science and Practicality of Tissue Products in Limb Salvage
outer layer wounds (donor sites/grafts, post-

Mohs surgery, post-laser surgery,
podiatric, wound dehiscence), trauma
wounds (abrasions, laceration,
second-degree burns, skin tears), and
draining wounds” [95]
Dermagraft® Shire Cryopreserved neonatal Yes Weekly 6 months −75 °C Yes PMA (2001)—“full-thickness
Regenerative foreskin fibroblasts cultured +/- 10 diabetic foot ulcers >6 weeks’
Medicine, Inc., on a bioabsorbable duration which extend through the
San Diego, CA polyglactin polymer mesh dermis, but without tendon, muscle,
scaffold joint capsule, or bone exposure” [20,
21, 39, 91]
Off-label—chronic wounds,
uninfected wounds, temporary or
permanent covering prior to STSG
graft on burn wounds [21, 75, 102]
(continued)
311
Table 23.1 (continued)
312

Cultured skin grafts
Hyalograft Fidia Advanced Autologous fibroblasts Yes One-time Several days – No Non-infected chronic lower extremity
3D® Biopolymers, seeded on a 3D hyaluronic application ulcers (diabetic foot ulcers)
Abano Terme, matrix
Italy
MySkin® CellTrain Ltd., Cell suspension of Yes One-time 2–3 days −90 °C No Burns and non-healing wounds
UK autologous sub-confluent application [103]
keratinocytes
Laserskin® Fidia Advanced Autologous sub-confluent Yes One-time 2 days – No 510(k) (2001)—“management of
Biopolymers, keratinocytes and fibroblasts application wounds in the granulation phase such
Abano Terme, biopsy on a biodegradable as pressure ulcers, venous and arterial
Italy benzyl esterified hyaluronic ulcers, diabetic ulcers, surgical
acid matrix incisions, second degree burns, skin
abrasions, lacerations, partial-
thickness grafts and skin tears,
wounds and burns treated with
meshed grafts. It is intended for use
as a temporary coverage for wounds
and burns to aid in the natural healing
process” [95]
Epicel® Vericel Co., Autologous keratinocytes Yes One-time 1 day 13−23 °C – HDE (2007)—deep dermal or full
Cambridge, MA and murine fibroblasts from application thickness burns comprising a total
epidermal biopsy seeded on body surface area of at least 30% for
petroleum gauze use with split-thickness autografts or
alone; post nevus excision [95]
Off-label—diabetic and venous ulcers
[21]
Kaloderm® Tegoscience, Allogenic keratinocytes Yes One-time 2 years −60 °C No Non-infected diabetic foot ulcers and
Seoul, Korea from neonatal foreskin application burns
a
PMA-FDA premarket approval to evaluate the safety and effectiveness of products and devices that are integral in preventing serious illness or injury
b
HDE humanitarian device exemption: regulatory pathway for products intended for use in rare/infrequent conditions
the host wound and are gradually replaced by bilayered dermal–epidermal composites [29].
native cells as the ulcer heals [21]. Small wounds They must be acellular to avoid rejection and
are likely to only require one application, which severe inflammation in the host, and because they
increases the financial feasibility of using this are derived from non-human sources, they require
product [21]. However, a disadvantage of Apligraf increased processing to decrease their immunoge-
is that wounds require new applications once per nicity [6, 30]. However, there are a variety of dif-
week, decreasing its cost-effectiveness [21]. On ferent preparations for xenografts that can impact
average, Apligraf costs $86,226 per avoided their contents and ultimate effect in patients [28].
amputation, and the direct costs associated with a Fresh, fresh frozen, lyophilized, and irradiated
lower-extremity amputation are roughly $50,000, preparations all maintain the epidermal and der-
a price that is considerably higher when the indi- mal layers of the xenograft [28]. A more recent
rect costs of amputation are also considered [24, modification to xenograft processing includes the
25]. Another limitation of the allograft is its shelf- incorporation of aldehyde cross-linking and silver
life of only 10 days at ambient temperatures [22]. ions to amplify the antimicrobial properties of the
It also requires debridement down to healthy graft, prolong its lifespan, decrease its antigenic-
bleeding tissue, but then, hemostasis must be ity, and inhibit collagenase to prevent collagen
achieved before application [22]. Use of Apligraf breakdown [29–36]. Aldehyde cross-linking also
is contraindicated in infected wounds, patients removes the epidermis and the dermal append-
allergic to bovine products (specifically bovine ages, resulting in an acellular dermal matrix that
collagen), and individuals with a hypersensitivity can be applied with either side down on the wound
to the agarose medium used for storage [22]. bed [28]. However, this cross-linking also can
Orcel® (Forticell Bioscience, Inc., NY, USA), prolong inflammation and delay graft incorpora-
indicated in the treatment of chronic diabetic tion into the wound, effectively transforming the
ulcers, is a composite allograft composed of a behavior of the graft from a biologic material into
bilayered cellular matrix in which allogenic epi- a more synthetic one [30].
dermal keratinocytes and dermal fibroblasts from Xenografts can be used as a temporary dress-
neonatal foreskin are cultured in 2 distinct layers ing before an autologous graft, and in partial
on a type I bovine collagen sponge [19, 27] thickness burns, xenograft matrices can be used
(Fig. 23.1a, Table 23.1). As the wound heals, as a permanent dressing [28]. Xenografts can be
native host cells replace the allogenic keratino- left in place until they naturally separate away
cytes and fibroblasts and fill in the collagen from the healing skin of the underlying wound,
sponge scaffold [21, 25, 26]. Orcel has a shelf- but dressing changes should be done every
life of 9 months, but it must be cryopreserved and 2–4 days in order to monitor the wound closely
is not indicated for use in infected wounds or in [28, 29]. However, given their immunogenicity,
patients with allergies to penicillin, gentamycin, xenografts have increased potential for scarring
streptomycin, amphotericin B, or any animal and immunogenic rejection [37, 38]. Xenogeneic
products due to Orcel’s processing [21, 27]. tissue products will be discussed in further detail
Additional allogenic tissue products are disin the dermal substitute and biosynthetic dressing
cussed in the dermal substitutes, biosynthetic sections.
dressings, and cultured skin graft sections.
While allografts are widely used and have
many benefits, they can be limited by their avail- cience and Practicality of Dermal
S
ability, and xenografts can help to offset any Substitutes
shortage of allografts due to their constant supply
[28]. Xenografts are made from acellular nonliv- Dermal substitutes are any tissue products that
ing tissue that is derived from different species effectively act as dermis. They can be comprised
(most commonly bovine or porcine) and are com- of human or non-human-derived tissue that has
posed of dermis in a variety of thicknesses or then been processed to create an acellular scaf-
fold with a basement membrane and a complete should not be used in patients with autoimmune
extracellular matrix [17, 39]. Because of the connective tissue disease or in infected wounds
complex nature of the dermal layer, dermal [41]. Moreover, because the tissue product is
substitutes can be classified into cellular or acel- sourced from a human cadaver, there is always
lular and living or nonliving [17, 39]. the potential for disease transmission despite
Acellular dermal matrix is composed of col- extensive screening of donors [41].
lagen, elastin, laminin, and glycosaminoglycans DermACELL® (LifeNet Health, Virginia
and derived from a decellularized cadaveric or Beach, VA) is another example of an allogenic
xenogenic source. The tissue has no living cells acellular dermal matrix that contains a nonliving
remaining in the graft and therefore has the dermal scaffold of matrikines, growth factors,
advantage of being immunologically inert, and cytokines, and extracellular matrix components
revascularization begins within 1–2 weeks after such as collagen, elastin, and glycosaminogly-
implantation of the graft [5, 40]. They are better cans [42–44] (Table 23.1). The intact structure
for use in fields that may be contaminated because acts a scaffold for host cells, and the signaling
they incorporate into a wound and achieve revas- factors serve to promote cell ingrowth, prolifera-
cularization more rapidly, making them more tion, and angiogenesis [45]. The acellular dermal
resistant to any potential infection [40]. matrix (ADM) also contains fibroblast receptors
Graftjacket® (Wright Medical Technologies, that aid the cells in attaching to the scaffold,
Inc., Memphis, TN) is a cadaveric allogenic acel- strengthening the matrix, and allowing it to with-
lular dermal matrix which consists of an intact stand sheering forces comparable to those
basement membrane and dermal matrix with endured by healthy, intact dermis [42–44].
ECM components, including type I collagen, DermACELL® is indicated for diabetic foot
elastin, and various aminoglycosides (Fig. 23.1d, ulcers and chronic non-healing wounds and can
Table 23.1). The dermal scaffold and intact base- be used on exposed joints, muscles, bones, and
ment membrane aid in adhering the tissue prod- tendons [30]. >97% of donor DNA is removed
uct to the wound and encourage ingrowth of cells from the product during processing to mitigate
and neovascularization through release of cyto- disease transmission and minimize immunoge-
kines and growth factors [21, 41]. It is indicated nicity, and the product is then sterilized with
for deep and superficial wounds, wounds with radiation and low temperatures [42].
sinus tracts, and tendon and osteal repairs [21, DermACELL has a shelf-life of 1.5–4 years,
®
29, 41]. Because the product is allogenic and depending on the exact product utilized, at room
acellular, it can be used as a permanent skin sub- temperature [42]. However, DermACELL® is not
stitute when autograft is not available in partial to be used in patients with allergies to any of the
thickness wounds, but it can also be utilized for antibiotics that are used in the processing and
immediate reconstruction as a temporary dress- preparation of the product [42].
ing prior to autograft skin grafting [19, 21]. Placental membrane- and umbilical-derived
Graftjacket® helps to optimally prepare the products like Amnioband® (MFT Biologics,
wound prior to autograft placement by increasing Edison, NJ) (ADM), Epifix® (MiMedx, Marietta,
wound bed vascularity and decreasing infection GA) (umbilical cellular dermal substitute)
potential and fluid loss in the area [19]. (ADM), Amniopatch Pliable® (cellular dermal
Graftjacket® can also be applied concurrently substitute), Epicord® (umbilical cellular dermal
with an autograft using the sandwich grafting substitute) (MiMedx, Marietta, GA), and Grafix®
technique in order to prevent wound desiccation (Smith + Nephew Osiris Therapeutics, Inc.,
and reduce bacterial colonization of the autograft Columbia, MD) (cellular placental-derived skin
[19]. The dermal substitute also comes pre- substitute) can also act as dermal substitutes in
meshed for ease of clinical application and tran- chronic and diabetic wounds [46–48]
sudate drainage and has a shelf-life of 2 years at (Table 23.1). These products can be preserved in
ambient temperatures [21, 41]. Graftjacket® a variety of different ways, including cryopreser-
vation in liquid nitrogen, silver nitrate, antibiot- Oasis® can be stored for up to 2 years at room
ics, glycerol sheets, dried sheets, and temperature and requires rehydration with nor-
gamma-irradiated sheets [49]. Umbilical and mal saline once the product has been applied to
placental products decrease rates of infection and the wound [29, 37]. However, because of its
minimize loss of proteins, electrolytes, and fluids xenogeneic origin, no angiogenesis occurs, and
from wounds [19, 29]. The products are rich in the product does not take [28]. Therefore, it is
growth factors, ECM proteins such as fibronectin only indicated for use as a temporary skin substi-
and collagen, and cytokines that promote neovas- tute and cannot be used permanently [29]. The
cularization, dermal fibroblast proliferation, and product can remain on the wound until it sloughs
mesenchymal stem cell recruitment, allowing off with the ingrowth of native epithelial cells to
these products to perform dermal functions and the wound [29]. However, many physicians pre-
closely mimicking the composition of human fer to change out the ADM every 2–4 weeks in
skin [49–51]. Placental and umbilical products order to more closely monitor the healing pro-
undergo minimal processing to ensure that they cess because Oasis® is not a semi-transparent
maintain their inherent dermal scaffold, func- material [29]. Oasis® should not be used in
tional properties, and progenitor cells (in the case patients with known porcine allergies, and
of the cellular products) [29]. These dermal sub- patients from various religious backgrounds may
stitutes are also able to conform to wounds with be opposed to the use of a porcine product [21].
more complex anatomies [46–48, 51]. Grafix, Like Oasis®, Promogran Prisma™ (3 M, Saint
specifically, can also be directly applied to Paul, MN) is a xenogenic acellular dermal
exposed bone, tendons, and muscles [48]. While matrix, but instead of being derived from porcine
they are able to conform to complex anatomies, components, it is composed of 55% bovine col-
they are minimally adherent and have poor lagen, 44% oxidized regenerated cellulose, and
mechanical properties, necessitating more fre- 1% silver oxidized regenerated cellulose freeze-
quent dressing changes [29]. They also have a dried into a sponge [55, 56] (Fig. 23.1d,
high biodegradability rate [51, 52]. Like other Table 23.1). Promogran™ works to heal wounds
allogenic tissue products, there is always the risk through minimizing protease activity, and, there-
of contamination and disease transmission fore, protecting growth factors from degradation
despite donor screening [19, 29]. [24]. The silver serves as an antimicrobial [pro-
Oasis® (Cook Biotech, Lafayette, IN) is a mogran]. It is indicated for wounds that have
xenogeneic non-cross-linked acellular dermal been debrided of any necrotic tissue, including
matrix (ADM) derived from processed porcine diabetic ulcers and trauma wounds [56].
jejunum and indicated for use in diabetic ulcers Promogran Prisma™ should not be used in
and partial- and full-thickness wounds [53, 54] patients with known sensitivities or allergies to
(Table 23.1). The processing required for this bovine products [56].
product is more extensive than that required for Kerecis® (Kerecis, Arlington, VA) is another
allogenic products because of the increased example of a xenogeneic acellular dermal substi-
immunogenic potential of xenogeneic products. tute. It is made from the skin of decellularized
The processing removes cells from the porcine Icelandic codfish skin that has been harvested,
jejunum but leaves a scaffold of ECM compo- lyophilized, and freeze-dried, and it is indicated
nents (glycosaminoglycans, fibronectin, proteo- for chronic vascular ulcers, trauma wounds, and
glycans, basic fibroblast growth factor, and partial- and full-thickness wounds, including dia-
transforming growth factor beta) intact [28, 53]. betic ulcers [50, 57] (Table 23.1). The dermal
Because Oasis® lacks aldehyde cross-linking, it substitute maintains its fat, protein, elastin, and
is less likely to cause scarring and inflammation, glycans and has an abundant supply of antimicro-
but is also does not possess the strength, pro- bial agents such as omega-3 polyunsaturated
longed lifespan, or decreased antigenicity that fatty acid, eicosapentaenoic acid, and docosa-
the cross-linking provides [30–36]. Dehydrated hexaenoic acid [50, 58]. Fish have dermis with
structures comparable to that of humans, but they porcine collagen embedded in a nylon mesh cov-
also possess rich supplies of type I collagen and ered by a semipermeable outer layer of silicon,
noninfectious microbiota that aid in the wound which is indicated for use in the treatment of
healing process [50, 59]. Through epidermal chronic wounds [5, 19, 21, 66] (Fig. 23.1b,
growth factors and fibroblast growth factors, the Table 23.1). The layer of nylon mesh provides a
native collagen in the fish skin has the ability to scaffold for fibrovascular growth into the tissue
promote collagen synthesis in the host’s wound product and wound, and the outer silicone-based
bed and stimulates fibroblast and keratinocyte layer serves as a microbial barrier and retains
migration, proliferation, and differentiation [50, moisture. While Biobrane® is able to retain mois-
60]. Fish collagen is also able to be degraded and ture, it is also sufficiently porous to allow for
absorbed into the wound because of its high level exudate drainage and antibiotic penetration to the
of biocompatibility with human tissues [50, 60]. wound when applied on top of the dressing [21].
Kerecis® adheres well to the wound bed, which Biobrane’s structure and collagen binding work
minimizes the number of applications necessary together to recruit fibrin and fibroblasts from the
for wound healing [50]. Fish products also do not wound bed, helping the product securely adhere
risk prion transmission like bovine and porcine to the wound [28]. As the wound heals and the
derived skin substitutes. Kerecis® can easily be native skin regenerates and grows inward, the
stored at ambient temperature for 3 years [50, 61, Biobrane® naturally separates away from the
62]. It also does not have the same restriction wound and can be trimmed away [21]. This pro-
against placement on potentially infected wounds cess makes dressing changes painless [28]. The
that many other skin substitutes possess, given its trimming process also decreases risk of infection
indication for use in trauma wounds. However, as it prevents fluid accumulation, providing an
Kerecis® cannot be used in patients with fish sen- outlet for drainage from the wound [28]. Because
sitivities or allergies. Biobrane® is not composed of human-derived
allogeneic material, it does not pose the same risk
of disease transmission as allogenic products.
Science and Practicality However, Biobrane® does have drawbacks of its
of Biosynthetic Dressings own, including its immunogenicity and ability to
cause scaring due to the synthetic materials [19].
Biosynthetic dressings are acellular tissue prod- Because of the antigenic potential of Biobrane®,
ucts engineered to contain both biologic and non- it is not indicated for use as a permanent skin sub-
biologic non-degradable materials such as silicone, stitute and must be removed [19]. Its use is also
nylon, and polyglactin [19, 29, 63–65]. The dress- limited to wounds without evidence of infection
ings act as scaffolds to promote cell growth and or eschar and wounds with an intact basement
generate neodermis [29]. A major advantage of membrane and dermis because its architecture
biosynthetic dressings is that their compositions does not closely approximate that of normal skin
can be controlled and growth factors and cytokines and, therefore, cannot replace it effectively on its
can be added as needed. The biosynthetic outer own [19].
layer acts as the epidermis, preventing loss of Transcyte® (Shire Regenerative Medicine, San
moisture and wound contamination. However, Diego, CA) is a biosynthetic dressing composed
they are not able to mimic the architecture of the of allogeneic fibroblasts from neonatal foreskin
skin and do not have a basement membrane. that have been seeded onto a bioabsorbable nylon
Another disadvantage of these biosynthetic dress- mesh scaffold covered with silicone, which is
ings is their ability to cause a robust inflammatory indicated for diabetic foot ulcers lasting more
response in the tissue, causing significant scarring than 6 weeks [21] (Table 23.1). The fibroblasts
or even immune rejection of the product. are cultured ex vivo for 4–6 weeks on the scaf-
Biobrane® (Smith and Nephew, St. Petersburg, fold, and when used on a diabetic wound, secrete
FL) is a bilaminar dressing with an inner layer of ECM components and local growth factors [21,
67]. Transcyte® has a shelf-life of 1.5 years and is Very similar to Integra® DRT, Integra® Bilayer
easier to remove than allografts, which is an Matrix (Integra Lifesciences, Plainsboro, NJ) is
important feature of a biosynthetic dressing given composed of a cross-linked bovine collagen-
that they must be removed and cannot be used as glycosaminoglycan biodegradable matrix and an
permanent skin substitutes [21]. outer layer of semipermeable polysiloxane
Integra® Dermal Regeneration Template (Figs. 23.1, 23.2, Table 23.1). The silicone helps
(Integra Lifesciences, Plainsboro, NJ) is a to prevent water loss from the wound and
bilayered matrix composed of bovine collagen improves durability of the tissue product [71].
cross-linked with chondroitin-6-sulfate glycos- The biodegradable matrix serves as a scaffold for
aminoglycans with a semipermeable silicone neovascularization and cell ingrowth [71]. It indi-
outer layer that acts as the epidermis cated for partial- and full-thickness diabetic
(Fig. 23.1b). Integra® DRT is FDA approved for ulcers and wounds and is immediately available
use in the healing of diabetic wounds [21] for wound coverage [29, 71]. Integra® Bilayer
(Fig. 23.1b, Table 23.1). The porous matrix Matrix has also demonstrated better cosmesis
serves as a scaffold for autologous cell and tissue elasticity than STSG alone [29]. Other
ingrowth, effectively regenerating a functional advantages of Integra include a reduction in
dermal layer [69]. Neovascularization of the wound site morbidity, including reduced infec-
dermal component of the membrane is expected tion when compared to SOC alone [29]. This bio-
to be completed at 3 weeks, and the top layer of synthetic dermal substitute can be used in
silicone can be removed at 2–4 weeks in prepa- conjunction with negative-pressure wound ther-
ration for skin grafting, which happens roughly apy to decrease time to graft placement and
3 weeks after the initial procedure in which increase take rates of skin grafts [29, 72]. While
Integra® DRT was placed [21, 68, 69]. Integra® there are a multitude of advantages, Integra® also
DRT facilitates the migration of macrophages has a steep learning curve for use, and there is a
and fibroblasts into the wound and promotes significant risk of seroma or hematoma formation
the formation of granulation tissue, increasing with Integra® (likely due to its use in acute
the survival potential of both the wound and wounds) [29]. However, surgeons can mitigate
any graft that will be placed [21, 70]. Once the this risk by meshing the skin substitute prior to
neodermis has formed in the healing wound, application to allow for improved wound drain-
Integra’s silicone layer can be removed, allow- age [29].
ing for split-thickness skin graft placement on Dermagraft® (Shire Regenerative Medicine,
the neodermis [21, 70]. While Integra® can be Inc., San Diego, CA) is another example of a bio-
used as an interim wound coverage until an synthetic dressing, and it is composed of cryopre-
autograft is ready, it can also act as an absorb- served neonatal foreskin fibroblasts cultured on a
able implant or a permanent skin substitute in bioabsorbable polyglactin polymer mesh scaffold
full-thickness or deep partial thickness wounds [21, 29, 70] (Table 23.1). The allogenic fibro-
[21]. However, for Integra® DRT to be used in blasts then multiply and secrete growth factors
wound healing, complete wound excision is such as collagen, tenascin, vitronectin, glycos-
required as it will not take on nonviable tissue aminoglycans, and other extracellular matrix
and should not be applied on an infected wound proteins, encouraging granulation tissue produc-
[21, 69]. Because the tissue product is avascu- tion and migration of the patient’s own cells into
lar, there is a high risk of infection and graft the wound bed [29, 73, 74]. The donor cells of the
loss [21]. Integra® DRT should not be used in dressing are gradually replaced with fibrovascu-
patients with hypersensitivities to bovine prod- lar tissue from the host over 3– 4 weeks [74].
ucts or chondroitin [20]. Integra® DRT should Dermagraft® is indicated for full-thickness dia-
ideally be placed on the same day as an exci- betic lower-extremity wounds that extend through
sion or debridement because any delays can the dermis but do not reach tendon, muscle, our
decrease the tissue products’ ability to take. bone and have been present for at least 6 weeks
a b
c d
e f
Fig. 23.2 Clinical images calcaneal foot view. (a) and (c) Integra® graft matrix was applied to accelerate
54-year-old NIDDM with persistent chronic non-healing healing over bone/tendon and increase heel pad thickness.
calcaneal wound for 3 years with normal pre-op vascular (d) Negative-pressure wound therapy was utilized and (e)
surgery evaluation and an HgA1c of 6.3. (b) A 2 cm full-thickness skin graft was applied after 3 weeks. (f)
wound/scar excision was performed to the calcaneal bone Wound at 2 month follow-up visit
[21, 39]. The growth factors and cytokines are Hyalograft 3D® (Fidia Advanced Biopolymers,
essential for building granulation tissue, stimu- Abano Terme, Italy) is an example of a cultured
lating matrix production, and angiogenesis. The skin graft that its derived from autologous fibro-
polyglactin mesh has several advantages over blast cells that have been seeded on a 3D hyal-
collagen-based materials including improved uronic acid matrix [78, 79] (Table 23.1).
strength and its ability to be broken down in vivo Similarly, Hyalomatrix® is composed of autolo-
by hydrolysis [73]. The semi-transparency of gous fibroblasts on a hyaluronic acid base, but it
Dermagraft® also allows for continuous wound covered by a silicon layer that helps to retain
surveillance during dressing changes [21]. moisture, acting as a temporary epidermis [78].
Despite the xenogeneic and synthetic compo- Hyaluronic acid is one of the most common poly-
nents of Dermagraft®, there has been very low saccharides found in the native dermal extracel-
incidence of rejection and infection [21, 75]. lular matrix and acts to attract and proliferate
However, Dermagraft® is contraindicated in fibroblasts and keratinocytes to the wound. These
infected wounds, patients with bovine allergies, products, because they provide elements neces-
infected ulcer, ulcers with sinus tracts, and in sary for the formation of an ECM, are commonly
wounds that have not yet been debrided [21]. used prior to split-thickness skin grafts [80]. In
Dermagraft® has a shelf-life of 6 months and is clinical practice, Hyalograft 3D® is commonly
contraindicated in patients with bovine allergies, used in combination with Laserskin® for the
infected ulcers, and ulcers with sinus tracts [21]. treatment of diabetic foot ulcers [80]. However,
Moreover, Dermagraft® is only used as a tempo- the take rate of the product is unpredictable [19].
rary coverage [21]. MySkin® (CellTrain Ltd., UK) is a cell sus-
pension of sub-confluent autologous keratino-
cytes delivered on a polymer silicone scaffolds or
cience and Practicality of Cultured
S as a spray (Fig. 23.1c, Table 23.1). The silicone
Skin Grafts substrate improves the grafts’ ability to withstand
the tearing and sheering forces that occur when
Cultured skin grafts are allogenic or autologous manipulating cultured skin grafts. Additionally,
human keratinocytes or fibroblasts that have been the polymer substrate allows it to cover a larger
expanded in culture onto a collagen matrix to wound than sub-confluent cells alone would have
produce a sheet suitable for grafting [76, 77]. The the potential to [81]. However, as of 2012,
basal keratinocytes in cultured skin grafts are MySkin® was sold as a spray due to physician
able to augment wound epithelialization [19]. preference, simplifying the application process.
However, there are significant disadvantages of In addition to ease of application, the use of a
using cultured skin grafts. They are fragile, and, sprayed cell suspension has the added benefit of
therefore, difficult to manipulate during the avoiding dispase, which is an enzyme that is nec-
application process and are challenging to handle essary to release the epidermal sheets from the
while doing dressing changes [19]. Due to the culture but also likely removes surface proteins
fragility of the sheet, the take rate of cultured skin on keratinocytes, decreasing the adhesive capac-
grafts can be difficult to predict and strict surgical ity of the cells [28]. As opposed to sheets of kera-
immobilization is required to maximize adhe- tinocytes, the cell suspensions also contain
sion. Additionally, cultured skin grafts cannot be melanocytes and papillary fibroblasts in variable
applied to full-thickness wounds with exposed fat ratios and quantities [28]. Use of a delivery sub-
or fascia due to their inability to adhere to the strate or spray and sub-confluent cells decreases
wound without the anchoring fibrils and other the cell culture time necessary prior to applica-
dermal regenerative components located at the tion [28]. The time needed to culture a sufficient
base of pilosebaceous layer of the dermis [19]. sub-confluent quantity of cells for use with dia-
Another limitation of cultured skin grafts is their betic foot ulcers is usually 15 days but can range
infection potential [19]. between 11 and 19 days [28]. However, because
MySkin is cultured from autologous cells, prepa- Table 23.1). Epicel® is frequently used as an
ration and culture time will always be required adjuvant therapy with an autologous split-
and will delay treatment of the wound, which is a thickness skin graft (STSG), but it can also be
significant disadvantage of MySkin and other used when STSGs cannot be obtained due to the
autologous-based products. extent of an injury or wound (more likely in the
Laserskin® (Fidia Advanced Biopolymers, setting of a burn, not a diabetic foot ulcer) [21].
Abano Terme, Italy) is composed of autologous Like other autologous grafts, the risk of rejection
sub-confluent keratinocytes and fibroblasts, tis- is mitigated. Epicel® can also permanently pro-
sue acquired from skin biopsy, that have then vide coverage of extensive wounds. However,
been cultured on a laser-microperforated biode- Epicel® requires a premanufacture epidermal
gradable matrix of benzyl esterified hyaluronic biopsy and about 3 weeks to culture a sufficient
acid, and it is indicated for diabetic foot ulcers number of cells [21]. After 3 weeks of culturing,
[21, 29, 82, 83] (Table 23.1). The Laserskin® the graft has a shelf-life of only 1 day, complicat-
matrix allows for cell proliferation and migration ing the application process [21, 86]. The take rate
into the wound, and the micro-perforations of Epicel can vary, and the long-term results of
allows for drainage of wound exudate [21]. Like the product have shown variable efficacy [21].
other autologous products, Laserskin has the The skin substitute also carries the risks of blis-
advantage of negating any potential for rejection tering, contractures, and infection [21].
but also necessitates a premanufacture skin Kaloderm® (Tegoscience, Seoul, Korea) is a
biopsy and culture time [21]. Because the cells cultured skin substitute composed of allogenic
are not confluent on the matrix, the time needed keratinocytes from the foreskin of a circumcised
to culture is decreased in comparison to confluent infant [87] (Table 23.1). Kaloderm® consists of
cultured skin substitutes. The matrix of Laserskin an ECM, cytokine- and growth factor-secreting
lends to easier manipulation and handling during keratinocytes, and collagenases to encourage
both initial application and dressing changes, and wound healing and decrease scar formation [87].
the transparency of the dressing allows for wound It is indicated for non-infected diabetic foot
visualization and monitoring during dressing ulcers, and it can be stored for up to 24 months
changes. Because the autologous cells are cul- at -60 °C or 3 months at -15 °C [87]. After thaw-
tured on the scaffold that is then used as a part of ing for 10 min, Kaloderm can be directly applied
the skin substitute, the use of the enzyme dispase to the wound, providing a skin substitute that can
is not required to remove keratinocyte sheets be used acutely without waiting for cells to prop-
from culture flasks, mitigating disruption to kera- agate or culture [87].
tinocyte surface proteins and adhesive potential
of the cells [21]. Due to the preserved adhesive
potential of the cells, Laserskin has good graft I mpact of Tissue Products
take and does not demonstrate the fragility that for Diabetic Foot Wound Healing
other cultured epithelial autografts possess. It has
also demonstrated low rates of infection [21]. Neuropathic foot ulcers are a significant compli-
Laserskin® is limited by its availability in the cation of diabetes that can greatly increase health
USA, as it is currently only available for use in care costs due to wound care and the potential for
Europe [21]. Moreover, Laserskin® is also lim- hospitalizations and amputations.
ited by its 2-day shelf-life [21].
Epicel® (Vericel Co., Cambridge, MA), indi-
cated for use in diabetic foot ulcers, is a sheet of Impact on Wound Healing
cultured skin substitute made from autologous
keratinocytes with murine fibroblasts obtained Tissue products do provide an advantage over
from epidermal skin biopsy that is then placed on SOC alone when measuring complete wound
petroleum gauze [21, 84, 85] (Fig. 23.1c, closure at 12 weeks [3, 88]. The mean number of
applications generally range from 1.2 to 10.1 alone, but when compared against each other, the
[89]. Healing rates with tissue products at studies do not definitely demonstrate superiority
12 weeks range from 24 to 100%, while healing of one product over the other [88, 92, 93]. In
rates with SOC alone ranged between 0 and 69% order to definitively determine a gold standard of
[88]. Diabetic ulcers treated with tissue products skin substitutes, more prospective comparative
were 1.67 times more likely to demonstrate com- trials are required to allow providers to make
plete closure than ulcers treated with SOC alone evidence-based decisions on which skin substi-
[88, 90]. When the proportion of healed ulcers at tute to use in their practice [88].
6 weeks is investigated, tissue products still dem- Overall, tissue products show a modest
onstrate an advantage over SOC alone. The risk decrease in healing time of diabetic ulcers when
ratio for complete ulcer closure at 6 weeks is compared to standard care alone, and dermal sub-
2.81, favoring tissue products [88]. stitutes demonstrate the most significant effects
While all tissue products work to target vari- over SOC. However, given the varying evidence
ous steps in the wound healing process, and, for these tissue products, at this time, it is diffi-
overall, they show an advantage over SOC for cult to draw a definitive conclusion about which
promoting complete wound closure, not all cate- product to use, and therefore, tissue product
gories or brands of tissue products demonstrate choice remains individual physician preference
an improvement in diabetic ulcer healing [88]. dependent.
Among the tissue products, dermal substitutes Determining and comparing time to complete
and biosynthetic dressings were the two catego- healing has remained a challenge in the field due
ries that demonstrated a statistically significant to heterogeneity of data collection and reporting
wound healing advantage over SOC [88, 89, 91]. [88]. However, the majority of studies do favor
The individual dermal substitutes that demon- use of skin substitutes for wound healing [88].
strated significantly improved healing over SOC
at 12 weeks were Dermagraft and Apligraf/
Graftskin, but no difference was observed for Impact on Limb Salvage
Healaderm and Orcel [88]. The biosynthetic
dressings with significant advantages over SOC There is a small absolute risk reduction for ampu-
were Amnioband, Amniopatch Pliable, Epicord, tation when comparing SOC and tissue products
and Epifix, while Grafix, Graftjacket, Promogram, [90]. In patients with lower-extremity diabetic
and Oasis showed no advantage over SOC [88]. ulcers, there was a significant reduction in the
In contrast to dermal substitutes and biosynthetic number of minor amputations in the tissue prod-
dressings, cultured skin grafts (as an overall tis- uct group, with a 3.9% rate of amputation in the
sue product category) showed no significant dif- advanced treatment group compared to the 4.3%
ference over SOC, as was the case with the rate of amputation in the standard of care group
individual cultured skin grafts that were studied [3]. The difference in major amputations between
(Hyalograft, Kaloderm, and MySkin) [88, 89]. the two groups was more significant with a 50%
Of the individual products studied when examin- decrease in major amputations in the advanced
ing closure of ulcers at 6 weeks, Amnioband, treatment tissue product group when compared to
Allopatch Pliable, and Integra showed signifi- SOC alone with amputation rates of 1.6% and
cant advantages over SOC alone, but Amnioexcel 3.2%, respectively [90]. Despite some evidence
did not [88]. Other individual tissue products of minimally decreasing rates of amputation, the
may also show a significant advantage in diabetic data is insufficient to draw definitive conclusions
wound healing over SOC, but there are currently about the efficacy of tissue products in prevent-
insufficient studies for some individual brands to ing amputations [3].
draw a significant conclusion. In addition to modest decreases in amputation
Both dermal substitutes and biosynthetic rates, other practical aspects of tissue product
dressings demonstrated improvement over SOC implementation in diabetic wound healing
include lower readmission rates (6.4% vs. 4.0%) free weeks over SOC alone [94]. Additionally,
and fewer ED visits (23.1% vs. 18.3%) [3]. There tissue products provided an incremental cost-
is also no significant increase in length of hospi-effectiveness ratio of $48,242 per QALY when
tal stay for patients treated with tissue products compared with SOC alone [94].
over the length of hospital stay for patients treated All tissue products examined demonstrate
with SOC alone [3]. decreased cost-effectiveness in the hospital out-
patient setting when compared to treatment in a
physician’s office due to higher application
Financial Comparison costs [89] (Table 23.2). A single diabetic foot
wound, when treated with tissue products in the
While there are an abundance of studies that hospital outpatient setting cost an average of
focus on the wound healing abilities of various $2001–$14,507, whereas the average cost of
tissue products, only recently there has been an treatment in an office ranged between $1207
increase in studies researching the cost- and $8791 [89]. The allogenic dermal matrices
effectiveness of these tissue products to deter- GraftJacket, Integra DRT, and Dermagraft are
mine if there is an economic incentive for our capable of healing more ulcers for $1000 per
healthcare system and patients. While tissue patient than the other products studied by
product treatments may cost an average of an Samsell et al., demonstrating the highest level
additional $1058 over SOC alone, this increase is of cost-efficiency of the skin substitutes investi-
offset by their ultimate long-term impact on gated [89].
wound healing through decreased minor and In order to evaluate whether tissue products
major lower-extremity amputations, increased are an economically sustainable option for dia-
ulcer-free weeks, and fewer ED visits and hospi- betic ulcers, the cost of the skin substitutes, as
tal readmissions [90, 94]. Amputations them- well as the long-term impact of wound closure,
selves can cost up to 10–40x the amount that limb salvage, and patient satisfaction with limb
would be required to treat diabetic foot wounds function should be taken into consideration. In
before they necessitate an amputation [94]. addition, the cost that patients will need to pay
Tissue products can also provide a modest impact out-of-pocket should also be taken into consider-
on quality adjusted life years (QALYs), provid- ation when determining treatment method and
ing an increase of 0.022 QALYs and 6.69 ulcer- tissue product selection (Table 23.3).
Table 23.2 Parameters utilized to determine incurred costs of various tissue products to heal a single DFU
Tissue Mean number of Product cost per application Jan 2018 CMS ASP Cost of product per
product applications on 5cm2 wound cost/cm2 treated wound
ApliGraf 2.5 $1,359.34 $30.89 $3,398.34
DermACELL 1.2 $1,060.96 $66.31 $1,273.15
Dermagraft 6.3 $1,241.63 $33.11 $7,822.24
EpiFix 3.5 $990.08 $165.01 $3,465.27
Grafix 8.7 $805.70 $134.28 $7,009.62
GraftJacket 1.3 $774.74 $96.84 $1,007.17
Integra DRT 2.0 $901.01 $128.72 $1,802.02
Oasis ultra 10.1 $115.58 $11.01 $1,167.40
CMS centers for medicare and medicaid services, ASP average selling price
Table 23.3 Costs of treating DFUs in hospital outpatient departments and physicians’ offices and estimated costs to
patients for various biologic skin substitutes
Cost of treating one Estimated patient Bundled Cost of treating Estimated
Tissue DFU in physician’s cost in physician’s HOPD one DFU in patient cost in
product office office payment HOPD HOPD
ApliGraf $3,781.74 $756 $3,921.08 $4,168.58 $834
DermACELL $1,457.18 $291 $1,882.12 $2,000.92 $400
Dermagraft $8,791.41 $1,758 $9,022.90 $9,648.54 $1,930
EpiFix $4,002.03 $800 $5,489.51 $5,836.01 $1,167
Grafix $8,343.85 $1,669 $13,645.34 $14,506.64 $2,901
GraftJacket $1,206.54 $241 $2,038.96 $2,167.66 $434
Integra DRT $2,108.74 $422 $3,136.86 $3,334.86 $667
Oasis Ultra $2,716.33 $543 $4930.82 $5,930.72 $1,186
HOPD hospital outpatient department
Conclusion healing endpoints and study timelines in concert

with new tissue products rapidly being released on
The shear magnitude of tissue products on the the market also complicate study comparison.
market, with new skin substitutes continually Twelve weeks was traditionally the endpoint used
being developed, complicates the synthesis and in studying diabetic wound healing, whereas now
analysis of these products. The information in studies have started to use 16 weeks, which may
this chapter only scratches the surface of tissue be a more appropriate endpoint for wound closure.
products available for diabetic wound healing, Additionally, more studies are needed to d etermine
attempting to highlight the tissue products that the long-term impact of tissue products on these
are most commonly used. Some tissue products chronic wounds.
were able to show an improvement in wound clo- While this chapter works to investigate the
sure over SOC, while others made no significant impact of skin substitutes on healing diabetic foot
impact on healing time. However, tissue products ulcers, we are not able to draw definitive conclu-
overall did show a very modest benefit in limb sions on the long-term effects of these products or
salvage, decreasing rates of both minor and major post-closure adverse events. Future studies should
lower-extremity amputations. continue to focus on the potential of tissue products
Not only do allogenic dermal matrices demon- in diabetic wound closure to better understand the
strate a greater ability to heal diabetic ulcers than long-term implications of using these products.
their other tissue product counterparts, but they There is also a relative paucity of research on the
also exhibit the greatest cost-efficiency of the tis- impact of tissue products on amputation rates and
sue products examined in this study [3, 89]. limb salvage, an important endpoint to measure
However, the absence of standardized metrics in long-term impacts of tissue product efficacy.
diabetic foot wound literature poses a considerable As we move toward further evidence-based
problem with drawing conclusions and comparing medicine and efficiency, it is important that we
study results. There is no standardization of the choose a product that will continue to evolve and
categorization of skin substitutes, with various be mindful of the cost as we move to bundle pay-
studies putting the same tissue product in different ment and cost-efficiency.
categories, confusing the results and diminishing
comparability of studies. Inconsistency in reported Acknowledgments No acknowledgments are made.
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Limb Wounds of Dermatologic
Disease: Dermatopathology,
24
Biopsy, and Medical Management
Helena B. Pasieka, Nicholas Logemann, Felix Yang,

and Alexandra Gosh
Wound Differential • Autoimmune and inflammatory diseases

• Opportunistic infection
Please note: This chapter will work to provide • Allergic contact dermatitis
examples of patients with different skin tones at • Cutaneous malignancy
every opportunity. • Calciphylaxis and other vascular diseases
The differential diagnosis for dermatologic
wounds are:
Autoimmune and Inflammatory
H. B. Pasieka (*) Diseases
Department of Dermatology, Georgetown University
School of Medicine, Washington, DC, USA This section will cover sterile/noninfectious eti-
Department of Dermatology, Walter Reed National ologies of atypical wounds that are the result of
Military Medical Center, Bethesda, MD, USA autoimmune diseases (e.g. discoid lupus erythe-
Department of Dermatology, Uniformed Services matosus) or aberrant inflammatory reactions (e.g.
University, Bethesda, MD, USA pyoderma gangrenosum). An awareness of these
Department of Medicine, Uniformed Services diagnoses is critical as they can be a source of
University, Bethesda, MD, USA diagnostic confusion if the diagnosis of an auto-
immune process is not considered and “missed”
N. Logemann and the patient then is not appropriately treated
Department of Dermatology, Walter Reed National
for an autoimmune process. Treatment of an
Military Medical Center, Bethesda, MD, USA
autoimmune process can differ greatly from other
Department of Dermatology, Uniformed Services
causes of chronic wounds and likely will require
University, Bethesda, MD, USA
e-mail: [email protected] the involvement of a specialist from dermatology
or rheumatology to adequately manage these
F. Yang
School of Medicine, Uniformed Services University, diseases.
Bethesda, MD, USA An important note on tissue submission: The
e-mail: [email protected] evaluation and workup of several autoimmune
A. Gosh diagnoses will require an investigation to deter-
Department of Dermatology, Georgetown University mine if there are fixed immune deposits in the
School of Medicine, Washington, DC, USA
skin biopsy. The study to evaluate for this is
Department of Dermatology, Uniformed Services called direct immunofluorescence (DIF) and it
University, Bethesda, MD, USA
requires that the sample be sent in a fixative

330 H. B. Pasieka et al.
called Michel’s transport medium (Zeus transport derma gangrenosum. Pathergy is the phenome-
media, a commercial product, is similar). non of a wound enlarging after manipulation and
Michel’s/Zeus medium is designed to facilitate is a hallmark feature of certain autoimmune skin
the transport of fresh tissue biopsies obtained in diseases.
the office to the lab where the immunohisto- Pyoderma gangrenosum presents as an
chemical analysis will be performed. expansile lesion that results from neutrophil
Clinical pearl: Ensure that you have your derangement. On examination, pyoderma gan-
transport medium at the ready prior to obtaining grenosum manifests as a painful ulcer with a wet
the sample; a commonly seen error is to place the central cribriform appearance in the central por-
peripheral sample into formalin and then move it tion of the ulcer, circumscribed by a violaceous/
into the Michel’s/Zeus fixative. As formalin gun-metal gray border (see Fig. 24.2). This viola-
instantaneously destroys the diagnostic immune ceous border is of clinical importance because it
deposits, even a transient exposure (such as a is an indication of actively expanding pyoderma
brief dip in error) will render the sample useless. gangrenosum.
Recommended biopsy technique and transport Pyoderma gangrenosum that has ceased to
are main takeaway points of this chapter and will expand will present with retraction of the borders
be summarized at the end. and once healed may take on an atrophic appear-
ance with thin skin and marked pigmentary alter-
Pyoderma Gangrenosum ations (see Fig. 24.3). In instances where
Clinical scenario: Patients often recollect that the pyoderma gangrenosum is suspected it is of para-
wound began as a tender and inflamed pustule. mount importance for the wound care provider to
Often, they attribute this early pustule to a spider recognize that there is the potential for reactiva-
bite (see Fig. 24.1a). In the event that the patient tion of pyoderma gangrenosum (i.e. “pathergy”)
attempts to “pop” the pustule, they find that to with additional trauma (e.g. debridement).
find that the resultant wound starts to expand (see Pyoderma gangrenosum can occur anywhere
Fig. 24.1b). on the body, but is common on the lower extremi-
A spider bite is rarely the cause. This case is ties. When pyoderma gangrenosum is suspected,
an example of pathergy in the setting of pyo- a thorough clinical history should be obtained.
a b
Fig. 24.1 (a) Initial presentation of a pustule with a vio- after the patient attempted to “pop” the pustule. This rapid
laceous border and central cribriform appearance on a expansion and intense inflammation after minor trauma or
patient with deeply pigmented skin, (b) 2–4 weeks later, manipulation is a classic example of “pathergy”
24 Limb Wounds of Dermatologic Disease: Dermatopathology, Biopsy, and Medical Management 331
Fig. 24.3 Typical appearance of a healed pyoderma gan-

Fig. 24.2 Pyoderma gangrenosum in a patient with a
grenosum wound with atrophy, dyspigmentation, and a
light skin tone. Note the presence of a violaceous border
“wrinkled tissue paper” appearance
on the proximal side of the wound (arrow), indicative of
an actively expanding wound. The characteristic cribri-
form (“sieve-like”) appearance of the base of the ulcer is
apparent
a b c
Fig. 24.4 (a) Typical progression of PG from tiny scar (July 29th) in a patient with underlying multiple
inflammatory pustule (May 24th), to (b) cribriform ulcer myeloma
of several centimeters (July 1st), to (c) atrophic healed
Up to 50% of pyoderma gangrenosum is associ- driving diagnosis. In such cases, the PG is

ated with an underlying systemic disease and unlikely to respond to treatment until the under-
may be associated with inflammatory bowel dis- lying etiology is also treated.
ease, rheumatoid arthritis, or hematologic disor- For example, the patient below (see
ders [1]. For this reason, a review of systems Fig. 24.4a–c) was found to have underlying
should be conducted to identify any clues to these multiple myeloma and an elevated IgA level,
occult diagnoses. In terms of demographics, the who developed numerous lesions of pyoderma
vast majority of pyoderma gangrenosum presents gangrenosum which persisted despite systemic
in adults. steroid therapy and intravenous immunoglobu-
Clinical pearl: When a patient has PG, con- lin. It was not until he began treatment for his
duct a focused and detailed review of systems multiple myeloma, and a resultant drop in his
and any diagnostic studies (such as colonoscopy IgA level that his wounds began to respond to
or laboratory studies) to identify an underlying, treatment.
Evaluation of suspected pyoderma gangreno- 3. History of inflammatory bowel disease or

sum involves histopathology and deep tissue cul- inflammatory arthritis
ture. A wedge excision of the ulcer edge is of the 4. History of papule, pustule, or vesicle ulcerat-
highest yield and should be performed to obtain a ing within 4 days of appearance
sample for pathologic evaluation, ideally by an 5. Peripheral erythema, undermining border, and
experienced dermatopathologist. As pyoderma tenderness at ulceration site
gangrenosum is the result of sterile neutrophilic 6. Multiple ulcerations with at least 1 ulcer on an
derangement, identification of a neutrophilic anterior lower leg
infiltrate is essential for the diagnosis of pyo- 7. Cribriform or “wrinkled paper” scar(s) at
derma gangrenosum. The Maverakis diagnostic healed ulcer sites
criteria can be used to aid in the diagnosis of pyo- 8. Decreased ulcer size within 1 month of initiat-
derma gangrenosum and they are listed below: ing immunosuppressive medication(s)
Maverakis Diagnostic Criteria [2] Expert tip: Consider pyoderma gangrenosum

Diagnosis of pyoderma gangrenosum requires 1 in patients with hidradenitis suppurativa (HS)/
major criterion: biopsy-proven neutrophilic infil- acne inversa. Patients with a history of hidradeni-
trate of ulcer edge. Additionally, 8 additional tis suppurativa may have a predisposition to
minor criteria have been established, with at least develop pyoderma gangrenosum [4]. HS is
4 out of 8 minor criteria providing 86% sensitiv- another neutrophilic disorder of aberrant immune
ity and 90% specificity. response. Classically, HS presents as recurrent
Major criterion: Biopsy of ulcer edge demon- abscesses and sinus tracts in the intertriginous
strates neutrophilic infiltrate (see Fig. 24.5). regions of the body (e.g. groin or axillae) (see
Minor criteria: Fig. 24.6a). Rarely, a patient will demonstrate
HS/PG overlap and may demonstrate both classic
1. Exclusion of infection HS lesions in the typical areas and ulceration on
2. Pathergy the lower extremity with tracts and fistulae (such
as typically seen in HS) (see Fig. 24.6b).
utoimmune Bullous Diseases

A
of the Skin
As the skin is an organ of immunity, it is a com-
mon target in autoimmune diseases.
Autoimmune blistering diseases are rare skin
conditions in which the body’s own immune sys-
tem actively targets adhesion proteins in the epi-
dermis resulting in bullae formation. Several
autoimmune disorders (e.g. bullous pemphigoid
or pemphigus vulgaris) and other connective tis-
sue diseases such as cutaneous lupus erythemato-
sus may manifest as blisters on the skin. It is
helpful to consider that most autoimmune blister-
ing diseases tend to be symmetric and bilateral.
Fig. 24.5 This image shows the classic histopathology While initially sterile, with friction, pressure, or
of pyoderma gangrenosum with sheet-like aggregates of superinfection, these bullae may persist leading
neutrophils nearly consuming the entirety of the dermis. to chronic wounds.
The intensity of inflammation ultimately can lead to
ulceration of the overlying epidermis. With this histo-
One of the most important steps in excluding
pathologic picture, infection must always be carefully an autoimmune blistering disease is by perform-
excluded with the use of special stains and appropriate ing a full skin and examination of mucous mem-
tissue cultures [3]. branes including ocular and oral mucosa. If
a b
Fig. 24.6 (a) Typical presentation of hidradenitis suppu- arrows) on the leg surrounded by erythema. This is a rare
rativa in the axilla with sinus tracts and scarring, (b) 6 cm variant of hidradenitis suppurativa/pyoderma gangreno-
cribriform lesion centrally with fistulous tracts (blue sum overlap
multiple areas of blister formation and/or ero- If bullous pemphigoid is suspected, skin
sion/ulceration are noted, this should raise con- biopsy with evaluation by H&E (see Fig. 24.7c)
cern for an underlying autoimmune blistering and DIF should be considered, with special care
disease. Further workup (discussed later) includes given to the appropriate transport media used for
a skin biopsy for both hematoxylin and eosin each specimen. For detailed recommendations,
(H&E) evaluation and a direct immunofluores- please refer to the Workup section at the end of
cence (DIF) study. this chapter (see Table 24.3).
Bullous pemphigoid (BP) traditionally pres- Clinical pearl: A note on trimming: A wound
ents as tense and firm bullae with mild to severe care provider may be tempted to trim bullae, but
pruritus in patients over age 60 (see Fig. 24.7a, this increases the risk for infection (see Fig. 24.7d).
b). Bullous pemphigoid may present in a limited Bullae fluid is sterile. The epidermal blister roof,
fashion below the knees. Of the several types of if intact, can serve as a barrier to infection. If a
autoimmune blistering diseases that have been blister is voluminous and uncomfortable for the
described, it is one of the most common. patient, the blister should be punctured with a
Circulating immunoglobulins recognize hemides- sterile needle and the contents drained, with the
mosomes (a protein that connects keratinocytes now deflated blister roof remaining over the top.
to one another) as foreign, destroying them, The small fenestration can be dressed with anti-
which results in dermal–epidermal disadhesion microbial ointment and dressed with a bandage.
and blister formation that eventually could result
in formation of shallow friction ulcers and non- iscoid Lupus Erythematosus
D
healing wounds [6]. The blisters of BP are dis- While many forms of cutaneous lupus exist, dis-
tinctive, very tense, and circular, with a shiny coid lupus erythematosus (DLE) is probably the
surface, reminiscent of the clear plastic “bubble most common lupus type to cause an ulcer. DLE
wrap” included in fragile packages. tends to manifest as annular erythematous lesions
a b
c d
Fig. 24.7 (a) Bullous pemphigoid on the digits of the the lateral malleolus suggests previously healed bullae in
lower extremities. You can see here how fresh bullae this area, (c) histopathology of bullous pemphigoid with
reflect light. On palpation these bullae are tense and firm subepidermal blister formation (arrow). As the epidermis
to palpation. Note the hyperpigmentation of the proximal loses its connection with the underlying dermis, the epi-
nail fold of the second digit, suggestive of a previous bulla dermis will slough off, resulting in ulceration [5], (d)
associated with bullous pemphigoid, (b) resolving bullae appearance of blisters after the blister roof has been
are less reflective and are not as tense and firm as active removed by trimming, revealing round, shallow ulcer-
lesions. Note that the circular hyperpigmentation around ations to the depth of the dermis beneath
that resolve with hypopigmented scarring. These associated with systemic disease. If DLE is sus-
lesions will rarely present on lower extremities if pected, a skin biopsy for H&E and DIF evalua-
the more common facial manifestations are not tion should be performed.
present.
While discoid lupus erythematosus tends to
be a disease limited to the skin [7], it can on Opportunistic Infections
occasion be associated with underlying systemic
lupus erythematosus, a well-known multisystem Opportunistic infection may also be considered
disease. Delphi criteria for the disease as deter- in the evaluation of wounds. Breakdown in the
mined by the American College of Rheumatology skin barrier may also yield easier entry to inva-
in 2019 include arthralgias, fever, leukopenia, sive organisms, such as atypical mycobacterial or
thrombocytopenia, psychosis, and proteinuria fungal species. This section will review common
[8]. As is the case with other autoimmune disor- microorganisms and associated opportunistic
ders, a thorough history will guide diagnosis infections along with associated patient history,
toward or away from DLE, in particular DLE risk factors, and presentation.
a b
Fig. 24.8 (a) This figure demonstrates the effect of over- fect the limb before attempting wound closure, (b) after 2
the-counter Domeboro compresses and 40% urea from days of twice daily application of urea and compresses
initial presentation, in which the provider desired to disin-
If an infectious etiology is suspected, a tissue skin (see Fig. 24.8a, b). Burow’s solution can be
culture specimen should be obtained and cultured obtained over-the-counter or can be purchased as
for aerobic and anerobic bacteria, atypical myco- a convenient powdered formulation in packets to
bacteria, and fungi. Deep tissue cultures, such as be mixed with water. The astringent property
those obtained via punch or excisional biopsy decreases swelling and weeping. Additionally,
technique, are typically sent to the pathology lab aluminum acetate is active against S. aureus and
in a sterile cup. They can be placed on a saline P. aeruginosa, decreasing bacterial colonization
dampened sponge or directly into the sterile cup and decreasing inflammation at the site. Urea is a
with a splash of normal saline to prevent the tis- potent keratolytic with humectant properties,
sue from desiccation. Tissue for culture should effective at gently lifting and removing retained
not encounter formalin. Tissue cultures need to hyperkeratosis while hydrating the skin. This
be sent to the lab as soon as possible for process- combination can be used to promote de-novo
ing, ideally within an hour or two of procure- healing, or prior to planned grafting or amputa-
ment. Unlike tissue placed in formalin, tissue tion to promote a healthy closure. The urea
cultures cannot be placed on a shelf and await should be discontinued once the skin is resolved
transport the following day. of hyperkeratosis and smooth.
In terms of management, debridement and/or Another useful tool to prevent colonization
antimicrobials tailored to culture data are emi- and infection is the use of gentian violet. Gentian
nent treatment options. violet has recently gained popularity as a topical
Clinical pearl: The sequential application of antiseptic due to its effectiveness, low cost, and
Burow’s solution, an antiseptic/astringent com- availability as an FDA-approved over-the-coun-
presses, followed by 40% urea cream qHS can be ter medication. Well known for its antimicrobial
very beneficial in swollen, inflamed, or thickened properties, gentian violet has been used to treat
oral candidiasis and in coating urinary catheters rative/ulcerated/inflamed nodules which usually
to reduce the risk of urinary tract candidiasis [9, present at the distal upper extremities and produce
10]. In terms of antibacterial properties, gentian successive proximal lesions along lymphatic
violet has been used in the treatment of impetigo drainage [11, 12] (See Fig. 24.9a–c).
as well as demonstrated in randomized controlled
trials to be more effective than iodine in killing Fungal Infections
MRSA [9]. The workup of wounds should also include fun-
Clinical pearl: Gentian violet is also a useful gal cultures, especially in transplant recipients,
indicator of patient adherence, as it turns the skin patients with HIV, or other immunocompromised
a characteristic violet after application. patients such as patients with uncontrolled diabe-
tes mellitus. See Table 24.2 for a relevant sum-
typical Mycobacterial Infection
A mary [14].
Atypical mycobacterial infections manifest as Clinical pearl: A note on Tinea incognito:
single or multiple erythematous lesions. See Tinea incognito is a dermatomycosis that can be
Table 24.1 for a summary of clinical presentations exacerbated by the use of systemic or local corti-
and history. In immunocompromised patients, costeroids. Use of these anti-inflammatory agents
atypical mycobacterial infections may induce a promotes the proliferation of the dermatophyte
distal to proximal “sporotrichoid spread”: suppu- and encourages the Tinea dermatophytes to dive
Table 24.1 Summary of atypical mycobacteria with relevant clinical presentation and history
Mycobacterium Cutaneous presentation History
M. marinum Sporotrichoid spread from point of “Swimming pool granuloma,” cleaning fish
inoculation tanks, swimming in freshwater lakes or
unchlorinated swimming pools
M. ulcerans Firm, painless, mobile subcutaneous Central/West Africa, Japan, SE Asia,
module, may progress to necrosis, Australia, South America
destruction of nervous, musculoskeletal,
vascular tissue
M. avium complex Rare cutaneous involvement, but presents History of AIDS/immunocompromised
(MAC) as necrotic papules with sporotrichoid
spread
M. fortuitum/chelonae Erythematous subcutaneous nodules with Recent trauma, surgery, injection
complex sporotrichoid spread
a b c
Fig. 24.9 (a) A patient with an erythematous right lower patient, inconsistent with lymphedema, (c) deep-seated
extremity with distinct skip areas and nodularity, incon- indurated nodules with sporotrichoid spread from the
sistent with venous stasis dermatitis or dermatosclerosis, same patient, suggestive of atypical mycobacterial
(b) skin markings/wrinkles over lesions in the same infection
Table 24.2 Summary of fungal infections in wound care

Fungal organism Cutaneous presentation History
Aspergillus flavus/fumigatus Necrotic papules/nodules Immunocompromised, impaired skin
barrier due to wounds, burn, trauma
Mucormycetes spp.a (formerly Dark eschar at point of inoculation, Immunocompromised, neutropenia,
Zygomycetes) commonly in facial/sinus areas poorly controlled diabetes
Candida albicansb Interdigital superinfection with Immunocompromised, high moisture
satellite lesions wound dressing
Tinea pedis Annular superficial erythematous Male sex, walking barefoot in locker
plaques of the feet with scale rooms, gyms
Tinea incognitoc Annular erythematous macules/ Misuse of systemic or local
plaques with hypopigmentation corticosteroids
and diminished/absent scale
a
See Fig. 24.10a–d
b
See Fig. 24.11
c
See Fig. 24.12
a b
c d
Fig. 24.10 (a) Ulcer with dry, necrotic eschar that had [13], (c) removal of necrotic tissue down to tendon [13],
slowly expanded over the course of months in a patient (d) histology demonstrates broad, non-septate hyphae
with poorly controlled diabetes mellitus [13], (b) removal consistent with mucormycosis (blue arrow). (d, Courtesy,
of the eschar revealed significant amounts of necrosis Arash Radfar, MD)
into adnexal structures such as hair follicles [9]

causing a fungal folliculitis. See Fig. 24.12.
When situated in the dermis, Tinea may be
more difficult to detect as the characteristic ery-
thema and round morphology may be obscured.
Additionally, tinea treated with steroids is usually
lacking the characteristic scale on the surface of
the skin. Fungal folliculitis usually requires sys-
temic antifungal medications for several weeks to
cure, as antifungal medications applied topically
do not reach the depth of the infection. Therefore,
dermatologists generally discourage the use of
combination or concomitant use of anti-inflam-
matory/antifungal creams.
Ecthyma Gangrenosum
Ecthyma gangrenosum is a cutaneous manifesta-
tion of septic Pseudomonas aeruginosa angioin-
Fig. 24.11 Erosio interdigitalis blastomycetica due to C. vasion. Lesions may initially develop on the
albicans infection extremities as hemorrhagic vesicles/bullae that
progress into a central black eschar surrounded
by tender and erythematous tissue [15].
Allergic Contact Dermatitis
Allergic contact dermatitis is another useful con-

sideration in the management of atypical wounds.
In contrast to pyoderma gangrenosum and DLE,
allergic contact dermatitis is a sterile reaction to a
foreign but innocuous antigen. The type IV
delayed hypersensitivity reaction associated with
allergic contact dermatitis can hinder wound
healing. Furthermore, the impaired protective
skin barrier in the setting of wound care may fur-
ther facilitate sensitization to allergens.
Several components of routine wound care are
potential causes of allergic contact dermatitis: top-
ical antibiotics such as neomycin and bacitracin,
ointments containing balsam of Peru, hydrogels
containing propylene glycol, and hydrocolloids
containing colophonium. Moisturizing substances
such as lanolin or wood alcohols can cause peri-
wound maceration [16].
According to North American Contact
Fig. 24.12 Confluent faint erythematous patch without Dermatitis Group (NACDG) patch testing data
scale overlying the lateral left lower extremity from a from 2017 to 2018, balsam of Peru and topical
patient with Tinea incognito
antibiotics are the most common causes of allergic
contact dermatitis. Balsam of Peru is of particular
concern to the wound care provider because it may
be found in combination ointments [16], whether fest with extensive inflammation and skin break-
applied in clinic or at home. Per NACDG patch down, but neomycin reaction may not necessarily
testing data from 2017 to 2018, 7.1% of allergic be the first thought that comes to mind.
contact dermatitis patients experienced reactions In addition to neomycin and bacitracin, other
to balsam of Peru [16]. Colophonium/resin may be antibiotics that may cause contact dermatitis
found in some hydrocolloid dressings and may include polymyxin B and gentamicin, a known
cross react with balsam of Peru [16]. cross-reactant with neomycin.
Antibiotics constitute a key component of Removing the offending allergen and continued
wound care, although common topical antibiotics avoidance will alleviate allergic contact dermatitis.
such as neomycin and bacitracin may induce Use of topical steroid ointment such as clobetasol or
allergic contact dermatitis and impede normal triamcinolone twice daily can speed the resolution
wound healing (see Fig. 24.13). Of the two, neo- of the eruption and provide relief of pruritus. Be
mycin is especially of note as it is the most used sure to avoid placing steroid ointment directly on
topical antibiotic. NACDG patch testing results surgical incisions in the immediate post-operative
up to 2018 have demonstrated that 5.4% to 13% period; we recommend sparing the area 1cm around
of patch-tested patients exhibit a contact dermati- the incision. Discontinue steroids as soon as the
tis reaction to this aminoglycoside and that it rash is no longer pruritic to avoid side effects from
consistently appears within the top 15 most com- topical steroids. If these allergens constituted a
mon causes of contact dermatitis [17–19]. The component of previous wound care, the wound care
associated contact dermatitis reaction can mani- provider may need to consider non-allergy-provok-
ing substitutes. Patch testing is a further step that
can establish a patient’s allergy profiles and person-
alize wound treatment regimens going forward.
Clinical pearl: It is important to distinguish
irritant contact dermatitis from allergic contact
dermatitis. Irritant contact dermatitis is caused by
direct tissue damage following exposure to a
known irritant—for this reason irritant contact
dermatitis tends to be localized. Because allergic
contact dermatitis is mediated through immuno-
logic mechanisms, allergic contact dermatitis
tends to involve skin beyond the area of applica-
tion. Allergic contact dermatitis also tends to be
intensely pruritic.
Cutaneous Malignancy
The wound care provider should also consider

that skin malignancies may be another source of
wounds. The protective skin barrier that is caught
in the vicious cycle of barrier disruption and
chronic inflammation may continue to deterio-
rate, or it may exit the cycle via malignant trans-
Fig. 24.13 Contact dermatitis on the abdomen of a
patient who had laparoscopic surgery. He was applying formation. Lesions in these cases tend to present
Neosporin™ to his surgical sites. You can see the intense as fungating wounds.
inflammation at the site of his surgical wounds and also an
“id reaction,” also known as an “autoeczematous
response,” manifesting as innumerable small papules, in
quamous Cell Carcinoma
S
the surrounding skin. The treatment for both conditions is Areas which have undergone radiation or thermal
withdrawal of the offending topical allergen treatment are at heightened risk for squamous
a b
Fig. 24.14 (a) Multinodal cutaneous squamous cell car- squamous cell carcinoma, deemed unresectable, (b) Post-
cinoma in a patient with a history of pyoderma gangreno- treatment appearance after administration of systemic
sum, with a fungating central lesion suggestive of immunotherapy
Fig. 24.15 Depicted is an example of squamous cell car-

cinoma on histopathology which shows a markedly atypi- Fig. 24.16 Here on the left buttock of a young man is a
cal with a lack of maturation, large keratinocytic islands large, crateriform non-healing wound at the center of sur-
and squamous eddies as well as thick overlying crust [20] rounding sinus tracts. Biopsy revealed that this was a
Marjolin’s ulcer. This poorly differentiated squamous cell
carcinoma developed after several years of uncontrolled
cell carcinoma due to increased keratinocyte hidradenitis suppurativa. Further workup revealed meta-
activity. Persistent ulceration or inflammation in static disease
the context of hidradenitis suppurativa, especially
in the inguinal folds, may be another driver of nomas and occur over lower extremity scars.
keratinocyte activity and risk for squamous cell While Marjolin’s ulcer is primarily associated
carcinoma. See Figs. 24.14a, b and 24.15. with old burn trauma and secondarily with osteo-
myelitis, they may also arise from venous stasis
Marjolin’s Ulcer ulcers, pressure ulcers, hidradenitis suppurativa
Marjolin’s ulcer describes a delayed malignant (see Fig. 24.16), or trauma.
transformation associated with scarred tissue. Malignant transformation takes on average
Most Marjolin’s ulcers are squamous cell carci- 30–35 years to manifest, but acute variations of
Marjolin’s ulcer exist with some reports of dis- Retiform purpura occurs from thrombus for-
ease following 6 months after injury [15]. Given mation in small cutaneous vessels and carries
this variable range, a patient who presents with with it a broad differential ranging from vasculi-
more than 3 months of a triad including nodular- tis to vessel occlusion. When the wound care pro-
ity, induration, and ulceration over an area of vider suspects a vascular etiology with retiform
scarring should warrant consideration of purpura, a sample for direct immunofluorescence
Marjolin’s ulcer. should be obtained and sent in Michel’s/Zeus
Other forms of skin cancer that could present transport media in addition to a sample for hema-
as a non-healing wound include basal cell carci- toxylin and eosin staining.
noma and rarer malignancies such as epithelioid
angiosarcoma. Nonmalignant causes of fungat- Calciphylaxis
ing wounds include pseudoepitheliomatous Calciphylaxis typically presents as extremely
hyperplasia, a close, but benign mimic of squa- painful, edematous, retiform, non-blanching pur-
mous cell carcinoma. For this reason, we prefer pura, plaques, or livedo reticularis. Of note, reti-
that such biopsies be sent to an experienced form purpura is not a specific finding of
dermatopathologist. calciphylaxis and heads a broad differential,
which will be covered further in this chapter.
In later stages of calciphylaxis, the wound
Vascular Diseases may form a central, leathery, bound down eschar
with a surrounding dusky, reticular plaque (see
Venous and arterial ulcers are commonly seen Fig. 24.17a–c). Traditional locations of calciphy-
and therefore will not be discussed here. This laxis have a predilection for areas with high
section will focus on less common dermatologic amounts of adipose tissue, such as the thigh, but-
entities caused by vascular diseases such as calci- tocks, trunk, and upper extremities, but may
phylaxis, vasculopathy, and vasculitis. involve atypical locations like the penis, digits,
A common and nonspecific manifestation of and lower extremities.
vascular disease in the setting of atypical wounds Calciphylaxis can be further characterized
is retiform purpura, a net-like lesion with non- into uremic and nonuremic disease. Risk factors
blanching and visible hemorrhage into the skin for uremic disease revolve around hypercalcemic
and mucous membranes. The non-blanching pur- conditions such as end-stage renal disease and
puric characteristic of retiform purpura differen- secondary hyperparathyroidism to calcium and/
tiates it from livedo reticularis, another net-like or vitamin D supplementation (see Fig. 24.18a).
lesion. Nonuremic etiologies can arise due to liver dis-
a b c
Fig. 24.17 (a–c) Retiform, “star-like” eschar as seen in calciphylaxis

a b
Fig. 24.18 (a) Faint dusky retiform plaques with overly- crograph shows calciphylaxis with calcium deposits in the
ing dried serosanguineous crust on leg of a patient with vessel in the deep dermis (see arrow) which have resulted
renal failure, early calciphylaxis lesion, (b) this photomi- in overlying dermal and epidermal necrosis [21]
ease, warfarin, or malignancy. Elevated alkaline

phosphatase and low serum albumin have also
been identified as risk factors for calciphylaxis.
Patients undergoing hemodialysis or the use of
calcium-based phosphate binders such as cal-
cium carbonate will place patients at a higher risk
of vascular calcium deposition and calciphylaxis
(see Fig. 24.18b). Additional risk factors identi-
fied include female gender, hyperphosphatemia,
obesity, and diabetes mellitus [22].
Management of calciphylaxis focuses on
removing the underlying source of hypercalce-
mia and preventing secondary infection of
wounds. Whether to debride the wounds is
debated, as in some cases this causes pathergy.
Partnership with dermatology is recommended. Fig. 24.19 This figure shows a massively inflamed
medium caliber artery in the subcuticular tissues charac-
teristic of vasculitis/polyarteritis nodosa. Inflammation of
Vasculitis vessels can lead to vessel destruction which eventually
Small to medium vessel vasculitis describe endo- can result in ulceration of the skin [25]
thelial inflammation in postcapillary vasculature
that can cause retiform purpura [23].
IgA vasculitis/Henoch-Schönlein purpura is syndrome may also present with retiform purpura
thought to induce retiform purpura through IgA [24]. Both microscopic polyangiitis and granulo-
immune complex deposition. matosis with polyangiitis may present with
ANCA vasculitis such as microscopic polyan- glomerulonephritis.
giitis, granulomatosis with polyangiitis/ Polyarteritis nodosa (PAN) is a medium vessel
Wegener’s granulomatosis, and eosinophilic vasculitis (see Fig. 24.19) that may exhibit sys-
granulomatosis with polyangiitis/Churg-Strauss temic manifestations with fever, arthralgias,
myalgias, abdominal pain, and renovascular Workup

hypertension or may simply be limited to cutane-
ous signs like retiform purpura. Cutaneous PAN This section ties together a summary of biopsy
tends to be a chronic and benign disease and locations and appropriate media to use for der-
recently has been theorized to be an altogether matopathology evaluation. Once the wound care
separate process from systemic PAN [26]. provider has considered the possibility of a der-
Other vasculitides that can cause retiform pur- matologic wound before debridement, the next
pura include rheumatoid vasculitis or septic step is to obtain three specimens for histopatho-
vasculitis. logic analysis (see Table 24.3).
It is important to keep each specimen orga-
Vasculopathies nized in its correct transport media. A common
In contrast to vasculitis, vasculopathies describe mistake is to send a sample in an inappropriate
an occlusion of the vasculature that can manifest medium, such as a sample intended for DIF or
as retiform purpura. This can arise from angioin- culture, incorrectly sent in formalin rather than
vasive organisms or occlusive conditions such as correctly sent in Michel’s/Zeus transport media
calciphylaxis or thrombophilia. or sterile cup, respectively.
Heparin-induced thrombocytopenia (HIT) All specimen containers should be labeled
may induce platelet activation and subsequent with the patient’s name and the site from which
thrombocytopenia and should be consistent with they were procured. It is also helpful for the clini-
the patient’s medication history. cian to provide an adequate history (i.e. concern
Cryoglobulinemia/cryofibrinogenemia for calciphylaxis) along with the specimen, as
describes the excessive vascular deposition of this can focus pathology evaluation.
antibodies or fibrinogen in response to cold
temperature.
Underlying coagulation disorders such as pro- btaining Specimens: Recommended
O
tein C/S deficiencies, antiphospholipid syndrome Sites and Transport Media
[27], livedoid vasculopathy, and use of levami-
sole-adulterated cocaine may also contribute For larger wounds, the main specimen should be
toward a presentation of livedo reticularis. obtained via an elliptical wedge incision at the
Angioinvasive organisms include fungi such ulcer edge (see Fig. 24.20). This specimen should
as Aspergillus and Mucor spp. These infections be from a wound that is over 72 h old and should
and their associated cutaneous manifestations are be sent in a formalin bottle for H&E analysis.
covered in the “Opportunistic Infections” section A tissue culture specimen should be obtained
above. from a representative site and should be about
The context of thrombophilia as well as an 4–6 mm in size. This should be submitted in a
accurate patient history is important to the con- sterile urine cup with sterile gauze/saline with
sideration of thrombophilia. orders for tissue culture for bacteria, fungi, and
Table 24.3 Summary of the three different biopsy specimens, sites, and recommended transport media
Main specimen Tissue culture specimen Peripheral specimen
Purpose Is there pyoderma Is there an opportunistic Is there underlying vasculitis,
gangrenosum, malignancy, or infection? vasculopathy, or autoimmune
calciphylaxis? process?
Specimen Elliptical wedge incision at Representative site, Representative site,
site ulcer edge, >72 h old 4–6 mm <24 h old
Media Formalin Sterile urine cup with sterile Michel’s/Zeus transport media
gauze/saline
Orders H&E Mycobacterial, fungal, and DIF
bacterial cultures
sum vs. bacterial infection. Histopathology may

occasionally make a definitive diagnosis, how-
Excisional ever, frequently the biopsy provides more infor-
biopsy for
H&E mation, but not a definitive diagnosis and
therefore, the wound care provider should also
draw from clinical and historical clues to solidify
the diagnosis.
4mm punch
biopsy for DIF
Further Management
4mm punch
biopsy for Pyoderma Gangrenosum
bacterial, fungal,
AFB cultures
If an atypical wound is suspected, the patient

Fig. 24.20 Representative specimen sites for H&E, tis- should be counseled to:
sue culture, and DIF analysis
• Check wound frequently.
• Avoid disturbing the wound by picking/pop-
acid-fast bacilli. Tissue cultures need to be sent to ping lesion.
the lab as soon as possible for processing, ideally • Use non-stick dressings to avoid pathergy
within an hour or two of procurement. Unlike tis- with dressing changes.
sue placed in formalin, tissue cultures cannot be • Return to clinic in the event of pathergy/
placed on a shelf and await transport the follow- enlarging wound.
ing day.
A peripheral specimen for DIF should be
obtained from a new specimen under 24 h old Atypical Mycobacterial Infection
when concern for vasculitis exists. This should be
submitted in Michel’s/Zeus transport media for Atypical mycobacterial infections are difficult to
direct immunofluorescence to ascertain the pres- treat and require partnership with infectious dis-
ence of autoimmune skin disease or vasculitis. ease to determine targeted systemic antimicrobial
Michel’s/Zeus transport media is a hyperos- therapy. The duration of treatment necessary is
molar sucrose solution which will allow any often several months.
immune components in the sample to remain
bound. It is important not to expose the periph-
eral specimen to formalin at all, as formalin will Fungal Infection
instantly destroy antibodies and subsequent DIF
will return a false negative result. This inaccurate When weighing fungal vs. autoimmune wound
reading will also require a second biopsy and etiologies, it is important to never combine ste-
more tissue. roids and antifungal medications as this runs the
If possible, it is best to have stains read by a risk of Tinea incognito, as discussed in the fungal
board-certified dermatopathologist. There is fre- infections section above.
quent overlap in the histopathological findings of Our recommendation is to trial topical anti-
atypical wounds: for example, a surface-level fungals first before attempting topical immuno-
reading of “neutrophilic invasion present” does modulatory agents.
not resolve the question of pyoderma gangreno-
Contact Dermatitis Clinical Pearls

Diagnostic pearls
Remove offending allergen with continued avoid- • Violaceous border in pyoderma gangrenosum
suggests an actively expanding lesion.
ance and consider alternative wound care modali-
• Retiform purpura with pain out of proportion
ties. Document the allergen and patient reaction suggests calciphylaxis.
in the electronic medical record. • If an atypical wound is suspected, the wound care
provider should consider obtaining three
specimens:
– Main specimen from lesion >72 h old, obtained
Malignancy by elliptical wedge incision and submitted for
H&E analysis in formalin bottle.
Marjolin’s ulcer and SCC should be preferably – Tissue culture specimen submitted in sterile urine
cup/gauze and submitted for bacterial, fungal,
excised via wide local excision.
and acid-fast bacilli cultures.
Multinodal SCC deemed unresectable may be – Peripheral specimen from lesion <24 h old,
managed by PD-1 inhibitory therapy. submitted for direct immunofluorescence in
Michel’s/Zeus transport media.
Calciphylaxis
Management pearls
After a diagnosis of calciphylaxis, management • Counsel patient on wound care with low threshold
extends beyond routine wound care consider- to return to clinic if concerned for pyoderma
gangrenosum.
ations such as removal of triggers, maximizing • Neomycin is a common contact allergen, avoid if
blood flow and nutrition, preventing infection, possible.
and promoting healing: • Do not combine antifungal and topical steroids due
to the risk of tinea incognito.
• Restore skin barrier function with topical
• Remove triggers. moisturizers containing ceramides.
–– Warfarin can be changed to apixaban. • Domeboro compressions/soaks +40% urea as
–– Sources of exogenous calcium should be astringent/antibacterial.
replaced with alternatives such as low • Gentian violet as an antifungal agent.
Ca2+ dialysate or non-calcium phosphate
binders like Sevelamer.
Acknowledgment This chapter contains images that were
• Check protein C and S levels. reproduced from the Michigan Medicine Department of
• Assess venous and arterial insufficiency on Pathology Virtual Slide Box Dermatopathology collection
lower extremities. (https://www.pathology.med.umich.edu/slides/search.php
• Maximize blood flow with pentoxifylline, ?collection=DermPath&dxview=show) with permission
from the Regents of the University of Michigan.
compression.
• Maximize nutrition with high protein diet.
Disclaimer The opinions and assertions expressed herein
• Utilize medications to prevent calcium depo- are those of the author(s) and do not reflect the official
sition such as IL and/or IV sodium thiosulfate, policy or position of the Uniformed Services University of
cinacalcet. the Health Sciences or the Department of Defense.
• Prevent infection with silver impregnated
dressings. Conflicts of Interest None.
• Optimize wound healing with advanced
wound dressings, HBO.
• Pain management: gabapentin, Cymbalta,
opioids.
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Prosthetics, Orthotics,
and Amputation Rehabilitation
25
Benjamin G. Higgs
Collaboration with Medstar Preventative Measures
The Medstar Georgetown University Hospital Comorbidities and other detrimental health out-
(MGUH) Center for Wound Healing (CWH) col- comes for patients with diabetes are well docu-
laborates with a variety of specialists to create a mented, including neuropathy, dysvascularity,
comprehensive environment for patient care, and an increased susceptibility of limb loss [1].
providing an avenue for patients with at-risk As of 2020, there are 34.2 million Americans,
limbs to meet with an extensive limb salvage nearly 1 in 10, living with diabetes mellitus (DM)
team. A prosthetist in clinic is one part of this [2]. Furthermore, an individual with diabetes is
team that also includes podiatry, vascular, plas- 28 times more likely to receive an amputation
tic, orthopedic, hyperbaric, and rheumatoid spe- than an individual without diabetes, and two-
cialties. At each clinic visit, the patient has an thirds of the 2.1 million Americans living with
opportunity to consult with several team mem- limb loss have diabetes [1–3].
bers in an effort to provide an inclusive plan to In diabetes related lower extremity amputa-
optimize care. Since this is a specialized limb tions, 85%, are preceded by foot ulcerations [1,
salvage team, the patient can rest assured know- 4]. Each year, ulcerations develop in 5% of dia-
ing that the route of amputation either provides betic patients, and 1% require amputation.
optimum function above what would be obtained Importantly, the ulcerative recurrence rate is 66%
when saving the limb or will occur as the last in this patient population and the likelihood of
result after other treatment modalities are amputation rises from 1% to 12% with these sub-
explored. This chapter will focus on the pros- sequent ulcers [5]. The 5-year survival rate of a
thetic and orthotic intervention assisting with major amputation is 50% [6]. Mortality is double
limb preservation or providing care throughout among diabetic patients with ulcerations than
the amputation process when limb salvage is no that among diabetic patients without [1, 7].
longer the most practical option. Considering the time required in treating ulcer-
ations, there is a great societal cost due to loss of
productivity and lesser quality of life for these
patients and their families. Chronic wounds
impact 6.5 million patients at a cost of $25 billion
annually [5].
B. G. Higgs (*) The majority of patients that require care
Hanger Clinic, Washington, DC, USA through the CWH is part of this neuropathic, dys-

350 B. G. Higgs
vascular, diabetic patient population. Due to the accommodate mild contractures or deformations
associated comorbidities and considering the of the foot that can create excessive pressure and
mortality rate, prevention is the utmost priority— hot spots leading to skin breakdown and provides
beginning with gait salvage. The challenge lies in ample space to accommodate soft dressings.
how to salvage gait and improve mobility. Many They lack any significant composition to stabilize
of the above-mentioned complications are com- to ankle and are a basic means of plantar pressure
pounded when a patient is stagnant and immo- distribution.
bile. Pressure ulcers are a localized injury to the Diabetic Healing Boot (DH Boot): Also
skin and/or underlying tissue as a result of pres- designed to distribute pressure across the plantar
sure or pressure combined with shear or friction surface of the foot. The DH boot provides
forces. Skin integrity is weakened and decondi- increased integrity and leverage when compared
tioned without frequent stresses, thus leaving a to the DH shoe. This taller design accommodates
non-ambulatory patient at higher risk for ulcer- or corrects contractures of both the foot and the
ations. Coincidentally, an ulcerative compro- ankle, promotes enhanced ankle stability, and
mised limb is also a limiting factor in the ability further offloads the plantar surface utilizing prox-
to ambulate. It is proven that increased activity is imal compression of the shank.
beneficial in the treatment of the at-risk foot. Pressure Relief Ankle Foot Orthosis:
However, a sudden increase in loading the foot (PRAFO): Available as several designs both off-
might explain why a foot ulcer could develop, the-shelf (OTS) or custom fabricated versions.
unable to tolerate the additional stresses [8]. In The PRAFO family of ankle foot orthoses (AFO)
order to maintain skin integrity and optimize the ideally maximize pressure distributions and
success of this patient population, pressure distri- accommodate or correct mild to severe deforma-
bution combined with a slow re-introduction of tions or contractures while either in seated or
pressure and shear forces is imperative [9]. supine positions, or for ambulation.
Mitigating the chance of ulceration formation Advancements in the ambulatory design include
would have a cascade effect of reducing the an adjustable tibial shell which accommodates
comorbidity amputation potential. A prosthetist edematous fluctuations or soling cutouts for opti-
in clinic allows the provision of prompt care mal forefoot or hindfoot offloading. One such
when preventative measures are needed in treat- robust design is also known as a Charcot Restraint
ing contractures and deformations leading to Orthotic Walker (CROW) due to the severe defor-
wounds. There are a number of orthotic modali- mation associated with the Charcot joint and the
ties that can help accomplish this task [10, 11]: common need of this AFO design to help accom-
Total Contact Cast (TCC): provided by techni- modate it. Total contact, depressions of the mid-
cians within the clinic. It has been identified that foot, and a rocker bottom soling help facilitate
ulcer healing is significantly better when irre- movement while stabilizing the joint and mitigat-
movable devices like the TCC are used [12]. It ing plantar pressure that could otherwise cause
mitigates noncompliance and is sufficiently pad- ulcerations or wounds.
ded to offload wounds appropriately. However, Diabetic Shoes and Pedorthic Care: A key
there are a number of circumstances where a modality in preventative measures. Off-the-shelf
TCC is no longer appropriate, ideal, or preferred. (OTS) shoes, custom molded shoes, and custom
Access to monitor the limb is challenging. foot orthoses are all options designed to provide
Hygiene is problematic. Limited weight bearing, long-term protection of the at-risk limb as a phys-
mobility, and possibility of lesser quality of life ical barrier to foreign objects and through reduc-
are factors to be considered. tion of pressure and friction. Shoes should have
Diabetic Healing Shoe (DH Shoes): Typically few to no internal stitches, mitigating any contact
intended for short-term use, DH shoes are points that could breakdown the skin [13]. Wear
designed to distribute pressure across the plantar and tear or stretching of the shoe upper material
surface of the foot. These lightweight shoes and gradual deterioration of soling along with
25 Prosthetics, Orthotics, and Amputation Rehabilitation 351
insole compression is expected as with any shoe cess, due to the undeniable physical and
frequently used. Annual replacement is encour- psychological toll. Many patients experience limb
aged to replace degraded shoes and insoles in loss in the same fashion as the loss of a loved
order to maintain optimal foot protection. one—progressing through the phases of grief, par-
With neuropathy, or a lack of sensation, ticularly lingering in depression [20–22].
impact does not always register as pain and there- Individuals with diabetes are at increased risk for
fore indicate a problem. Trauma to the foot arises psychological distress due to a lack of psychologi-
from ill-fitting footwear, undetected foreign cal support and contending with comorbidities
objects inside the shoes, and accidental injury prior to amputation [23]. There is limited research
through impact. Poor vascularity can delay heal- on the psychological aspects for patients with dia-
ing, allowing for infection to cultivate and propa- betes, particularly for those also experiencing limb
gate. Over half of ulcers with vascular origin are loss [20]. While an ideal treatment modality would
infected on presentation [12, 14]. Infections pre- include the addition of a psychiatrist to the inter-
cede about two-thirds of lower extremity amputa- disciplinary team [21], the ability for prosthetists,
tions [15]. Appropriate education along with peer supporter, and a specialized Amputee Care
donning/doffing procedures will help mitigate Coordinator (ACC) to meet with patients in
these issues [16]. However, less than one-third of advance provides patients with additional
those with appropriately fitting footwear actually resources to aide their recovery. See Fig. 25.1 for
use these items [17]. Diabetic foot disease is a General Rehabilitation Timeline [24].
lifelong condition predisposing the patient to risk
of a new ulcer, amputation, or early death. A
holistic treatment approach is required for opti- Prosthetist Consultation
mal prevention and wound management.
The primary objective of the integrated team Unlike patients with traumatic amputation, those
at Wound Center is mobility and functionality with diabetes and dysvascularity typically have
obtained via gait salvage—typically accom- an opportunity to prepare for surgery and the
plished with preventative measures in an effort to associated lifestyle changes. A pre-amputation
preserve the limb. The prosthetist’s clinical pres- consultation with a prosthetist is the first time a
ence opens the lines of communication and patient discusses definitive next steps surround-
enables discussion in mapping out current ing the prosthesis. While the discussions of this
orthotic treatments to aide in wound closure. Gait encounter vary, it is common to share and set
salvage and limb salvage are not mutually exclu- realistic expectations, inclusive of both short- and
sive. While limb salvage is typically an appropri- long-term recovery. This is also the initial oppor-
ate approach, in order to meet the primary tunity for the patient to convey thoughts and con-
objective, gait salvage, early amputation, and set- cerns, to ask questions, and to discuss functional
ting realistic expectations might be a more viable design options with their prosthetist. An open
solution for an active patient [18]. dialogue is important to bridge the gap between
potentially divergent patient desires and initial
prosthetists assessments.
Pre-amputation Consultation
Approximately two million people in the USA live Peer Support

with limb loss and 185,000 amputations occur
yearly in the USA [3]. Amputation etiology An often overlooked, yet vital role in an ampu-
includes neuropathic and vascular 81.9%, trauma tee’s recovery is peer support. While prosthetists
16.4%, cancer 0.9%, and congenital 0.8% and is a work with amputees daily, most have not experi-
life changing event for a patient [19]. Each etiol- enced the event of an amputation. Only a fellow
ogy presents challenges during the recovery pro- amputee can truly appreciate and understand the
352 B. G. Higgs
Fig. 25.1 General rehabilitation timeline
journey and obstacles that lie ahead. This does Reichmann, 92% of amputees reported improved
not negate the ability for a prosthetist to success- outlook after meeting with their peer visitor. An
fully provide clinical care; however, connecting additional 50% requested an additional visit
amputees to one another provides a valuable while in rehabilitation. This was of particular
resource that can be monumental in the outcomes interest to bilateral amputees or amputees over
and success of a patient [20, 22]. the age of 60 years. Peer support yields positive
Not surprisingly, given the implications of psychosocial value that contributes to positive
ulceration treatment and its adverse effects on outcomes in a patient population already experi-
mobility, coupled with the feelings of anger and encing increased psychological distress [26].
resentment [5], depression is 2x more likely in Resources like the Amputee Coalition of
patients with DM [25]. Pairing the patient with a America’s Certified Peer Visitor (CPV) and
peer in a similar demographic can improve Hanger Clinic’s AMPOWER are two such men-
morale and confidence while aiding in the recov- torship programs that are currently available to
ery and outcomes post-amputation. According to help amputees connect. Goals include fostering a
community of inclusion, education, and mentor- Immediate Post-operative

ship in an effort to support amputees and their Prosthetic Care
families throughout their recovery [27, 28].
Recovery begins immediately post-surgery. The
body initiates its regeneration process upon sur-
Amputee Care Coordinator gical trauma. The surgical team provides general
medical and wound care dressings to tend to the
A unique role implemented at the MGUH CWH to sutures and the edematous limb. There are four
further synergize the coordinated care is the ACC. common approaches in caring for a patient imme-
This position ensures continuity of patient care diately following amputation: soft dressings,
from initial pre-amputation consultation through rigid dressings, immediate post-operative pros-
receiving definitive prosthesis. Similar to a case thesis (IPOP), and removable rigid dressings
manager, the ACC tracks each patient in the CWH (RRD). The objectives in utilizing these modali-
documenting date of amputation. Based on date of ties include mitigating pain and contractures,
amputation, prosthetist and peer support are sched- limb protection, and controlling edema to opti-
uled. Discharge plans are monitored and patient mize limb volume and shape in preparation for
status updates are relayed to the Wound Center for prosthesis usage [11, 32].
continued coordinated care. Healthcare costs rise Soft Dressings: Inclusive of wound dressings,
as time to prosthetic d elivery increases; therefore, ACE wrap, Tubigrip, or shrinkers. Soft dressings
it is essential to keep patients engaged through are cost-effective and readily available peri- and
ambulation [29]. The follow-up provided by the post-surgery and are an appropriate means to
ACC means patients at MGUH CWH experience a control edema. Care must be taken to ensure
care pathway designed to improve outcomes, simi- sutures are protected from friction during don-
lar to other case manager platforms [30]. ning and doffing. ACE bandages require method-
ical donning to ensure appropriate pressure
gradient and to mitigate excessive proximal com-
Traumatic Amputee pression which could create a tourniquet effect,
resulting in a bulbous limb shape, thereby negat-
Much of the focus on amputee care in this chapter ing the intended purpose of the dressing.
surrounds patients with diabetes and dysvascular- Rigid Dressings: Proven over the past several
ity. The ability to initiate a care plan in advance of decades to be the optimal clinical approach for
the amputation is always preferred. However, due post-operative care. Rigid dressings provide a
to the inherent nature of traumatic amputations, level of compression needed to continue to shape
this patient population unfortunately lacks the the limb and reduce volume. The rigid design
ability to have the pre-amputation consultation in prevents the knee from flexing, protects the
its entirety as outlined above. Nevertheless, the sutures from post-surgical strain, and prevents
traumatic amputee requires these resources and contracture formation while also providing a
benefits from the same level of prosthetist, peer high level of protection against falls. Fall preva-
support, and ACC meetings. When a pre-amputa- lence is high post-operatively with injuries result-
tion consultation is not an option, post-amputation ing in extended hospital stays or revision surgeries
peer support is proven along with the support of [33]. Rigid dressings demonstrated significantly
family, friends, and the workplace organization to decreased healing time for transtibial amputation
play an integral role in developing confidence and to initial casting for a prosthesis when compared
motivation in these patients [22]. Fortunately for to soft dressing [34–36]. Additionally, the use of
traumatic amputees, despite the inability to plan removal rigid dressings (RRD) is shown to reduce
and prepare for amputation, they are often more acute care length of stay [35]. Reduced healing
successful with their prosthetic recovery when time and shorter time spent in acute care both
compared to their diabetic counterparts [31]. benefit the amputee patient and potential pros-
354 B. G. Higgs
thetic intervention. While utilization of RRDs did as edema, redness, inflammation, and fluid reten-
not reduce fall incidents, RRDs did reduce num- tion. As outlined earlier, post-operative dressings
ber and prevalence of injuries [37]. are designed to assist the recovery by controlling
IPOP: A rigid dressing that is fitted with a edema and optimizing limb shape in preparation
prosthetic pylon and foot, suspended with a belt for a prosthesis. An IPOP might be initiated,
strap. IPOPs provide patients with a visual refer- while sutures remain and the wound is closing in
ence to assist in overcoming the psychological an effort to begin weight bearing. Upon closure
aspect of amputation. It also permits the patient of the wound and suture removal, a preparatory
to initiate weight bearing. However, care must be prosthesis may be provided for total weight bear-
taken to ensure maintaining suture protection ing. A preparatory prothesis is different than an
while developing skin tolerance. It can be diffi- IPOP in its material, suspension method, and
cult for patients to grasp toe-touch or light pres- when it is provided. The preparatory prosthesis is
sure, compared to full body weight. Although fabricated out of a durable polymer or carbon
indicated for a traumatic amputee, IPOP is con- fiber and utilizes a gel liner with a pin or suspen-
traindicated for patients with at-risk dysvascular sion sleeve rather than a waist belt. It is provided
limbs due to poor blood flow and increased sus- promptly after wound closure and suture removal
ceptibility of further skin breakdown. Utilizing rather than immediately post-operatively. The
an IPOP allows for low level function while heal- preparatory prosthesis is nearly identical to a
ing from time of amputation, through wound clo- definitive prosthesis; however, it is designed and
sure and suture removal. Upon removal of the fabricated with the understanding the limb will
sutures, the patient’s skin is typically no longer a undergo significant changes in the early months
limiting factor in providing a prosthesis. and patient functionality is likely to change.
RRD: Offer the same features and outcomes The first several months post-surgery are cru-
of the rigid dressing with the significant added cial to a patient’s success [29, 38]. The provision
benefit of being readily removable. Standard of a preparatory prosthesis provides an avenue
rigid dressings require the use of a cast saw for for the limb to mature. Perhaps more importantly,
removal, which typically occurs every few days. the preparatory prosthesis grants time for a
In comparison, RRDs enable a caregiver to read- patient to intrinsically evaluate themselves and
ily remove the dressing, provide the opportunity re-evaluate their initial wants and needs. With an
to monitor the skin, and change soft dressings entry level prosthetic design, the patient will have
easily or address other issues with limb recovery a better sense of what they can and cannot accom-
on a more frequent basis. According to a meta- plish while using this prosthesis and more accu-
analysis by Churilov, the RRD reduces the num- rately validate their Medicare defined K-Level
ber of days it takes to fit the first prosthesis [36]. (Table 25.1) [39]. Often starting with, but not
The RRD should be the new standard of care, restrictive to, K2 components, the majority of
combining the ability for frequent limb observa- basic activities of daily living can be practiced. It
tion and protection to optimize recovery while allows physical therapy and gait training to
expediting the time to initial ambulation. broaden beyond pre-prosthetic training. While
not typically providing the highest levels of func-
tionality, the preparatory prosthesis enables early
Preparatory Prosthesis ambulation, serving as a diagnostic tool. If a
patient cannot accomplish a more complex goal
A new amputee will undergo a multitude of such as climbing stairs or running, the prosthetist
changes during limb healing and maturation. will evaluate if the prosthesis is a limiting factor
Most notably, volume and shape are impacted. or work in collaboration with the patient care
Regardless of cause, an amputation is a traumatic team to determine if there are other physiological
event to the body, with common side effects such or psychological considerations to be addressed.
Table 25.1 Medicare functional classification levels for Definitive Prosthesis

amputees, updated January 2020 [39]
K-level Description Limb maturation occurs from 1 to 12 months
K-0 Does not have the ability or potential to post-operatively, at which point the limb volume
ambulate or transfer safely with or without
assistance and a prosthesis does not enhance has relatively stabilized [40, 41]. Skin tolerance
their quality of life or mobility toward bearing weight and pressure has improved.
K-1 Has the ability or potential to use a prosthesis Functionality and long-term goals have been
for transfers or ambulation on level surfaces at assessed. This period of time is ideal to provide a
fixed cadence. Typical of the limited and
unlimited household ambulator
definitive prosthesis to the new amputee.
K-2 Has the ability or potential for ambulation A definitive lower extremity prosthesis is
with the ability to traverse low level designed for use over the next several months or
environmental barriers such as curbs, stairs, or years barring any substantial physiological or
uneven surfaces. Typical of the limited
functional changes. It is inclusive of several com-
community ambulator
K-3 Has the ability or potential for ambulation ponents: suspension, socket, pylon, foot. For
with variable cadence. Typical of the more proximal amputation levels, a knee or hip
community ambulator who has the ability to joint might be needed.
traverse most environmental barriers and may Suspension: A means to attach the prosthesis
have vocational, therapeutic, or exercise
activity that demands prosthetic utilization to the limb. Commonly used interfaces are gel
beyond simple locomotion liners. They create a high level of friction against
K-4 Has the ability or potential for prosthetic the skin in order to suspend the prosthesis with a
ambulation that exceeds basic ambulation pin attachment or through a suction seal. The gel
skills, exhibiting high impact, stress, or energy
levels. Typical of the prosthetic demands of
also creates a level of cushion around the limb,
the child, active adult, or athlete absorbing impact and assisting with pressure dis-
tribution. In addition, liners add a level of com-
pression to the skin to contain shape and volume
The utilization of a preparatory prosthesis enhancing prosthetic control. Anatomical con-
affords a patient the opportunity to assess their tours over boney prominences, skin fit, waist
long-term desires and true functional goals. For belts, or other strap mechanisms are also viable
example, a patient might exhibit a need for means of suspension.
increased activity, ability to ambulate with vari- Socket: The highly customized portion of the
able cadence, and encountering uneven ter- prosthesis that encompasses the limb. The
rain—warranting an upgrade in componentry, socket is derived from an impression of the
thereby changing the K-Level from K2 to K3 patient’s limb and modified for an intimate fit.
(Table 25.1). Another patient might have an The goal is to optimize pressure distribution
early goal of high activity, e.g., playing basket- which enhances control of the prosthesis,
ball on a dynamic foot. However, through the reduces unnecessary energy consumption, and
initial ambulatory timeframe, this primary goal distributes floor reaction forces against the limb
might evolve into a desire to navigate inclined to mitigate skin breakdown. Typically fabricated
terrain, necessitating a different ankle design out of polymers or carbon fiber to reduce weight
with increased range of motion through articula- and material thickness while maintaining integ-
tion. Further physical, occupational, or psycho- rity and durability.
logical therapy might be needed to improve Pylon: The segment of the prosthesis that con-
strength, balance, and confidence. In conjunc- nects the socket or knee to the foot made of a
tion with a more defined physiological outcome, lightweight aluminum, titanium, or carbon mate-
early ambulation can aid the reduction of the rial. A pylon enables adjustability for the prosthe-
$327 billion diabetic related annual health care sis, ensuring the foot position relative to the
costs [2, 29]. socket, knee, and hip is in an inherently stable
356 B. G. Higgs
orientation. It allows for rapid and precise the socket might be necessary by heating and
changes to height and alignment based on patient changing the shape, or addition/subtraction of
presentation to optimize their gait pattern for effi- padding. If a patient’s limb has changed signifi-
ciency, reducing energy consumption and fall cantly, a socket replacement would be required to
risk. Contracture accommodation may be neces- ensure optimal fit and function.
sary to maintain balance, stability, and posture Patients’ needs continually evolve. Functions
and is further accomplished with the modular change over time. It is imperative for the clinical
nature and versatility of the pylon. team to have ongoing dialogue to ensure patient
Foot: The most dynamic aspect of the prosthe- needs are met. One must not overlook the impor-
sis. The foot connects the prosthesis to the tance of including the patient within this dia-
ground. There are a wide range of designs depen- logue. According to Valizadeh, there is a
dent on a patient’s functional needs. Entry level significant difference in what the clinical team
SACH (solid ankle, cushion heel) feet provide deems essential when compared to what the
basic needs for standing, transfers, and single patient perceives to be essential [22]. Continued
cadence ambulation. Enhanced designs include discussions can ensure patient needs are met in
energy storing feet with carbon springs that conjunction with professional input, rather than
deflect and roll under pressure. Articulating based entirely on clinical assumptions. Surveys
ankles add hydraulic chambers to further control and outcome measures provide an additional
motion through dampening resistance. avenue to enhance patient communication and
Microprocessor controlled articulating ankles are success. The self-reported measure of the
able to change dorsiflexion and plantarflexion Prosthetic Limb Users Survey of Mobility
hydraulic chambers independently and can have (PLUS-M) provides a means for the patient to
a marked improvement on balance and better provide insight in order to assist with their clini-
mimic biological gait [42]. Self-powered ankles cal care [44].
add motors to replace the missing gastrocnemius
complex. This active design has been shown to
reduce energy consumption, however, remains Summary
bulky and costly [43]. The overall goal of a foot
is to provide a fluid motion to mimic the anatomi- A collaborative team provides patients with
cal foot for balance, stability, and function. diverse clinical opinions in an effort to optimize
The dynamic nature of the human body patient function. Gait salvage is the goal in an
ensures that limb shape and volume are under effort to ultimately reduce mortality rates. This
constant change, even after reaching limb matu- can be accomplished through limb salvage or
ration. Volume changes occur through the day. amputation. Preventative measures are priori-
External limb pressure from the socket during tized to save the at-risk, dysvascular limb.
ambulation causes volume loss. Alleviating this Orthotic intervention provides pressure distribu-
pressure upon prosthesis removal results in limb tion to prevent or treat ulcerative or contracted
volume increase. Compression is also utilized at limbs to allow for healing. When healing is not
night or when not using the prosthesis to mitigate likely, or would yield low function, amputation
the fluctuation, but a discrepancy will persist. provides another means to improve gait. Peer
Dietary choices can impact limb volume fluctua- support, ACC, and prosthetic consultations are
tion. Patients on dialysis undergo extreme vol- resources available to the patient that can help
ume changes between dialysis appointments overcome physical and mental obstacles associ-
[41]. Long-term changes occur due to muscle ated with amputation. Post-operative care pre-
atrophy, activity levels, and physiological aging. pares the patient for prosthetic intervention and
Socks provided to the amputee are a readily ambulation. A preparatory prosthesis allows for
available solution for patients to accommodate early ambulation along with setting realistic
these daily volumetric changes. Modifications to goals and expectations, assisting in designing the
first definitive prosthesis, intended for long-term 13. Schaper N, Apelqvist J, Bakker K. Reducing lower
leg amputations in diabetes: a challenge for patients,
use. Ongoing collaboration with the prosthetist, healthcare providers and the healthcare system.
physical therapist, and limb salvage team pro- Diabetologia. 2012;55(7):1869–72.
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designed to meet individual needs and optimize the Eurodiale studies: what lessons for diabetic foot
care? Curr Diab Rep. 2011;11(4):302–9.
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Surgical Offloading, Tendon
Balancing, and Prophylactic
26
Surgery in Diabetic Limb Salvage
John S. Steinberg, Paul J. Carroll, Jayson N. Atves,

and John D. Miller
Introduction Following improvements in surgical technique

and perioperative management, indications for
Surgical indications and techniques for limb sal- surgery in the patients with diabetes have
vage in the complex patient population are a con- expanded. In 2003 Armstrong and Frykberg
stantly evolving field of medicine and surgery. revised diabetic foot surgery classification into
Commonly, patients present with a biomechani- categories of indication based on risk [3] as seen
cally induced ulceration of the foot or ankle, in Table 26.1. Importantly, they established the
peripheral neuropathy, and some degree of con- concept of elective and prophylactic surgeries in
comitant relative tissue ischemia. Beaulieu et al. the diabetic population shifting a paradigm of
reported the majority of these patients often have surgical intervention from “last-resort” to “early
multiple conditions and comorbidities which prevention.” Using this system methods for surgi-
challenge limb salvage efforts [1]. Further, cal offloading range from prophylactic tendon
Hobizal and Wukich noted several host factors lengthening and transfers to curative procedures
including medical comorbidities, nutritional sta- with adjunctive surgical offloading techniques. In
tus, glycemic control, nonadherence to medical this chapter we review the guiding tenets for sur-
regimens, and socioeconomic status play a cen- gically based offloading pedal ulcerations utiliz-
tral role in patient outcomes [2]. ing ostectomies, osteotomies, tendon balancing,
and other prophylactic surgery in the complex
patient population.
J. S. Steinberg In the complex and comorbid populations,
University School of Medicine and MedStar especially in those patients with peripheral neu-
Georgetown University Hospital, ropathy, the formation and complication of
Washington, DC, USA deformity can create a perilous situation which
e-mail: [email protected] precipitates wound formation, progression, and
P. J. Carroll stagnation. As with deformity at any level of the
Department of Plastic and Reconstructive Surgery, lower extremity, this situation can not only
MedStar Franklin Square Hospital,
Baltimore, MD, USA impede one’s ability to ambulate safely and
e-mail: [email protected] effectively but also has major implications for
J. N. Atves (*) · J. D. Miller quality of life. This lends to the major role and
Department of Plastic and Reconstructive Surgery, need for consideration of ground reactive forces
MedStar Georgetown University Hospital, throughout the lower extremity and the body’s
Washington, DC, USA susceptibility to the formation of multi-level and

360 J. S. Steinberg et al.
multi-tissue deformity, especially in the face of may precipitate excessive force distribution
peripheral neuropathy. Although the full extent resulting in and contributing to the formation of
of lower extremity biomechanics lies well out- an assortment of pathologies which may also
side the scope of this discussion, ultimately, gait blunt the remaining tissues ability to heal or
biomechanics in the complex wound patient are cause the formation of new areas of excessive
an especially important consideration due to the force. This is nowhere more apparent than in the
lower extremity’s relationship with the weight- plantar aspect of the foot; however, anatomic
bearing surface, its interaction with ground reac- areas surrounding joints with significant excur-
tive forces, and perhaps most importantly in a sion like the ankle, midtarsal, tarsometatarsal,
patient’s ambulatory efforts and demands. metatarsophalangeal, and interphalangeal joints
Inherently, the extremity’s contact with the are especially susceptible. This process is mag-
ground in an ambulatory manner will repeti- nified in those patients where underlying defor-
tively undergo extreme multiplanar forces which mity exists in the presence of peripheral
neuropathy, where protective and corrective
Table 26.1 Risk-based classes of diabetic foot surgery. responses to ground reactive forces are blunted
Adapted from: Armstrong, D.G. and Frykberg, R.G. or grossly absent (Table 26.2).
(2003), Classifying diabetic foot surgery: toward a ratio- Deformity of the foot and/or ankle may pres-
nal definition. Diabetic Medicine, 20: 329–331 [3]
ent in a variety of ways which may perpetuate
Potential risk wound formation and its correction may preclude
Diabetic foot for high-level
surgery class Description amputation
the ultimate healing of a wound through undesir-
Class I: Procedure performed to Very low able and ultimately destructive force distribution
elective alleviate pain or within the extremity or the formation of altered
limitation of motion in a mechanics which can irreparably alter gait. A
person without loss of
deformity of the foot and/or ankle is truly of
protective sensation
Class II: Procedure performed to Low functional significance when the tissues do not
prophylactic reduce risk of ulceration permit sufficient mobility for the alignment and
or re-ulceration in motions required during the normal gait cycle.
person with loss of Abnormal bone or joint alignment, ankylosis,
protective sensation but
without open wound and/or instability often occur in the foot and/or
Class III: Procedure performed to Moderate ankle but the onus of recognition of the exact
curative assist in healing open anatomic level(s), plane(s), severity of deformity
wound and especially the formulation of appropriate
Class IV: Procedure performed to High intervention(s) and/or consultations is ultimately
emergent limit progression of
acute infection placed upon the treating surgeon and team. The
Table 26.2 Excessive plantar pressures and causative ulcer factors

Intrinsic factors Extrinsic factors Behavioral factors Iatrogenic factors
• Limited joint mobility • Non-adapted footwear • Barefoot/ • Unstable biomechanics
(too tight, prominent unprotected
seams) walking
• Congenital, post-traumatic, other • Foreign body (pebbles, • Lack of daily foot • Poorly performed
severe foot deformities (Charcot) nails, etc.) surveillance debridement/amputation
• Impossibility of • Resection of 1 or more
foot care metatarsal heads
• Poor hygiene • Escalating amputations
26 Surgical Offloading, Tendon Balancing, and Prophylactic Surgery in Diabetic Limb Salvage 361
primary goal of foot and/or ankle reconstruction, heads is embedded within the flexor tendons and
whether prophylactic or therapeutic, should be to is believed to migrate distally with progressive
provide a structurally well-aligned and stable hammering of the lesser digits, further reducing
foot and ankle complex. Treatments should seek plantar cushioning of the metatarsal heads [6].
to achieve a plantigrade foot which provides Additional nonenzymatic glycation of soft tis-
dynamic alignment and stability during stance sues resulting from long standing diabetes melli-
phase, clearance during swing phase, adequate tus may also lead to thickening and reduced
step length and provides energy conservation tissue flexibility of skin, tendon, ligaments, and
throughout. joint capsules [7]. Although innocuous appear-
ing, digital contractures in higher risk patients
quickly progress to a preulcerative or ulcerative
Goals of Surgical Intervention state. Therefore, early detection and minimiza-
tion or removal of these excessive forces is criti-
Fundamental goals of limb salvage surgery cal in prevention or maintaining remission from
include obtaining an infection-free, plantigrade, ulceration.
and stable extremity ideally maximizing ambula-
tory function within the patient’s physical and
medical capacity [4]. Also core to these tenets is Imaging and Diagnostics Studies
the recognition and removal of high force areas
where and when possible. Areas of callous for- Radiographs
mation with or without associated overlying ery-
thema may indicate areas of osseous deformity Plain film radiographs in multiple views are
predisposing to ulceration. Any foot or ankle imperative for evaluating wound etiology partic-
deformity, be it hallux limitus, hammertoes, ularly if the wound is located on a weight-bearing
osteoarthritis, equinus, bony prominences, and/or surface, as bony irritation on the foot or ankle can
Charcot neuroarthropathy, may play a causal role potentiate wound formation or support chronic-
in force-induced ulcer development, stagnation, ity. Weight-bearing plain film radiography may
and chronicity. Raspovic et al. demonstrated that confirm or better define osseous relationships and
biomechanically induced ulcerations will inevita- may display preliminary signs of underlying vas-
bly lead to re-ulceration, increased amputation cular disease such as calcifications. Transverse,
risk, and a decrease in quality of life unless cor- frontal, and sagittal plane joint relationships may
rected [5]; therefore, recognition of their presence be evaluated and joint integrity can be investi-
and understanding of their potential progression gated prior to clinical assessment. These param-
warrant preemptive and proactive mentality in eters are essential when planning musculoskeletal
treatment. balancing procedures.
Soft tissue changes may also contribute to
lower extremity ulceration and should always be
assessed. Plantarly prominent metatarsal heads Advanced Imaging
have been attributed to developed weakness of
the intrinsic pedal musculature, exacerbating Advanced imaging techniques such as magnetic
plantarflexion toe deformities in the neuropathic resonance imaging (MRI), computed tomogra-
foot. Adipose cushioning under the metatarsal phy (CT), or radiolabeled scintigraphy/nuclear
scans may be appropriate for some patients in significant increase in complications and without
whom initial evaluations suggest osteomyelitis prolonged recovery time [10].
(OM). MRI may be useful to image the deeper
layers of the foot and ankle. CT may be used to Procedure
visualize changes in the cortical bone due to Patient is placed in the supine position. After
infection or for anatomical contour, position, administration of preferred anesthesia and intra-
and/or alignment. However thorough clinical venous antibiotics an Esmarch is applied and the
evaluation and weight-bearing plain film radio- ankle tourniquet inflated. A dorsomedial skin,
graphs are often all that is needed for deep, and capsular incision is made over the first
assessment. metatarsophalangeal joint, protecting the dorsal
medial cutaneous nerve and extensor hallucis
longus tendon. If present, osteophytes are
First Digit and Metatarsophalangeal resected from the first metatarsal head surround-
Joint ing the joint. Resection arthroplasty of the base
of the proximal phalanx with oscillating sagittal
First Metatarsophalangeal Joint saw typically involves a generous resection of the
Arthroplasty proximal phalanx, potentially up to one-third of
the phalanx. Aggressive resection can include
Limitations in first metatarsophalangeal joint insertion of the flexor hallucis brevis, which may
(MPJ) mobility are a common forefoot occur- lead to toe shortening with transfer metatarsalgia
rence contributing to plantar hallux ulceration. and weakness in toe push-off.
While pressure reduction is usually attempted Various modifications of soft tissue interposi-
with external shoe modifications, this alone will tional arthroplasty have been reported including
not correct underlying osseous deformity and autografts (extensor hallucis longus, extensor
may result in an ulcer development despite best hallucis brevis, and extensor digitorum longus),
practices [8]. In 1886 Reidel described resection allografts, and acellular tissue matrices.
of the base of the proximal phalanx and exostec- Commonly the remaining capsule is then trans-
tomy of the head of the first metatarsal as an versely interposed into the joint and sutured to
alternative to unsatisfactory outcomes of first the lateral capsule with absorbable suture.
metatarsal head resection. This was later popular- Typically the joint is axially fixated with 0.062-
ized by U.S. Army Captain William Keller in mm Kirschner wire from ~5 degrees of valgus
1904, and more recently the efficacy of a Keller- and ~10 to 15 degrees of extension. The foot is
type first MPJ arthroplasty procedure in diabetic dressed in standard postoperative dressing and
patients with plantar first MPJ ulceration second- postop shoe. Sutures and Kirschner wire are
ary to arthritic joint immobility has been well removed in the clinic at 3 weeks, at which time
established [9] (Fig. 26.1). Patients who received the patient was allowed to bear full weight in a
surgical resection of the base of the proximal hard-soled shoe and begin range of motion.
phalanx were noted to heal their plantar ulcer- Regular shoes and activities were gradually
ation faster than the nonsurgical group without advanced at that time.
a b
c d
Fig. 26.1 Clinical images (a, c) and radiographic images flexion motion of the first metatarsophalangeal joint and
(b, d) multiple views—preoperative (a, b) and postopera- decreased ground reaction force to the hallux with subse-
tive (c, d) status post-Keller style arthroplasty of the first quent healing of the chronic recalcitrant plantar hallux
metatarsophalangeal joint. This specific patient experi- wound
enced increased postoperative mobilization of the dorsi-
Lesser Digits siflexion, while at the same time positioning the

and Metatarsophalangeal Joints affected toe in hyperextension. A stab-wound
incision (around 3 mm) is made at the middle of
Lesser digital deformities such as hammer, claw, the proximal phalanx by either blade or 18-gauge
and mallet toes are frequent and known to needle (author’s preference), and the tendon is
increase pressure associated with neuropathic transected in a transverse swiping motion. The
ulceration [11]. Lesser digit ulcerations are often long extensor tendon should now hold the toe
the result of structural deformity and therefore straight. All stab wounds should be irrigated and
are associated with high rates of recurrence [12]. may or may not require suture. Typically a pres-
Rigid digital contractures may cause preulcer- sure bandage is applied for the first week. The
ative or ulcerative lesions to the dorsal aspect of foot remains offloaded for 24 h, after which the
contracted joints due to rubbing in shoe gear and patient can bear weight again. The patient is
also to distal digits. Contractures that are manu- examined at 1-week and subsequently followed-
ally reducible may be corrected with soft tissue up at regular intervals.
release alone; however, if the deformity is rigidly
contracted and nonreducible it typically requires
joint arthroplasty for correction. Lesser Digital Arthroplasty
If contracture unrelieved by percutaneous flexor

Percutaneous Flexor Tenotomy tenotomy or the deformity is precluded from soft
tissue reduction by nature of being a rigid defor-
If the long flexor tendons overpower the intrinsic mity, digital resection arthroplasty may allow for
musculature, a flexion deformity of the DIPJ contracture reduction to facilitate wound healing
level is likely to occur. As a result, the distal tip of and/or reduce the risk of wound recurrence [14].
the digit will become plantarflexed with increas- Resection at the proximal interphalangeal joint
ing pathologic pressures resulting in hyperkera- permits shortening which allows for correction of
totic buildup and eventually ulceration in the deformity and relaxation of contracted soft tis-
neuropathic patient [12]. Flexor tenotomy can be sues (Fig. 26.2). If reduction is still not possible
performed for prevention of diabetic foot ulcers, following adequate resection, extensor tendon
in flexible lesser digits. Based on 6 published ret- lengthenings or dorsal MPJ capsulotomies may
rospective studies regarding flexor tenotomies for be performed to augment reduction.
diabetic ulceration a total of 264 tenotomy proce-
dures yielded a mean healing rate of 97% at a Procedure
duration of 4 weeks [13]. While the lasting pre- Digital or ankle local anesthesia blocks are
ventative effects of flexor tenotomy are not yet administered as needed. The affected proximal
well described, current results demonstrate that interphalangeal joint is surgically exposed by
flexor tenotomies are a simple, effective, and either dorsal longitudinal incision or trans-
low-risk intervention for reducing non-rigid ham- versely with the skin tension lines at the level of
mer and claw toes with a high healing percentage the joint. Dissection is carried out to expose the
and a short mean time to heal. These procedures distal condyles of the proximal phalanx and a
can also be done in an office setting with limited transverse supracondylar resection is made with
equipment costs and time constraints. bone-cutter or sagittal saw as desired. A 0.045″
Kirschner wire is then introduced at the proxi-
Procedure mal interphalangeal joint centrally and exited
Following completion of anesthesia per physi- distally. The toe may then be digitally manipu-
cian preference. The flexor digitorum longus of lated and the wire passed proximally to stabilize
the selected digit is placed under tension (“bow- the digit in the corrected position. The wire may
stringing”) by positioning the ankle joint in dor- then be bent external to the digit to prevent
a b
c d
Fig. 26.2 Radiographic imaging AP foot views (a–d)— (PMMA) antibiotic spacer may be a useful means of long-
first metatarsophalangeal total joint arthroplasty with term functional preservation
implantation of a long-term polymethylmethacrylate
proximal migration. The incision is then closed ity is scrubbed and draped in routine aseptic
and standard postoperative dressing applied fashion. A 3 mm incision is made dorsally at
with postoperative shoe. Incisions are then the planned osteotomy site after fluoroscopic
removed in the clinic in 2–3 weeks, and K-wire identification of the surgical neck of the meta-
removed at 4 weeks. tarsal. A perpendicular or short oblique osteot-
omy will be made at the neck or diaphysis of
the affected lesser metatarsus [2–5]. The
Lesser Metatarsal Head Osteotomies authors prefer to complete this with a 12 mm
Shannon burr at a speed of 1600 rounds per
Ulcerations are also commonly encountered minute and a torque of 80 N-m. Fluoroscopy
beneath the lesser metatarsal heads. In the event and manual manipulation of the metatarsal
adequate offloading or soft tissue rebalancing is head can be used again to confirm completion
unable to resolve these high pressure areas surgi- of the osteotomy. Following the osteotomy, the
cal offloading of the metatarsal head whether metatarsal head will freely displace dorsally.
through osteotomy or metatarsal head resection Fixation is not commonly utilized, however,
may be efficacious [15]. Isolated metatarsal head can be used in the form of a K-wire to maintain
resections while effective at resolving plantar corrected position. Skin closure will be
metatarsal ulcerations have been shown to have achieved with a single suture. Full weight-
high rates of transfer lesion development to an bearing in a “postoperative” shoe will be per-
adjacent metatarsal head and other complications mitted immediately and used until bone healing
such as floating toe [16]. Newer techniques noted on radiographs.
adapted from elective surgery such as the Weil
type osteotomy or floating type osteotomy allow
for reduction in plantar pressures while retaining Use of Functional Antibiotic Spacers
predictability and limiting dissection in the
comorbid patient. Elution of local antibiotics can yield high con-
Distal metatarsal metaphyseal osteotomy centrations into target tissues and can be particu-
(DMMO) is a percutaneous extra-articular larly effective in the setting of chronic
lesser metatarsal neck osteotomy [17], which osteomyelitis and poorly perfused tissues.
can be applied in a minimally invasive fashion Additionally, these antibiotics can be conjoined
to reduce the plantar pressure of the metatarsal with structural filler or spacers such as non-
head responsible for skin ulcerations in dia- absorbable polymethylmethacrylate impreg-
betic feet. Early studies demonstrate notable nated cement, which can be particularly useful
improvement in plantar pressures with reduc- when needing to replace osseous structure lost
tion in the rate of transfer lesions as compared during excision of infected tissue. Early random-
to historical rates with metatarsal head resec- ized controlled trials demonstrate improved clin-
tions [18]. However, in these cases, the need to ical cure rates when utilizing antibiotic
shorten the metatarsal bone must be weighed impregnated bone cement as bone filler in the
against the need to maintain a functional meta- setting of diabetes related osteomyelitis [19].
tarsal parabola to prevent recurrent or transfer Additionally, placement of antibiotic eluting
skin lesions. cement spacers has been shown to have long-
term stability, even in weight-bearing zones [20].
Procedure While these techniques are still in their infancy,
Patient remains in the supine position on the newer devices and compositions will continue to
operative table and the local block is completed expand their utilization and efficacy in this field
with the anesthetic agent of choice. The extrem- (Fig. 26.3).
a b
c d
Fig. 26.3 Clinical images (a, c) and radiographic images (b, d) AP foot view—preoperative (a, b) and postoperative
(c, d) of right third toe proximal interphalangeal joint arthroplasty for rigid hammertoe correction
Osseous Midfoot Deformity achieved. Layer closure is performed, dry sterile

dressing is applied.
Ulcerations of the midfoot can lead to devastat-
ing outcomes. Literature shows that 9% of dia-
betic neuropathic patients with midfoot Osseous Midfoot Reconstruction
ulcerations will go onto proximal amputation
[21]. As with forefoot ulcers, midfoot ulcers are When an exostectomy is not sufficient enough to
generally caused by increased plantar from a surgically treat the deformity, a reconstruction
Charcot, subluxed midfoot joint(s), exostosis, may be necessary to stabilize the midfoot to pre-
poorly performed partial foot amputations [22– vent further joint collapse. If a reconstruction of
24]. First line treatment for midfoot ulcerations is the midfoot is required, generally a combination
external offloading with surgical shoes, custom of osteotomies and fusions is needed as these are
shoes, total contact casting, or Charcot restraint multiple planar deformities (Fig. 26.4). Extensive
orthotic walker (CROW) boot. When conserva- preoperative planning is of paramount impor-
tive treatment fails, surgical intervention is gen- tance when treating Charcot deformities as the
erally recommended. goal of the reconstruction is to [25]:
• Maintain anatomic realignment

Midfoot Exostectomy • Limit soft tissue dissection/use minimally
invasive internal fixation
Plantar foot exostoses can lead to increased plan- • Obtain joint fusion
tar pressure resulting in ulcerations. In patients • Fuse/fixate joint one level beyond Charcot
with stable midfoot joints, consolidated midfoot affected midfoot
Charcot, or who are not in immediate risk of mid- • Use rigid fixation
foot collapse, an exostectomy may be an accept- • Shorten foot to reduce soft tissue tension
able surgical option. • Use of external fixation if indicated
Procedure Procedure
The patient is positioned on the operating table in The patient is positioned on the operating table in
the supine position with an ipsilateral hip bump. the supine position. Ipsilateral hip bump is rec-
The author discourages the use of tourniquet to ommended to prevent external rotation of the hip.
avoid incision healing complications. Incision A thigh tourniquet is recommended for patients
placement is generally along either the medial or without peripheral vascular disease. The equinus
lateral glabrous function, depending on the lateral- deformity is generally addressed first either by a
ity of the exostosis. This is recommended to allow percutaneous tendo-achilles lengthening or gas-
for weight-bearing and prevent wound dehiscence. trocnemius recession. The authors also recom-
A 3 cm incision is made along the glabrous junc- mend fusing the subtalar joint to stress shield the
tion care taken to avoid unnecessary undermining. midfoot correction. Incision placement is along
The muscle belly is retracted inferiorly and dissec- the medial glabrous junction of the midfoot, over
tion is carried plantarly along the bones until the the base of the deformity. Dissection is carried
exostosis is encountered. After adequate dissec- down to bone. A subperiosteal dissection is per-
tion of the exostosis a sagittal saw is used to resect formed superiorly and inferiorly across the mid-
the prominence flush with the plantar border of the foot laterally. A second incision is placed along
midfoot bones. The author recommends resection the lateral glabrous and the subperiosteal dissec-
of an additional 3 mm of bone to ensure the exos- tion is then completed. After the dissection is
tosis is resected. Fluoroscopy is used to confirm completed, the placement of the midfoot osteot-
resection of the exostosis. The incision is irrigated omy is based on the deformity. A section of bone
with copious amounts of saline. Hemostasis is in the midfoot is resected, to realign the foot in all
a b c d
e f g h
Fig. 26.4 Clinical images (a, b, e, f) and radiographic struction with TAL, corrective arthrodesis of the STJ,
imaging (c, d, g, h) multiple views—preoperative (a–d) TNJ, and CCJ, and corrective midfoot osteotomy with
and postoperative (e–h) status post-single-stage multi- internal fixation
level, multi-plane, multi-tissue deformity Charcot recon-
three cardinal planes. It is also recommended to radiographs to observe bony consolidation at the
prepare and fuse adjacent midfoot joints to surgical sites.
increase stability of the construct. After the mid-
foot is realigned and temporarily or provisionally
neutralized, rigid fixation is placed. Options for sseous Rearfoot and Ankle
O
fixation included plates and screws, intramedul- Deformity
lary fixation or external fixation can be used.
Intramedullary beaming is recommended when As is true with deformities within the remainder
appropriate as it decreases soft tissue dissection of the extremity, instances where accommodative
compared to the use of plating. Beaming from the treatment modalities are either insufficient or
first metatarsal across the midfoot to the talus is inappropriate to address the rearfoot and/or ankle
performed to stabilize the medial column. deformity, corrective surgical treatments should
Followed by additional medial column beaming then be considered. Numerous scenarios may
from the second metatarsal into the talus and contribute to a biomechanical deformity in the
lastly lateral column beaming from either the rearfoot and ankle; however, fortunately several
fourth or fifth metatarsal into the calcaneus. In treatment options exist in which to address these
fixating the lateral column, it is important to cases. Ultimately, the specific treatment modality
address the calcaneal cuboid joint sag to prevent should aim to correct the identified primary and
increased pressure plantar to the cuboid. secondary deformities in order to balance the
Following internal fixation and external fixator deforming forces about the extremity and do so in
may be placed to further protect and offload the an effective and definitive manner with the least
reconstruction. Following the reconstruction potential for morbidity to the patient. Exact pro-
patients are non-weight-bearing for several cedure selection for rearfoot and ankle recon-
weeks with regular monitoring of plain film struction is largely based in the specific anatomic
level(s) and plane(s) of involvement which is patients with complex pathologic conditions of
often identifiable by a careful physical examina- the rearfoot and/or ankle that may otherwise war-
tion and with use of imaging modalities of plain rant a below the knee amputation [26–28]
film radiography and computed tomography. (Fig. 26.5). The TTC fusion is defined by certain
Those cases where deformity is either not suffi- risk factors of patients undergoing the procedure
ciently reducible manually, even after soft tissue and includes individuals with comorbidities asso-
release, or is severe in extent, are largely addressed ciated with poor surgical healing or with local
with osseous reconstructive procedures. healing deficits that predispose to a high rate of
delayed healing, nonunion, and malunion, among
others. The TTC fusion can be a viable and func-
Tibiotalocalcaneal Arthrodesis tional option for those with significant deformity
of the rearfoot and/or ankle including significant
Concomitant ankle and subtalar joint fusions, col- malalignment, bone loss, and/or instability.
lectively a tibiotalocalcaneal (TTC) arthrodesis, is Perhaps the stereotypical example of such a surgi-
often considered as a limb salvage procedure in cal candidate is the Charcot’s neuroarthropathy
a b
c d
Fig. 26.5 Radiographic imaging lateral ankle view—postoperative (a–d) status post-tibiotalocalcaneal arthrodesis of
four different patients with various fixation constructs
ankle and/or rearfoot; however, many other additional surgery and thus surgical dissection
instances do occur. The greatest drawbacks to the and rehabilitation. However, in the scenario where
TTC fusion are that it introduces a relatively large the alternative treatment is a more proximal
amount of indwelling hardware, increasing the amputation, a TTC may be considered as a useful
risk of infectious processes, and requires major option (Fig. 26.6).
a b c d
e f g
h i j k
Fig. 26.6 Clinical images and radiographic imaging plantar foot with eradication of infection, optimization of
multiple views—preoperative (a–d) and postoperative healing potential, soft tissue envelope closure, offloading
(e–k) status post-staged approach to multi-level, multi- circular external fixator, subsequent corrective lateral
plane, multi-tissue type deformity reconstruction in the approach fibular “takedown” tibiotalocalcaneal arthrode-
face of inciting wound formation with infection to the sis with TAL and PT tendon transfer
Procedure structural and/or non-structural bone grafting as

The patient is positioned supine on the operating warranted. Additionally, minimally invasive sur-
table with the heel just distal to the edge of the gical joint preparation may be utilized from stan-
bed. An ipsilateral hip bump is utilized as war- dard arthroscopic port locations at the
ranted to attain vertical orientation of the foot and anterolateral, anteromedial, and posterolateral
avoid external rotation of the extremity. A plat- and posteromedial ankle, as well as the anterolat-
form fashioned from several folded blankets or eral and posterolateral subtalar joint. This
operative foam is utilized to elevate the operative approach has the benefit of minimizing surgical
extremity above the level of the contralateral dissection; however, it requires greater surgical
extremity for ease of operative performance, skill and precision than the standard open
including for unobstructed use and views of intra- approach, requires additional equipment, and will
operative fluoroscopy. Alternatively, to remove ultimately restrict one’s options for definitive fix-
the potential for obstruction the contralateral ation construct. Standard open approach surgical
extremity may be placed into “frog leg” position- dissection is carried from skin, superficial fascia,
ing or may be secured with foam padding off the deep fascia, and periosteum/capsule to the level of
bed entirely into a surgical stirrup or the like. A bone of the ankle and subtalar joints. A plethora
thigh tourniquet may be placed in patients without of instrumentation are available in which the car-
existing peripheral vascular disease and used in tilage of the corresponding surfaces of both the
accordance with individual surgeon preference. ankle and subtalar joint is denuded to the level of
The extremity is prepped and draped to at least the healthy and bleeding subchondral bone. Care is
level of the tibial tuberosity in order to maintain taken in which to provide for a maintenance of
accurate visualization for intraoperative align- bone stock so as not to create an excessive amount
ment and orientation of the extremity as well as of bony resection which may add to a loss of
for access during concomitantly performed proce- length and integrity of the extremity while simul-
dures. Soft tissue procedures are largely per- taneously achieving any additional bony angular
formed first in order to initiate, if not attain, or translational correction of the existing
appropriate reducibility of the existing rearfoot deformity(ies) which was not attained in soft tis-
and/or ankle deformity. Equinus ankle deformity, sue corrective procedures. Once the joints are suf-
for instance, may be addressed first either by a ficiently prepared, flushed, grafted as preferred,
tendo-achilles lengthening or tenotomy or gas- and reduction is attainable, the ankle and subtalar
trocnemius recession. Incision placement for the joints are neutralized into the reduced positions
tibiotalocalcaneal arthrodesis is largely dependent and preferred definitive fixation is placed. Given
upon the preferred surgical approach and hard- the extent and location of the procedures a surgi-
ware construct in which the surgeon will gain cal drain is placed and a layered closure is per-
access to the ankle and subtalar joints and place formed. The extremity is placed into a thick,
definitive internal fixation, respectively. An ante- well-padded, and compressive splint and the
rior, anteromedial, and anterolateral ankle inci- patient is maintained in a non-weight-bearing sta-
sion will provide for direct access to the ankle tus for a minimum of 2 months with monitoring
joint alone. An Ollier’s style dorsolateral foot of appropriate clinical and radiographic healing.
incision will provide for direct access to the sub-
talar joint alone. A utilitarian lateral incision will
provide for direct access to the ankle joint and Pantalar Arthrodesis
subtalar joint concomitantly; however, a distal
fibular “takedown” osteotomy may be required in When significant deformity, represented by com-
order to appropriately gain surgical access to the plex malalignment, bone loss, bone infection or
ankle joint. This approach does provide for con- necrosis, and/or instability occurs at both the level
comitant access to both the ankle and subtalar of the ankle and/or foot and within the foot, a pan-
joints with the added benefit of direct access to the talar arthrodesis may be considered as a functional
distal fibular bone which may be utilized for both means of limb preservation [29]. This option pro-
a b c
d e f
Fig. 26.7 Radiographic images (a–f) multiple views— joint with eradication of infection, optimization of healing
preoperative (a–c) and postoperative (d–f) status post potential, soft tissue envelope closure, offloading circular
staged approach to multi-level, multiplanar, multi-tissue external fixator with antibiotic spacer and, progression of
type deformity reconstruction in the face of inciting wound ankle Charcot neuroarthropathy to consolidated state, and
formation with infection to the plantar-lateral foot with subsequent corrective combined lateral approach fibular
subsequent acute Charcot neuroarthropathy of the ankle “takedown” and medial approach Pantalar arthrodesis
duces rigid stability and, when performed cor- lar arthrodesis from either severe post-traumatic or
rectly, adequate reduction of malalignment of the neuropathic arthropathy with an average of
foot and ankle complexes for ambulation 46 month follow-up. They concluded that pantalar
(Fig. 26.7). Numerous approaches and constructs arthrodesis is a reasonable limb salvage option
are available to the surgeon and specific selection regardless of the cause of disability or specific
is largely driven by individual patient presentation, internal fixation device.
including but not limited to the exact anatomic
location(s), plane(s), and severity of involvement Procedure
of their pathology. As is the case with the tibiotalo- Generally, for a combined medial and lateral
calcaneal arthrodesis, the pantalar arthrodesis approach the patient is positioned supine on the
requires additional surgery and rehabilitation, operating table with the heel just distal to the edge
including the ubiquitous placement of internal of the bed. An ipsilateral hip bump is utilized as
fixation. Additionally, with absolute stability and warranted to attain vertical orientation of the foot
rigidity to the ankle and foot, patients require a and avoid external rotation of the extremity. A
rocker-bottom sole modification to their shoe gear platform fashioned from several folded blankets or
in order to afford appropriate midstance rocker for operative foam is utilized to elevate the operative
more normal gait. However, the alternative, and extremity above the level of the contralateral
perhaps quite viable and functional option in the extremity for ease of operative performance,
face of failure of the pantalar arthrodesis, may well including for unobstructed use of intraoperative
be a below the knee amputation. Herscovici et al. fluoroscopy. Alternatively, to remove the potential
[30] saw acceptable outcomes including zero for obstruction the contralateral extremity may be
amputations in their 20 patients undergoing panta- placed into “frog leg” positioning or may be
secured with foam padding off the bed entirely of the existing deformity(ies) which was not
into a surgical stirrup or the like. A thigh tourni- attained in soft tissue corrective procedures. Once
quet may be placed in patients without existing the joints are sufficiently prepared, flushed, grafted
peripheral vascular disease and used according to as preferred, and reduction is attainable, the ankle,
surgeon preference. The extremity is prepped and subtalar, talonavicular, and calcaneocuboid joints
draped to at least the level of the tibial tuberosity in are neutralized into their, respectively, reduced
order to maintain accurate visualization for intra- positions and preferred definitive fixation is
operative alignment and orientation of the extrem- placed. Given the extent and location of the proce-
ity as well as for access during concomitantly dures a surgical drain is placed and a layered clo-
performed procedures. Soft tissue procedures are sure is performed. The extremity is placed into a
largely performed first in order to initiate, if not thick, well-padded, and compressive splint and the
attain, appropriate reducibility of the existing rear- patient is maintained in a non-weight-bearing sta-
foot and/or ankle deformity. Equinus ankle defor- tus for a minimum of 2 months with monitoring of
mity, for instance, may be addressed first either by appropriate clinical and radiographic healing.
a tendo-achilles lengthening or tenotomy or gas-
trocnemius recession. Incision placement for the
combined medial and lateral approach pantalar Adjunctive Procedures
arthrodesis is dictated by access for appropriate
performance of bony preparation and hardware Outside of the auspices of this discussion, but
placement in which the surgeon will gain access to rather important for considerations in osseous
the ankle and subtalar joints, as well as the talona- reconstruction of the rearfoot and ankle are
vicular and calcaneocuboid joints. A curvilinear adjunctive procedures often performed as a sup-
lateral incision will provide for direct access to the plementary portion of the aforementioned tibio-
ankle, subtalar, and calcaneocuboid joints con- talocalcaneal and pantalar fusions in the complex
comitantly; however, a distal fibular “takedown” patient population. The talectomy and the supra-
osteotomy must be performed in order to appropri- malleolar osteotomy are extraordinarily useful
ately gain surgical access to the ankle joint. As adjuncts to the already advantageous osseous
with the tibiotalocalcaneal arthrodesis, this reconstruction procedure options and should be
approach provides for concomitant access to mul- considered as viable adjuncts in the surgeons
tiple joints with the added benefit of direct access perioperative planning.
to the distal fibular bone which may be utilized for
both structural and/or non-structural bone graft-
ing. A medial incision from the tip of the medial Talectomy
malleolus to the skin overlying the naviculocunei-
form joint provides direct access to the talonavicu- Surgical correction of severe osseous deformity
lar joint. Standard open approach surgical and/or osteonecrosis and/or osteomyelitis using a
dissection at each incision is carried from skin, talectomy procedure has previously been
superficial fascia, deep fascia, and capsule to the described in many lower extremity pathologies
level of bone of the ankle, subtalar, calcaneocu- and remains a powerful adjunct within the recon-
boid, and talonavicular joints. A plethora of instru- structive options in the limb salvage patient popu-
mentation are available in which the cartilage of lation. It appears that the mere removal of
the corresponding surfaces of the joints of interest chronically infected and/or necrotic bone of the
is denuded to the level of healthy and bleeding talus can provide the means in which to appropri-
subchondral bone. Again, care is taken in which to ately reduce existing malalignment and rid the
provide for a maintenance of bone stock so as not body of potentially harmful and unstable tissues.
to create an excessive amount of bony resection In the complex patient population talectomy is
which may add to a loss of length and integrity of combined as part of a reconstructive procedure in
the extremity while simultaneously achieving any the form of tibiocalcaneal fusion or pantalar
additional bony angular or translational correction fusion (Fig. 26.8). Langan et al. saw limb salvage
a b c
d e f
g h i j
Fig. 26.8 Clinical and radiographic images multiple potential, talectomy, midfoot osteotomy, extensive foot
views—preoperative (a–c) and postoperative (d–j) status and ankle soft tissue releases, soft tissue envelope closure,
post-staged approach to multi-level, multiplanar, multi- offloading and compressive circular external fixator and
tissue type deformity reconstruction in the face of inciting subsequent exchange of external fixation for internal fixa-
wound formation with infection to the dorsolateral foot tion with pantalar arthrodesis
with eradication of infection, optimization of healing
a b
Fig. 26.9 Radiographic imaging AP ankle views (a, b)— ankle “gutter” decompression achieved with this osteot-
preoperative (a) and postoperative (b) status post-medially omy. Of note, a corrective midfoot osteotomy was per-
based closing wedge type supramalleolar osteotomy for formed concomitantly to reduce the malunited triple
progressive valgus deformity of the tibia secondary to arthrodesis and reposition the foot
malunion triple arthrodesis. Note the significant lateral
occurred in 38 of 45 patients (84.4%) where talec- tibia (and fibula where warranted) may provide
tomy was utilized with 6 of 7 patients (85.7%) single and multi-dimensional correction of the
who ultimately underwent amputation having a extremity in order to produce a more functionally
history of prior infection [31]. Ultimately, they ambulatory limb, especially important in the neu-
concluded chronic lower extremity deformities ropathic population (Fig. 26.9). Horn et al. saw
can successfully be treated with a talectomy as a significant improvement in all postoperative
portion of the reconstructive procedures. radiographic angles in 22 patients with the use of
Admittedly, the loss of height of the talus bone a supramalleolar osteotomy and a dynamic six-
will precipitate structural limb length discrep- axis external fixator [35]. They found this method
ancy; however, this may be remedied with shoe particularly effective for correction with complex
modification or with concomitant use of distrac- deformities, a compromised soft tissue envelope,
tion osteogenesis limb lengthening procedures. or a prior history of infection. Additionally, the
Siddiqui et al. also saw enhanced arthrodesis in
14 of 15 patients (93.3%) by combining distal
Supramalleolar Osteotomy tibial distraction osteogenesis with simultaneous
tibiotalocalcaneal or tibiocalcaneal arthrodesis
Outside of strictly isolated planar deformities of for the rearfoot and ankle in a limb salvage sce-
the ankle joint, the supramalleolar osteotomy nario. They concluded that the supramalleolar
may also be utilized as a useful adjunct in the osteotomy with distraction osteogenesis supports
reconstruction of complex rearfoot and ankle enhanced vascularity to their rearfoot and ankle
deformities [32–34]. An osteotomy through the arthrodesis sites [36].
oft Tissue and Tendon Balancing

S for soft tissue ankle equinus. The authors often
Procedures utilize the traditional Hoke [39] style percutane-
ous triple hemi-section of the distal excursion of
Tendon Lengthening the Achilles tendon for patients with either com-
bined gastrocnemius-soleus equinus as well as
Equinus deformity has classically been described those with isolated gastrocnemius equinus, due to
as limitation of passive ankle joint dorsiflexion to its relatively minimally invasive approach, short
less than a right angle of the foot on the leg. This procedure length, and profound effect on improv-
limitation of joint mobility in dorsiflexion motion ing ambulatory ankle dorsiflexion range of
at the ankle has been implicated as a major motion (Figs. 26.10 and 26.11).
deforming force in the development and chronic-
ity of plantar wound formations as well as mid- Procedure
foot Charcot collapse, among many other With the foot held in maximal dorsiflexion and
pathologies. Glycation-induced collagen cross- the Achilles tendon tensioned, vertical incisions
linking secondary to diabetes mellitus sequelae are made posteriorly at the midline of the skin
causes general disorganization of the Achilles and fascia and into the Achilles tendon at 3, 6,
tendon, decreasing tensile strength and elasticity and 9 cm proximal to the most superior aspect of
while increasing stiffness [14]. These changes in the calcaneus. It is the author’s preference to
addition to the reduction in strength and flexibil-
ity common in increased sedentary lifestyle and
advanced age result in pathologic reduction in
ankle dorsiflexion during stance and swing
phases of gait. This contracture creates profound
increases in plantar pressures to the forefoot and
midfoot, oftentimes precipitating plantar ulcer-
ations in the neuropathic population [37].
Measuring the maximal passive dorsiflexion
available at the ankle with the subtalar joint
locked and the knee extended and then flexed
accomplishes this task. Distinction between gas-
trocnemius or isolated equinus vs. gastrocnemius-
soleus or combined equinus is significant when
considering the correct procedure and level to
perform surgical lengthening of the posterior
group. The Silfverskiold Test is a common and
reproducible way to determine the source of
ankle contracture [38].
Tendo-Achilles Lengthening (TAL)
Tendo-achilles lengthening is a common proce- Fig. 26.10 Clinical image posterior view—incision
dure performed in an assortment of instances of placements for Hoke style triple hemi-section distally
foot and ankle pathology and in a number of based tendo-achilles lengthening (TAL). Traditionally, the
ways in order to achieve restoration of the suffi- Hoke TAL is performed with two medially directed (distal
and proximal) and one laterally directed (central) hemi-
cient ankle dorsiflexion joint excursion required sections; however, surgeon preference dictates actual per-
during normal gait. In the complex wound formance as long as the hemi-sections are performed in
patient, the TAL is truly a utilitarian procedure alternating directions
a b
Fig. 26.11 Clinical images lateral view (a, b)—preoperative (a) and postoperative (b) status post-Hoke style tendo-
achilles lengthening (TAL)
mark these intervals using a ruler and skin marker a gastrocnemius recession alone may be indi-
to ensure safe distance is maintained between cated (Fig. 26.12). The GR has several added
incisions. At each marked interval the surgeon benefits over a distally based TAL procedures,
should palpate the medial and lateral borders of including direct visualization of surgical anat-
the Achilles tendon and a #15 blade is then omy, more proximal calf location which may
inserted mid-substance within the tendon body benefit from superior vascularity, avoidance of
with the blade facing in-line with the tendon procedure in diseased tendon commonly seen
fibers. The blade is then rotated 90° and exited in the comorbid population, and an anecdotally
the tendon in a sweeping motion alternating more “controlled” lengthening of the tissues.
between medial and lateral exits at each interval. Additionally, access for a GR provides for the
In effect this creates three separate partial hemi- ability to also perform a lengthening of the
sections of the Achilles tendon 50% from mid- soleus muscular fascia in what is termed a gas-
line. Oftentimes a “release” of ankle contracture trocnemius-soleus recession, which may be
will be noted with forced dorsiflexion of the preferable for patients with combined gastroc-
ankle, and additional partial swipes may be nemius-soleus equinus and may also be per-
attempted at each tenotomy site to ensure com- formed via an endoscopic approach (Fig. 26.13).
plete hemi-section. This will provide for a correc- The authors ascribe to a traditional Baumann
tion for both combined gastrocnemius-soleus [40] type approach to the GR and GSR when
equinus and isolated gastrocnemius equinus until appropriate (Fig. 26.14).
a sufficient intraoperative Silfverskiold test is
confirmed. Procedure
At 10 cm distal to the tibial tuberosity a 6 cm
incision is centered at 50% of the posterior bulk
astrocnemius Recession (GR)
G of the calf between the medial tibial crest and the
and Gastrocnemius-Soleus Recession posterior aspect of the calf. With the ankle
(GSR) stressed passively into maximal dorsiflexion and
moving from lateral to medial a long-handled
Alternatively, if the Silfverskiold test deter- scalpel with #15 blade is utilized to incise the
mines equinus is visualized only with the knee anterior portion of the gastrocnemius intermus-
extended but not with the knee flexed, patients cular fascia, including the plantaris tendon,
may have isolated gastrocnemius equinus, and exposing the underlying gastrocnemius muscle
a b c
d e f
Fig. 26.12 Clinical images medial view (a–f)—preop- nemius equinus. Postoperative (e, f) status post-Baumann
erative (a–d) Silfverskiold test performed in a patient after style gastrocnemius recession (GR) shows a reduction of
a successful transmetatarsal amputation with free tissue the passive ankle joint dorsiflexion range of motion
flap for closure displaying formation of isolated gastroc-
stroke or acquired flexible forefoot equinovarus

following partial foot amputation. Patients with
plantar-lateral foot ulcerations, lateral column
amputations with the loss of the peroneus brevis
insertion or loss of peroneal tendon function
often have increased supinatory motion and thus
can benefit from the ATTT [43, 44] (Fig. 26.15).
Transfer of the anterior tibial (AT) tendon to the
lateral column can effectively balance the foot by
increasing everting forces and decreasing lateral
column pressures (Fig. 26.16). Traditionally, the
distal insertion of the tendon is released from its
medial attachment and transferred laterally to the
lateral cuneiform. This aids to balance the power-
ful supinatory force of the posterior tibial tendon
while maintaining active dorsiflexion of the foot.
Additionally, lateralizing the transfer on the foot
can increase its everting force, thus can be used
to treated spastic rearfoot varus, spastic
equniovarus, fixed equinovarus, and excessive

supination.
Fig. 26.13 Clinical image medial view—incision place-
ment for endoscopic gastrocnemius-soleus recession Procedure
The patient is placed in the supine position. A
thigh tourniquet and ipsilateral hip bump is gen-
belly. This will provide for a correction of iso- erally used. As with most tendon transfers, gen-
lated gastrocnemius equinus. Additional releases eral anesthesia with paralysis is recommended.
to subsequent portions of the gastrocnemius The transfer of the anterior tibial tendon is gener-
intermuscular fascia may be performed until a ally performed through three incisions. When
sufficient intraoperative Silfverskiold test is con- harvesting the tendon, the initial dorsal medial
firmed. As mentioned, additional recession of 3–4 cm incision is made over the medial
the soleus intramuscular fascia is also easily cuneiform- metatarsal joint (directly over the
accessible from this approach for instances of insertion of the tendon). Expose and transect the
combined gastrocnemius-soleus equinus for tendon at its insertion and tag end of the tendon
GSR [41]. with a suture. The second incision is placed just
lateral to the myotendinous junction in the distal
lower leg. Palpate the course of the anterior tibial
Tendon Transfers tendon to just below the muscle belly. A 3–4 cm
incision is made just lateral to the tendon. This
nterior Tibial Tendon Transfer
A incision can be placed about 10–12 cm proximal
The anterior tibial tendon transfer (ATTT) was to the ankle joint. Incise the tendon sheath and
first described in 1940 for the correction of resid- expose the AT tendon. Harvest the transected ten-
ual pediatric clubfoot [42, 43]. Since then, the don proximally to its origin. Once harvested, a
indications for the ATTT) have expanded, where 2-0 prolene can be used) to whip stitch the distal
it is widely used to counter varus and supinatory portion of the tendon. The placement of the third
forces while maintaining active dorsiflexion [43]. incision is dependent on the desired function of
This is particularly useful in the treatment of the tendon. If pure dorsiflexion is desired, then
acquired pathology such as dropfoot following the incision is placed over the lateral cuneiform
a b
c d
Fig. 26.14 Clinical images medial view (a–d)—intraop- visualization of the soleus, gastrocnemius and plantaris,
erative Baumann style gastrocnemius recession with (a) (d) status post-recession of the gastrocnemius intermus-
incision planning, (b) use of a vaginal speculum for cular fascia, including the plantaris tendon, exposing the
appropriate visualization in the interval between the gas- underlying gastrocnemius muscle belly
trocnemius and soleus intermuscular septum, (c) anatomic
and the tendon is transferred into bone. If more of patient is splinted and non-weight-bearing for 6
an eversion force is needed, a 3–4 cm can be weeks.
placed over the base of either fourth or fifth meta- When planning this transfer, the AT tendon
tarsal or distal cuboid. The tendon may be trans- muscle must have a minimal muscle strength of
ferred into any of these bones. Next a tendon 4. Anything less will not have the desired result.
passer is tunneled subfascially from the third Pitfalls to the complete AT tendon transfer
incision to the second incision. The tendon is include complete loss of function of the tendon at
pulled through to the lateral incision. Once the its native insertion, over tensioning can cause a
desired location of the transfer is exposed, a drill severe pes planovalgus deformity and nerve irri-
hole is made through the bone. The suture on a tation [43, 44]. It is all also recommended a
straight needle is fed through the bone tunnel out tendo-achilles length be performed in conjuga-
the plantar foot. The foot is then everted and dor- tion with the transfer to address any equinus
siflexed slightly beyond neutral and a biotenode- deformity.
sis screw is used to secure the tendon into the
bone. The excessive suture is cut. The foot is plit Tibialis Anterior Tendon Transfer
S
placed through a gentle range of motion to deter- The split tibialis anterior tendon transfer (STATT)
mine if desired correction) is achieved. Incisions procedure has gained some favor primarily as
are irrigated and layer closure is performed. The half of the transfer remains intact at its native
a b
Fig. 26.15 Clinical images AP view (a, b)—preopera- varus following transmetatarsal amputation. Note the sig-
tive (a) and postoperative (b) status post-anterior tibial nificant correction of the forefoot varus positioning and
tendon transfer (ATTT) for retained flexible forefoot maintenance of balanced positioning postoperatively
insertion. The indications for the STATT are sim- loop passer is fed through the tendon sheath from
ilar to the complete tendon transfer. The tendon the tendon’s insertion at the medial cuneiform
can be transferred to the same locations as the first metatarsal joint proximally up to the second
complete transfer [45]. If the desired location is incision. The suture is pulled through the tendon
the base of the fifth metatarsal, the tendon may be sheath distally. The foot is slightly plantarflexed
tenodesed to the peroneus tertius. and inverted to tension the tendon. In a back-and-
forth sawing motion the suture is pulled distally
Procedure toward the tendon insertion splitting the tendon
Patient positioning, anesthesia, incision, and har- in half. Care must be taken to pull the suture in
vest technique are the same for the STATT and the longitudinal direction of the tendon. If the
AT tendon transfers with one minor difference. suture deviates, it can cause premature transec-
After the tendon is exposed in the lower leg, an tion of the tendon. This can cause loss of tendon
osteotome or malleable retractor is placed under length. Once the suture exits distally at the inser-
the tendon and tension is applied to the tendon. tion, the lateral half of the tendon is identified)
After the tendon) is held taut, using a # 15 blade and transected. This portion is pulled proximally.
a longitudinal full-thickness stab incision is made A 2-0 prolene is whip stitched through the har-
in the central aspect of the tendon. A 0–0 prolene vested tendon. The lateral portion of the tendon is
or braided suture is fed through the split until then tunneled subcutaneously to the lateral foot
equal length suture is on either end of the split. and transferred into the base of the fourth, fifth
(The authors prefer to use fibertape to split the metatarsal or distal cuboid. It may also be teno-
tendon longitudinally.) A tendon passer or suture desed to the peroneus brevis. As with the AT ten-
a b c
d e f
Fig. 26.16 Clinical images multiple views—sequential suture in the form of a whip style stitch to the distal ten-
cadaveric performance of the AT tendon transfer into the don, (e) final passing of the tendon to the dorsal foot with
lateral cuneiform bone via: (a) three-incision approach, fixation via a biotenodesis screw, and (f) additional fixa-
(b) harvesting of the AT tendon at its insertion, (c) passing tion with external button fashioned from the plunger of a
of the tendon to the anterior leg compartment, proximal to 60 cc syringe and dry sterile sponge
the extensor retinaculum, (d) placement of a passing
don transfer the foot must be slightly everted and as it preserves native anterior tibial tendon func-
dorsiflexed beyond neutral before fixating. tion as well decreases risk of severe pes planoval-
Postoperative course is the same as with the AT gus deformity. Similarly, a tendo-achilles
tendon transfer. Planning for the STATT is the lengthening is recommended in conjunction with
same as with the AT tendon transfers. The STATT the transfer. Pitfalls to the STATT include under
has advantages over the complete tendon transfer correction and tendon rupture.
a b
Fig. 26.17 Clinical images AP view (a, b)—preopera- following Lisfranc level amputation. Note the significant
tive (a) and postoperative (b) status post-posterior tibial correction of the forefoot varus positioning and mainte-
(PT) tendon transfer for combined equinovarus deformity nance of balanced positioning postoperatively
osterior Tibial Tendon Transfer

P This is commonly seen when osteomyelitis to
The anterior placed transfer of the posterior tib- the base of the fifth metatarsal requires loss of
ial (PT) Tendon was first described by Ober in peroneus brevis insertion point (Fig. 26.17). A
1933 [46]. Putti discussed transferring the ten- four-incision approach is preferred in order to
don through the interosseous membrane in harvest, prepare, pass, and subsequently secure
1937, but this procedure was popularized by the entirety of the PT tendon into a lateralized
Watkins in 1955 [47]. Transfer of this tendon to position relative to the axis of motion of both
the dorsum of the foot is mainly indicated for the subtalar joint and long axis of the midtarsal
dorsiflexory weakness or paralysis such as is joint (Fig. 26.18). The authors prefer a complete
found in weak or paralyzed anterior muscle PT tendon transfer utilizing a four- incision
group, equinovarus, spastic equinovarus, recur- approach as it provides greater functional action
rent clubfoot deformities, dropfoot, Charcot- of the tendon while also completely removing it
Marie-Tooth disease, peroneal nerve palsy, and from contributing as a deforming force.
Duchenne muscular dystrophy. PT tendon trans- Additionally if the spring ligament and capsule
fers can also be used to reduce deforming supi- of the talonavicular joint are intact they are
natory forces and reduce varus recurrence such likely not to permit midfoot progression to pla-
as in the setting of peroneal tendon weakness. nus deformity.
a b c
d e f
Fig. 26.18 Clinical images multiple views—sequential suture in the form of a whip style stitch to the distal ten-
cadaveric performance of the PT tendon transfer into the don, (e) passing of the tendon to the anterior leg compart-
cuboid bone via (a, b) four-incision approach, (c) with ment via and interosseous membrane approach, (f) final
harvesting of the PT tendon at its insertion, (d) passing of passing of the tendon to the dorsal foot with fixation via a
the tendon to the deep posterior leg compartment, proxi- biotenodesis screw
mal to the flexor retinaculum with placement of a passing
Procedure navicular tuberosity. This incision is generally

The patient is placed in the supine position. A 3–4 cm in length. Dissection is carried down to
thigh tourniquet and ipsilateral hip bump is gener- the tendon insertion, care is taken to preserve the
ally used. As with most tendon transfers, general flexor digitorum longus tendon. Preserving as
anesthesia with paralysis is recommended. The much of the PT tendon as possible, the tendon is
transfer of the posterior tibial tendon to the dor- dissected off the navicular distally to proximally.
sum of the foot is generally performed through Using a 2-0 prolene a whip stitch is placed through
four incisions. The first incision made medial the distal tendon. A second 3 cm incision is made
directly over the insertion of the tendon on the 13–15 cm proximal to the distal tip of the medial
malleolus on the medial calf just posterior to the xternal Fixation for Surgical
E
medial aspect of the tibial crest. Dissection is car- Offloading
ried down through the fascia, the first tendon
encountered is the flexor digitorum longus which The use of external fixation is a viable alterna-
is retracted out of the way. Next the PT tendon is tive or even primary treatment to the aforemen-
encountered. The distal tendon stump is then tioned offloading strategies, especially when
pulled proximally through the second incision. A strict offloading or additional structural stability
hemostat may be used to assist with retrieval. is absolutely necessary (Fig. 26.19). An external
Next using a large hemostat blunt, careful dissec- fixator may be applied either immediately fol-
tion is performed in distal and lateral direction on lowing a definitive reconstructive closure attempt
the posterior tibia. Care must be taken to avoid the or during an interim period where an open surgi-
neurovascular bundle as it resides in this area. cal site requires offloading, structural support, or
Once the interosseous membrane is encountered, immobilization. Patients with tenuous or fragile
it is penetrated and the hemostat is advanced dis- grafts or flaps or other procedures like joint
tally and laterally until the anterior skin is tented. arthroplasty or fusion, osteotomy, and hardware
A third, 3 cm incision is made over the tented removal/exchange may benefit from the weight-
skin. The hemostat is opened widely to enlarge relief and/or structural support provided by an
the interosseous window. Leaving the hemostat external fixator. A wire or pin hybrid “frame”
open, a tendon passer is fed from the third inci-
sion to the second incision. The tendon is then fed
through the membrane anteriorly out through the
third incision. The fourth incision 3–4 cm can be
placed over the lateral cuneiform or cuboid
depending on desired tendon function and length
(lateralizing the tendon insertion increased ever-
sion force). The tendon is then passed deep to the
extensor retinaculum and out the fourth incision.
A drill hole is made through the bone and the
suture on a free needle is fed through the bone
tunnel and out the plantar foot. The foot is held at
neutral in the sagittal plane and/or slight eversion
when correcting for a varus deformity or lateral
column ulcers. The tendon is tensioned and the
biotenodesis screw is inserted. All incisions are
irrigated, and a layered closure is performed. The
patient is placed in a splint and non-weight-bear-
ing for 6 weeks. The surgeon should be mindful of
the length of the tendon when considering a PT
tendon transfer. Care must be taken to preserve as
much length as possible. The interosseous win-
dow should be wide enough to prevent any tether-
ing of the tendon. It is also recommended to
address any equinus deformity with an Achilles Fig. 26.19 Clinical image AP ankle view—ringed (cir-
tendon lengthening or posterior ankle capsule cular) external fixator with hybridized skinny wire and
release when performing the PT tendon transfer. half-pin construct design. The use of external fixation pos-
sesses a wide variety of constructs and uses in the com-
If there is concern for medial column instability a plex wound population from static offloading,
flexor digitorum longus tendon transfer to the immobilization, osseous compression, and dynamic mul-
navicular can be considered. tiplanar deformity correction
may be applied in innumerable construct fash- ulceration, prior to wound formation.

ions and several manufacturers provide circular Deformities such as hammertoes, bunions, hal-
or “Ilizarov” frames, principally aimed at lux rigidus, tailor’s bunions, pes planus, pes
offloading or providing immobilization of a par- cavus, and ankle equinus are the most common
ticular area about the foot and ankle. The pri- pathologies that can lead to ulcerations in the
mary shortcoming to this type of offloading is neuropathic foot [48, 49]. When custom shoes
the morbidity associated with such a construct. or inserts fail to properly accommodate poten-
Well-known potential complications associated tial sites of ulcerations, surgical correction
with external fixation frames include pin or wire should be necessary.
site irritation and/or infection, pin or wire fail- When performing an elective surgical proce-
ure, pin or wire associated fracture as well as dure on a high risk patient, the surgeon must
external fixator associated psychosis or “cage understand the increased risk of wound healing
rage.” Certainly, not every patient is considered a complication and infection compared to a
candidate for this type of offloading and those healthy individual. The authors recommend a
under consideration should be properly coun- thorough vascular work-up including arterial
seled about the realistic expectations, the bene- studies with vascular surgery consultation, gly-
fits of such a construct, and the potential for cosylated hemoglobin A1c of 7.9 or lower, fast-
complication. Although not infallible, one may ing glucose level of less than 200 mL/dL on day
minimize the potentiation for the aforemen- of surgery, smoking/nicotine cessation greater
tioned and associated complications of external than 6 weeks prior to surgery on any high risk
fixation by minimizing the patients collective surgical patient. It is also recommended to limit
time within the fixator, by providing as rigid and the amount of absorbable suture used and con-
stable a construct as the tissues will tolerate, and sider using antibiotic powder or biodegradable
by providing for inherent contingency of the antibiotic delivery device on hardware and inci-
internal component parts so that, should a pin or sions. Following surgical correction of a pedal
wire experience breakage or irritation/infection, deformity, it is strongly encouraged patients
a simple removal in office or bedside may be uti- receive custom inserts/shoes after they have
lized, sparing the patient unneeded operative and completely healed. Patients should be followed
anesthesia intervention for wire or pin exchanges. routinely indefinitely after surgery for preventa-
The authors prefer to plan utilization of external tive care.
fixation for a maximum time period of
4–8 weeks, when possible, utilize a four-ring
construct (two tibial rings, one talus ring, and Summary
one footplate ring), utilize a hybridized skinny
wire and half-pin combination of fixation at the The diabetic foot and ankle is a complex struc-
tibial rings, and utilize the narrowest ringed con- ture with multiple intrinsic and extrinsic factors.
struct amenable to the patient’s anatomy. In Surgical offloading and prophylactic surgery per-
these ways, the possibility of many of the most formed at the appropriate time can be critical in
common complications of external fixation can preventing amputation. Identifying high pressure
be minimized. areas and selecting the appropriate surgical pro-
cedure is of paramount importance. Insufficient
surgical offloading or unnecessary surgical pro-
rophylactic Surgery in Limb
P cedures increase the risk of amputation. However,
Salvage when performed appropriately, surgical offload-
ing and prophylactic surgery can be a power tool
In the high risk patient population, it may be in treating and preventing ulcers in the high risk
beneficial to prophylactically correct a pedal diabetic foot.
deformity which has the potential to insite
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Eizenberg N, Wolfe R, Graham HK. Lengthening of
Negative Pressure Wound Therapy
27
Paul J. Kim
Introduction device consists of a porous interface (foam or

gauze material), drape, tubing, canister, and a
Negative Pressure Wound Therapy (NPWT) has pump. Further, NPWT is used over closed inci-
been utilized in wound care and limb salvage/ sions to decrease incision-related complications.
limb function preservation for almost 30 years. There have been many innovations in the original
This technology is considered an adjunctive stan- device design that include improvements in the
dard of care treatment modality utilized in both software, hardware interface, the addition of
the inpatient and outpatient settings. Imparting instillation, foam and drape construct. Other
negative pressure onto the surface of wounds innovations include increasing portability
optimizes the wound bed by promoting the gen- through smaller devices as well as mechanically
eration of granulation tissue, neovascularization, and not electrically powered pumps (Fig. 27.1)
enhancing venous and lymphatic drainage, reduc- (Table 27.1).
tion of bacteria, and decreasing wound size. The
Author Disclosure: 3 M. Inc.
P. J. Kim (*)
Department of Plastic Surgery, University of Texas
Southwestern, Dallas, TX, USA
Department of Orthopedic Surgery, University of
Texas Southwestern, Dallas, TX, USA

392 P. J. Kim
Fig. 27.1 There are a

variety of innovations Instillation Incisional
that have branched from
the traditional NPWT
NPWT NPWT
device Novel Drape
Waffle Design
NPWT
Portable Open Abdomen
NPWT NPWT
Table 27.1 Advantages and disadvantages to NPWT ined the effect of different pressures on granula-
systems
tion tissue growth [1]. This study may have been
Advantages Disadvantages erroneously extrapolated to suggest that granula-
Standard Promotes wound Has battery backup
tion tissue growth is the goal of NPWT. However,
NPWT bed conversion but still needs
to a healthier electricity for it is important to understand that granulation tis-
state recharge sue should be viewed simply as a sign of wound
Mechanically Mobility Limited for the use bed health and not necessarily the clinical end
powered of smaller, goal. The presence of granulation tissue indicates
portable minimally
NPWT exudative wounds adequate perfusion and low bioburden (bacteria
Incisional Decrease in No direct and nonviable tissue). Granulation tissue is
NPWT incisional visualization of the essentially a bed of capillaries imbedded in a col-
complications incision lagen matrix. This environment increases the
Higher cost than
traditional incision
likelihood of epithelization or provides a base to
dressings receive and incorporate a split-thickness skin
NPWT with Clearance of Potential for leaks graft, allograft, or xenograft.
instillation bacteria and maceration NPWT can be programmed for continuous
Can only be application of negative pressure or intermittent
utilized in the acute
setting or some application of negative pressure. The evidence
long-term acute suggests that the intermittency (periods of lower
care settings or no negative pressure) is the preferred method
NPWT negative pressure wound therapy in stimulating the wound bed. Morykwas et al.
report that there is a 40% greater granulation tis-
sue growth with intermittent negative pressure as
Mechanism of Action compared with continuous negative pressure [2].
The intermittency appears to stimulate a greater
There are multiple proposed mechanisms of response in cell proliferation and angiogenesis
action for NPWT. The base device of NPWT pro- [3]. The engagement and disengagement of
vides multiple positive effects on the wound bed negative pressure provides the stimulus to the
beyond that of decreasing overall wound dimen- wound bed to react in response to tissue stress.
sions and exudate removal (Fig. 27.2). Some The effect appears to be on small vessels in pro-
believe that the primary clinical goal for the use moting a more organized, more dense vascular
of NPWT is to promote the growth of granulation structure [4, 5]. Despite the evidence to suggest
tissue. Morykwas et al. in a porcine study exam- that intermittency is superior, many clinicians
27 Negative Pressure Wound Therapy 393
Fig. 27.2 There is good Well Aligned

alignment between the
goals of wound healing Goals of Wound Healing Mechanism of NPWT
and the mechanism of • Remove Goals of Wound Healing
exudate • Remove exudate
NPWT
• Promote granulation tissue • Promote granulation tissue
• Increase local perfusion • Increase local perfusion
• Decrease bacteria and • Decrease bacteria and contamination
contamination
Novel Foam
NPWT
with Instillation
NPWT
Fig. 27.3 This figure conceptualizes the combination of foam is the roof, and the novel drape is the shingles. The
the innovations of NPWT. NPWT is the foundation of the innovations build on the fundamental benefits of standard
house, while NPWT with instillation is its walls, the novel NPWT
utilize the continuous setting for pragmatic rea- sions decreases the strain across the wound bed
sons including the reduced likelihood of leaks and provides laxity in the tissue. Thus, the type of
and alarms, and for greater patient comfort. A tissue or anatomical location of the wound dictates
more recent porcine study by Lessing et al. the degree of macrodeformation [8]. For example,
reports no difference in granulation tissue thick- indurated tissue will have less ability for macrode-
ness between continuous and intermittent nega- formation. Microdeformation is imparted through
tive pressure [6]. Further, they report that the use the perforations in the porous foam. This type of
of NPWT with instillation promotes greater gran- force is responsible for protein activation and the
ulation thickness than either continuous or intercellular effects that promote cell migration and
mittent negative pressure. neovascularization [3]. The variants of NPWT
The mechanical forces imparted by negative including Negative Pressure Wound Therapy with
pressure provides for both macrodeformation and Instillation (NPWTi) and incisional NPWT pro-
microdeformation [7]. Macrodeformation is vide additional and different effects on tissue.
essentially the centripetal forces that shrink the The most widely used NPWTi device utilizes
overall wound dimensions when negative pressure a solution that is programmed to intermittently
is applied. The decrease in overall wound dimen- bathe the surface of the wound (Fig. 27.3). There
394 P. J. Kim
are other NPWTi devices that provide continuous mittency of negative pressure which the evidence
flow of solution across the wound bed. Essentially, suggests is superior to that of a continuous nega-
NPWTi combines the benefits of negative pres- tive pressure setting as discussed above.
sure and wound irrigation. The proposed Incisional NPWT decreases the initial tensile
mechanism of action of NPWTi is to provide a forces experienced along the incision line by
medium, through the instillate, to hydrate, solubi- 50% by distributing the forces over a wider sur-
lize, and evacuate the nonviable tissue as well as face area [14]. Further, incisional NPWT has
provide a medium for the bacteria to be removed been reported to decrease edema through reliev-
and perhaps decrease the likelihood of reattach- ing venous congestion and enhancing lymphatic
ment. NPWTi has been demonstrated to not only drainage [15–17]. This may have 2 consequences:
reduce planktonic bacteria amounts but also (1) the decrease in edema decreases the tension
destroy mature biofilm in in vivo and ex vivo por- along the incision, (2) expedite healing by more
cine models [9, 10]. Yang et al. report in chronic rapidly removing inflammatory factors. Incisional
human wounds a 48% reduction of bacterial negative pressure is not designed to directly
amount utilizing NPWTi as compared with a remove the underlying fluid in the incisional area.
14% increase in bacterial amount with the use of It is recommended that drains be used to serve
standard NPWT [11]. Some have postulated that this purpose. These drains should be placed at a
the reduction of bacteria may simply be the effect distance from the foam/drape or gauze/drape
of an antimicrobial solution on the wound bed construct to prevent interference with the device.
and has little to do with the NPWTi device itself. Some have proposed that there are long-term
Kim et al. report in a randomized controlled trial benefits that include an increase in tensile
of NPWTi in infected wounds; no difference in strength across the incisional area and more orga-
various surrogate clinical outcomes (e.g., length nized scarring [17].
of hospitalization, number of surgeries) utilizing
normal saline as compared with polyhexanide
with betaine [12]. Kim et al. reported in a retro- Indications
spective study on infected wounds a significant
decrease in the number of operations, length of NPWT is utilized for soft tissue defects in all
hospitalization, and shorter time to final surgical areas of the body. It is not indicated in areas such
procedure utilizing NPWTi with normal saline as as inside the abdominal or thoracic cavities, spi-
compared with standard NPWT [13]. This study nal cord or brain, directly over identifiable ves-
suggests that there is an additive positive effect sels or nerves. NPWT can promote granulation
for the use of NPWTi beyond that of solely utiliz- tissue over less vascular structures such as bone,
ing an antiseptic solution or standard NPWT. capsule, ligament, or tendon. However, the area
A variety of solutions have been utilized with must have adequate perfusion in order for this to
NPWTi. To date there is no robust data to suggest occur. Thus, noninvasive or invasive vascular
one type of solution is clearly superior to another. studies and/or intervention should be conducted
Antiseptics may have a role in highly infected or prior to treatment onset. NPWT should be
contaminated wounds. However, there may be reserved for wounds that are not progressing, for
cytotoxic effects on healthy tissue that prohibit complex wounds, or in compromised patients.
its prolonged use. Normal saline is a viable alter- Historically, NPWT was utilized to promote
native in many cases due to its wide availability wound healing over time in a relatively clean
and its tolerability. The instillate can also serve to wound bed. Armstrong et al. in the pivotal study
moisturize the wound surface, thereby hydrating in post-amputation foot wounds report a faster
the underlying tissue and reduce desiccation. time to granulation with the use of NPWT com-
This is especially important for tissues such as pared with standard gauze dressing (42 vs.
ligament, tendon, and joint capsule. Another 84 days) [18]. The technology has evolved as an
potential advantage is that NPWTi requires inter- adjunctive therapy in wounds that are infected/
contaminated, and for closed surgical incisions in tissue over deeper exposed structures. In the
high-risk populations. Each NPWT platform has lower extremity the fundamental principles of
unique properties and characteristics that require optimized perfusion, medical management and
proper application in order to maximize its ben- optimization of comorbidities, nutritional
efits (Table 27.2). enhancement, serial sharp excisional debride-
ment, and offloading/immobilization should be
adhered to along with NPWT. There should be an
Chronic Wounds ultimate treatment goal when utilizing
NPWT. This includes: (1) terminal epithelializa-
NPWT should be considered for wounds that are tion, (2) creation of a wound bed that will support
not healing as demonstrated by wound volume or a split-thickness skin graft or other grafts, (3) as
surface area reduction. Further, the quality of the part of staged approach for a local flap or free tis-
tissue in the wound bed may also benefit from sue transfer. NPWT should not be used for a
NPWT by promoting the growth of granulation lengthy period without regular wound evaluation
to assess that NPWT has had positive effects on
the wound. If NPWT has demonstrated little or
Table 27.2 Tips and pearls for the use of NPWT
no change to the wound bed, other treatment
systems
options should be considered.
Tips and pearls
Traditional NPWT should not be used if there
Standard NPWT • Establish a definitive treatment
goal (terminal epithelization, is an active infection or necrotic tissue in the
wound bed preparation for a graft) wound bed. The infection should be treated and
• Use bridging techniques away the necrotic tissue removed prior to application
from weightbearing or boney of NPWT. If the patient is not a surgical candi-
prominences
Mechanically • Use only on small, minimally
date or the patient refuses surgical intervention,
powered portable exudative wounds NPWTi with the novel foam with the large perfo-
NPWT • Should be reserved for outpatient ration may be an option for wounds that have
to maximize its portability areas of necrotic and fibrotic tissue. This foam
Incisional • Utilize drains as necessary away
will be discussed in further detail below.
NPWT from the incision line
• If utilizing the traditional black NPWT has also been utilized as a bolster for
foam (not the prefabricated grafts [19, 20]. The foam or gauze is applied over
construct), cut the width that an autologous graft, allograft, or xenograft and
expands at least 2 cm on both sides
negative pressure is applied. The proposed benefit
of the incision line
NPWT with • Do not use large volumes of for this approach is to reduce seroma or hematoma
instillation solution per dwell cycle formation that could otherwise lift the graft off the
• The volume of instillate may need wound bed surface by evacuating fluid. The other
to be adjusted at each dressing proposed benefit is to affix the wound bed and the
change with changing dimensions
of the wound graft together to prevent graft drift or floating of
• Use of ostomy rings or paste may the graft. There have been multiple reports of this
be helpful to maintain a seal technique in the literature; however these have
utilizing the traditional polyvinyl been relegated to case studies/case series and
drape, but do not use these
products with the silicone underpowered comparative studies, thus the ulti-
composite drape mate benefit remains unclear [21–25].
• The novel foam should only be
used with NPWT with instillation
and not with traditional NPWT
Closed Incisions
NPWT negative pressure wound therapy
NPWT has been demonstrated to decrease com-

plication in high-risk populations across all sur-
396 P. J. Kim
a b c
Fig. 27.4 (a) A photo of the posterior aspect of the heel photograph of an incisional negative pressure device
after a partial calcanectomy and primary closure was per- applied over the incision. This device was applied for
formed to treat a chronic plantar heel ulcer with underly- 10 days. (c) A clinical photograph 4 weeks after closure.
ing osteomyelitis. This is a patient with type 2 diabetes Note the well-healed incision
and peripheral vascular disease. (b) An intraoperative
gical specialties over closed incisions (Fig. 27.4). strong trend (p = 0.06) with a fourfold reduction
The device is placed over an incision at the time [28].
of surgical closure in the operating room. Surgical Prior to the introduction of the prefabricated
dehiscence can occur for a variety of reasons dressings for incisional NPWT, traditional dress-
including host factors including age, comorbidi- ing kits were utilized. It is important that if utiliz-
ties, and anatomical location. Incisional NPWT ing the traditional dressing kits, the width of the
provides for local management of the incision. contact foam/gauze span the incision with the
The literature is replete with publications sup- material applied at least 2 cm on each side of the
porting the use of incisional NPWT to decrease incision line. This allows for negative pressure to
complications (dehiscence and infection) related affect the tissue surrounding the incision line.
to surgical incisions in a variety of anatomical The prefabricated dressing kits are specifically
locations. Stannard et al. were one of the first to constructed for closed incisions and are con-
report a significant decrease (1/5th less likely) in structed with these specific dimensions. There
surgical site infections for open fracture manage- has been some speculation that lower negative
ment [26]. De Vries et al. report in a metanalysis pressure settings should be utilized over closed
of randomized controlled trials that there is a incisions. There is no robust evidence in either
decrease in surgical site infections with the use of direction whether this should be conducted.
incisional NPWT as compared with customary
dressings [27]. The potential cost saving in com-
plication prevention is difficult to estimate. Infected/Contaminated Wounds
Karlakki et al. report in a randomized controlled
trial a significant reduction of length of hospital- There is a growing acceptance for the use of
ization for primary hip and knee arthroplasties NPWT with instillation (NPWTi) as an adjunct
but do not report a significant reduction in surgi- treatment for infected/contaminated wounds
cal wound complications although there was a [29–34]. Typically, these wounds are excisionally
debrided and antibiotic therapy initiated prior to quicker conversion of the wound bed for closure
application of NPWTi. Kim et al. report in a pro- or coverage with a graft, (3) reduces bacteria
spective, multicenter, randomized trial a 3-log amounts, (4) has a lower number of postoperative
difference in the reduction of bacteria in favor of wound-related complications [37]. In the acute
NPWTi as compared with conventional NPWT care setting. NPWTi may be the preferred nega-
[35]. All wounds in this study were surgically tive pressure platform.
debrided and managed in the acute care setting. It
is important to explore all tunnels to prevent
instillate fluid from being trapped in deeper tis- Innovation
sue pockets. NPWTi can be used in the interval
between staged excisional debridement. NPWTi Foam
is discontinued once the wound bed is ready for
closure or coverage. However, NPWTi can also A novel foam with larger perforations have
be utilized to prepare the wound bed prior to the more recently been introduced (Fig. 27.5). This
single-staged closure or coverage or utilized after construct involves the use of at least 2 stiffer
the initial excisional debridement with no imme- foam pieces stacked on top of each other. The
diate plan for coverage or closure [36]. perforated foam dressing is placed in contact
A recent metanalysis suggests that NPWTi, as with the wound bed, then another foam dressing
compared to NPWT and other wound therapies, is placed on top of the perforated foam dressing.
has positive clinical and economic benefits by This foam construct is used in conjunction with
facilitating efficiency in wound bed conversion. NPWTi and not with standard NPWT. The prob-
Gabriel et al. report that NPWTi: (1) requires a able mechanism of action is as follows: (1) the
fewer number of surgical debridements, (2) a solution emulsifies the nonviable tissue (necrotic
Fig. 27.5 (a) This photograph of a chronic plantar foot application of NPWT with instillation (normal saline) and
wound with significant amount of liquified, nonviable tis- the novel foam. This was applied for 3 days. Note the con-
sue. The patient had a prior surgical intervention that version of the wound to a healthier state with a decrease in
dehisced creating a chronic ulcer. This is a patient who the amount of nonviable tissue as well as the growth of
refused surgical intervention for excisional debridement. granulation tissue
(b) This photograph is at the first dressing change after
398 P. J. Kim
and fibrotic tissue) during the dwell cycle, (2) as activate to adhere to the skin surface. The sili-
the negative pressure is applied, the larger per- cone contact layer is also safe on fragile skin.
forations draws tissue through these holes, (3) This drape can be used for traditional NPWT or
the cycling of dwell and negative pressure with NPWTi. This novel drape is yet to be widely
against this novel foam construct mechanically available or adopted but it is a significant step
breaks up the tissue, (4) the instillate provides forward.
an avenue for the nonviable tissue to be evacu-
ated into the egress canister. This novel foam
may be a good option for wounds that contain Portability
nonviable, necrotic, or sloughy tissue in patients
who are not surgical candidates, refuse surgical Portability has allowed for NPWT to be more
intervention, there is no surgeon available for easily transferred from the acute setting to home
excisional debridement, or have had inadequate or rehabilitation facility. Rechargeable battery
sharp debridement performed [38]. Although powered NPWT devices allow for the patient to
this innovation is promising, there is currently be more mobile. Other portable NPWT devices
no robust studies with only a limited number of do not require electrically powered pumps but
case studies/series reporting positive outcomes rather rely on potential energy stored in a coiled
[39, 40]. spring. These mechanically powered devices are
small and extremely portable. However, this
construct has no exudate container, thus is
Drape reserved for small, low exudative wounds.
Armstrong et al. in a multicenter, randomized
Since the introduction of NPWT, the drape used trial report no inferiority in wound size reduc-
to affix the foam dressing has been a polyure- tion or wound closure between a mechanically
thane film coated with an acrylic adhesive on the and an electrically powered NPWT devices
contact side. The newest construct utilizes a [41]. The next leap in innovation for portability
polyurethane/acrylic/silicone composite. It has of NPWT should include the ability to provide
been suggested that the stiffness of the original instillation.
polyurethane material can lead to leaks by break-
ing the contact with the surrounding skin with
movement of the patient. This can result in mac- Remote Monitoring
eration of the surrounding skin and the loss of
suction. Therefore, ostomy rings and paste have As delivery of healthcare has evolved with a
been used to secure the drape onto the skin. movement towards shorter hospital stays while
Further, once the polyurethane drape is applied, maintaining quality of care provided to patients,
the same drape cannot be removed and reap- monitoring of a NPWT device in the acute care
plied. Additional drapes are applied or bolster setting is simpler than in an outpatient setting.
strips of the drape in order to create a better seal. Currently some NPWT devices have embedded
This results in wasted material and time. Further, sensors that provide information of NPWT use
skin damage can occur with removal due to the (device turned off) and malfunction (blockage,
tacky nature of the acrylic adhesive. The poly- leaks, alarms) information. This information can
urethane/acrylic/silicone blend is more tolerant be relayed to the patient, facility, visiting nurses,
to stretch and can be applied and reapplied with- or wound center in real time. This allows for a
out the need for additional supplies. For this quicker response to problems associated with the
novel drape to be utilized effectively, the sur- device. Newer software updates on some devices
rounding skin must be dry and if the skin is cold, provide step-by-step troubleshooting animations
it may take some time for the acrylic/silicone to to assist in NPWT management.
Conclusion 9. Phillips PL, Yang Q, Schultz GS. The effect of nega-

tive pressure wound therapy with periodic instillation
using antimicrobial solutions on pseudomonas aeru-
NPWT has emerged as an adjunctive frontline ginosa biofilm on porcine skin explants. Int Wound J.
approach to complex/chronic wounds. NPWT is 2013;10(Suppl 1):48–55.
used globally in the continuum of care of a wound 10. Davis K, Bills J, Barker J, Kim P, Lavery
L. Simultaneous irrigation and negative pressure
from the acute care setting to outpatient facility wound therapy enhances wound healing and reduces
to home. The innovations have accelerated in the wound bioburden in a porcine model. Wound Repair
past decade and NPWT indications have Regen. 2013;21(6):869–75.
expanded significantly. Data continues to be gen- 11. Yang C, Goss SG, Alcantara S, Schultz G, Lantis Ii
JC. Effect of negative pressure wound therapy with
erated that report the effectiveness of this therapy instillation on bioburden in chronically infected
as well as its impact on overall healthcare costs. wounds. Wounds. 2017;29(8):240–6.
Further, technological advances have improved 12. Kim PJ, Attinger CE, Oliver N, Garwood C, Evans
its utility, reliability, and efficacy. It is important KK, Steinberg JS, et al. Comparison of outcomes for
normal saline and an antiseptic solution for negative-
to maintain and practice fundamental principles pressure wound therapy with instillation. Plast
of wound care and limb function preservation Reconstr Surg. 2015;136(5):657e–64e.
along with the use of NPWT and its derivatives. 13. Kim PJ, Silverman R, Attinger CE, Griffin
L. Comparison of negative pressure wound therapy
with and without instillation of saline in the manage-
ment of infected wounds. Cureus. 2020;12(7):e9047.
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Ankle Spec. 2020;13(5):383–91. pressure wound therapy with instillation compared
23. Petkar KS, Dhanraj P, Kingsly PM, Sreekar H, with standard negative-pressure wound therapy: a ret-
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domized controlled trial comparing negative pres- Reconstr Surg. 2014;133(3):709–16.
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Hyperbaric Oxygen Therapy
in Functional Limb Salvage
28
Kelly Johnson-Arbor
Introduction tube to facilitate the construction of bridge abut-

ments and piers [3]. Bridge workers entered the
Hyperbaric oxygen therapy (HBO) is a treatment caisson, which was then pressurized with air to
in which patients breathe 100% oxygen while expel water from the device; the workers could
pressurized in an enclosed treatment chamber to then excavate land and perform their construction
a depth greater than sea level. While HBO is duties while breathing the pressurized air.
often recognized as a treatment for decompres- Unfortunately, after exiting the pressurized cais-
sion illness (“the bends”) in SCUBA divers, there son at the end of their shift, many workers exhib-
are multiple other applications of HBO in the ited physical signs and symptoms that are now
medical community, including the adjunctive recognized as the classic manifestations of
treatment of patients with complicated wounds decompression illness. This painful syndrome
who are referred for limb salvage attempts. was termed “caisson disease.” Many bridge
The use of hyperbaric pressurization as a workers, including those who worked on con-
treatment for medical conditions dates back to struction of the Brooklyn Bridge in New York,
the 1600s, prior to the discovery of oxygen [1]. In were noted to assume a bent-over posture in an
1664, an English physician, Dr. Henshaw, used attempt to relieve the pain. This position was
organ bellows to compress air into an enclosed thought to resemble a stooped posture known as
chamber; this was intended to “promote insensi- the “Grecian Bend” which was affected by fash-
ble respiration” and “to facilitate breathing” of ionable women during this time period; the term
his patients [2]. While the administration of com- “the bends” is derived from this nomenclature
pressed air was likely not associated with signifi- [4]. Despite the ongoing morbidity associated
cant clinical improvements, the introduction of with caisson disease, bridge construction contin-
caisson construction 200 years later represented a ued worldwide during the nineteenth century. In
monumental achievement in the current under- 1841, during excavation of the Loire River in
standing of hyperbaric physiology. The use of France, caisson workers reported having severe
caissons was pioneered in 1839 by the French extremity pain, after working for prolonged peri-
engineer named Triger, who used a pressurized ods in the pressurized caisson [4]. During con-
struction of the Hudson River tunnel in New York
K. Johnson-Arbor (*) in 1879, up to 25% of all caisson workers died;
MedStar Georgetown University Hospital, after a medical lock was introduced to provide a
Washington, DC, USA slow decompression for the workers, the mortal-
e-mail: [email protected]. ity rate dropped to 1% [5].
edu

402 K. Johnson-Arbor
The physiology of hyperbaric oxygenation While the above-mentioned conditions are the
remained poorly understood in the 1920s, when a most commonly indicated diagnoses for the
physician at the University of Kansas, Dr. Orval administration of HBO in the United States, other
Cunningham, utilized HBO for medical condi- conditions such as traumatic brain injury and
tions including influenza pneumonia [2]. A grate- cerebral palsy are occasionally treated with HBO
ful patient donated one million dollars to allow on an “off-label” or experimental basis. Although
Dr. Cunningham to construct the world’s largest HBO is indicated for the enhancement of healing
hyperbaric chamber in Cleveland, Ohio [6]. This in patients with selected wounds, there is a lack
chamber was 6 ft tall and contained 72 rooms, of robust evidence to support the use of this treat-
including one that held a grand piano [6]. ment in the care of patients with wounds second-
Unfortunately, the facility was denounced by the ary to calcific uremic arteriolopathy, pyoderma
American Medical Association as quackery, and gangrenosum, chronic peripheral vascular dis-
the chamber was dismantled and sold for scrap ease, and venous insufficiency; these conditions
metal during World War Two [2]. are considered to be “off-label” or experimental
Modern HBOT facilities are largely located in within the context of HBO administration. As the
outpatient wound centers, and serve as a primary evidence supporting the use of HBO for these
or adjunctive treatment for selected medical con- “off-label” conditions is minimal, and consider-
ditions. Currently, HBO is used as a primary ing that the risks of the treatment may outweigh
treatment for decompression sickness, air embo- any recognized potential benefits, the use of HBO
lism, and carbon monoxide poisoning. It is also must be carefully considered for patients with
used as an adjunctive treatment for additional these and other experimental diagnoses [8, 9]. In
medical conditions including compromised addition, in the United States, insurance reim-
grafts and flaps, chronic refractory osteomyelitis, bursement for the use of HBO for “off-label”
and diabetic foot ulcerations (DFU). The diagnoses is limited, further complicating the
Undersea and Hyperbaric Medical Society cur- ability to utilize HBO as a treatment for these
rently recommends the use of HBO as a treat- conditions.
ment of the following conditions [7].
1. Air or gas embolism Hyperbaric Physiology

2. Decompression illness
3. Acute carbon monoxide poisoning Hyperbaric oxygenation involves the systemic
4. Arterial insufficiencies, including enhance- breathing of 100% oxygen under pressure. This
ment of healing in selected problem wounds process results in increased tissue oxygen deliv-
(including DFU) ery on a cellular level. The administration of sys-
5. Radiation-induced soft tissue and bone temic inhalation of hyperbaric oxygen results in
necrosis the enhanced production of reactive oxygen spe-
6. Intracranial abscess cies (ROS) and reactive nitrogen species (RNS)
7. Clostridial myonecrosis [10]. When present in increased amounts, ROS
8. Necrotizing soft tissue infections and RNS stimulate the synthesis of cellular
9. Compromised grafts and flaps growth factors such as vascular endothelial
10. Crush injuries and compartment syndromes growth factor (VEG-F) as well as mobilization of
11. Chronic refractory osteomyelitis stem cells from the bone marrow [11]. Under
12. Thermal burns hyperbaric conditions, endogenous production of
13. Severe anemia where transfusion is impossi- VEG-F is significantly increased [12]. The
ble due to religious or medical concerns heightened activity of both VEG-F and stem cell
14. Idiopathic sudden sensorineural hearing loss mobilization results in de novo blood vessel
28 Hyperbaric Oxygen Therapy in Functional Limb Salvage 403
growth (vasculogenesis) and new blood vessel manuscript detailing the use of HBO for the treat-
growth by local endothelial cells (angiogenesis) ment of anemia [18]. Boerema exsanguinated
[10]. These processes result in an increased effi- healthy piglets and replaced the blood volume
ciency in new blood vessel growth, especially in with a plasma-like solution. The piglets’ result-
patients with diabetes and in areas of previous ing hemoglobin concentration was 0.4 g/dL, a
radiation therapy. For this reason, HBO is often hemoglobin concentration which is incompatible
utilized as a treatment for patients with DFU as with life. The piglets were then pressurized in a
well as skin and soft tissue necrosis due to previ- hyperbaric chamber to 3 absolute atmospheres
ous radiation therapy. (ATA) for 45 min. The animals survived this
Hyperbaric oxygenation also can mitigate the exposure, despite having essentially no hemoglo-
tissue necrosis and microcirculatory collapse that bin present, and recovered uneventfully after they
occurs after reperfusion of ischemic tissues [13]. were re-infused with normal blood. Boerema
Ischemia-reperfusion injury is characterized by noted that under hyperbaric conditions, the
neutrophil adhesion to the endothelium of injured amount of oxygen dissolved in the plasma can
tissue which occurs after the initial restoration of greatly exceed the amount present while breath-
blood flow; this results in the production of free ing air under normobaric conditions. This phe-
radicals and inflammatory mediators and leads to nomenon is due to Henry’s Law, which states that
secondary tissue damage [14]. The administra- the amount of gas dissolved in a solution is
tion of HBO reduces the adhesion of neutrophils directly proportional to the partial pressure of the
to microvascular cell walls, reduces lipid peroxi- gas. When partial pressures of a gas increase,
dation, and decreases the inflammatory response such as under hyperbaric pressurization, more of
in ischemic tissue [13]. These mechanisms of that gas dissolves in solution. Breathing room air
action may account for some of the beneficial (21% oxygen) under normobaric conditions
effects noted when HBO is used for the treatment results in a PaO2 of approximately 100 mmHg;
of acutely compromised skin flaps and grafts, as breathing 100% oxygen under hyperbaric condi-
well as necrotizing soft tissue infections and tions results in a PaO2 of greater than 1600 mmHg
acute arterial ischemias. [19]. Under hyperbaric conditions, oxygen dis-
Hyperbaric oxygenation has beneficial effects solved in the plasma can approximate or meet the
on infection control. The growth and prolifera- body’s metabolic demands of oxygen extraction
tion of anaerobic bacteria is inhibited in the [20]. This explains the rationale for the use of
hyperbaric environment [15]. Administration of HBO as a treatment for anemia in patients who
HBO can enhance the soft tissue penetration of cannot receive blood transfusions, and also repre-
selected antibiotics, including aminoglycosides, sents a mechanism of action of the use of HBO in
trimethoprim/sulfamethoxazole, and linezolid patients with symptomatic SARS-CoV-2
[16, 17]. HBO may also exert a synergistic effect (COVID-19) infection [21].
against bacterial growth when used in conjunc-
tion with antibiotics, and also enhances the
oxygen- dependent mechanisms (“oxidative HBO and Limb Salvage
burst”) by which granulocytes kill microorgan-
isms [17]. Hyperbaric oxygen chambers are commonly
The systemic hyperoxygenation induced by found within outpatient wound centers in the
HBO also has favorable effects on the manage- United States, and can serve as an integral part of
ment of anemia in patients who are unable to the multidisciplinary limb salvage process. The
receive transfusion of blood products due to med- use of HBO as an adjunctive treatment for limb
ical or religious concerns. In 1959, the Dutch sur- salvage has been reported for many types of
geon Boerema published “Life without blood,” a wounds including DFU and compromised skin
grafts or flaps, as well as vasculitis ulcers and comes. For the purposes of this investigation,
wounds due to peripheral arterial disease [22]. standard wound care was defined as surgical
While the beneficial effects of HBO are likely debridement of devitalized tissue, use of mechan-
applicable to wounds of various etiologies, dia- ical offloading, infection control, and revascular-
betic foot ulcerations and compromised skin ization. Outcomes of interest for this review
grafts and flaps represent two of the better under- included major amputation and incomplete heal-
stood applications of HBO for limb salvage. The ing at 1 year. Questions investigated by the
use of HBO for DFU and compromised skin GRADE review committee included (1) for a
grafts and flaps will be discussed in more detail patient with a DFU, is HBO with standard wound
in this chapter. care more effective than standard wound care
alone for the outcomes of interest; (2) for a patient
with a Wagner Grade 2 or lower DFU that has not
HBO and Diabetic Foot Ulcerations shown significant improvement after 30 days of
treatment, is HBO with standard wound care more
Hyperbaric oxygenation has been used frequently effective than standard wound care alone for the
as an adjunctive treatment of ischemic Wagner outcomes of interest; (3) for a patient with a
grade 3 or greater DFU (i.e., DFU extending to Wagner Grade 3 or higher DFU that has not
deeper structures and associated with abscess, shown significant improvement after 30 days of
osteomyelitis, or tendonitis). A majority of the treatment, is HBO with standard wound care more
evidence supporting the use of HBO encom- effective than standard wound care alone for the
passes the treatment of DFU [23]. Patients with outcomes of interest; (4) for a patient with Wagner
DFU often exhibit impaired peripheral vascular- Grade 3 or higher DFU who has just had surgical
ity, lymphocytic function, and bacterial killing debridement of the foot, is acute postoperative
that inhibits wound healing potential [24]. The HBO with standard wound care more effective
mechanisms of action of HBO, including neovas- than standard wound care alone for the outcomes
cularization and enhanced bacterial killing abil- of interest. Thirty randomized controlled trials
ity, account for the beneficial effects noted in and observational studies involving HBO and
patients who receive HBO as a treatment for DFU were included in this review; a majority of
DFU. The neovascularization induced by HBO is the initially identified studies were excluded from
not immediately identifiable; it takes approxi- review as they did not report on outcomes of inter-
mately 8–10 treatments before this process is est or include patients in the specific study popu-
detectable, and up to 20–30 treatments before a lations. The analysis of the available evidence
plateau in neovascularization occurs [25]. Due to showed that HBO is beneficial in preventing
this, the hyperbaric treatment course for patients amputation and promoting complete healing in
with DFU often involves 30–40 consecutive patients with Wagner grade 3 or greater DFUs
treatments. who have had recent surgical debridement of the
Using GRADE (grading of recommendations, foot, as well as patients with Wagner grade 3 or
assessment, development, and evaluation) meth- greater DFUs that have not shown significant
odology, an analysis was performed in 2015 of improvement after at least 30 days of treatment.
published systematic reviews pertaining to HBO For patients with DFUs graded as Wagner 2 or
and diabetic foot ulcerations (DFU) [15]. The lower, there was insufficient evidence found to
intent of this review was to rate the quality of evi- justify the use of adjunctive HBO.
dence and general practice recommendations for A series of additional articles have also inves-
the treatment of DFU with hyperbaric oxygen tigated the effectiveness of HBO in treatment of
therapy. The study design included identification patients with DFU. A cohort study of 6259 indi-
of a specific relevant population (patients with viduals with DFU associated with failed healing
DFU), an intervention (HBO versus standard for at least 4 weeks despite adequate lower
wound care), and identification of important out- extremity arterial flow was performed to compare
the effectiveness of HBO versus standard therapy amputation was indicated based on this informa-
[26]. The primary outcomes evaluated in this tion, the actual amputation rates were not
study were wound healing and lower extremity included in the manuscript. Additional limita-
amputation. The results of the study indicated tions included a limited percentage of patients in
that patients who received HBO were more likely the HBO group who completed a full course of
to have an amputation and were less likely to HBO and the inclusion of patients with Wagner 2
achieve wound healing compared with the DFU which is not consistent with accepted indi-
patients who received standard therapy. However, cations for HBO in the United States.
this study had significant limitations including a A third study, performed in 2018, investigated
disparity in the baseline characteristics of the two whether HBO could improve wound healing and
cohorts. Forty-five percent of patients in the HBO reduce the rates of major amputation in patients
cohort had a Wagner 3 or greater DFU, while with ischemic DFU [28]. This study evaluated
only 18% of patients in the standard therapy 120 patients; subjects were administered stan-
cohort had a Wagner 3 or greater DFU; this sig- dard wound care with or without a course of
nificant difference in DFU severity between the HBO. The primary outcomes analyzed were free-
two groups was a likely factor in the variance in dom from amputation above the ankle, and com-
primary outcome results between the two cohorts. plete healing after 12 months of follow-up. There
Additionally, the study included patients with was no significant difference in complete wound
Wagner 2 DFU; in the United States, the presence healing or limb salvage noted between the two
of a Wagner 2 DFU is generally not an accepted groups. As with the two previously described
indication for HBO. studies, this study also had significant limitations
A subsequent study investigating the utility of including the inclusion of patients with Wagner 2
HBO in the prevention of amputation in patients DFU as well as a low percentage of patients in
with DFU was performed in 2016 [27]. In this the HBO group who actually completed their
double-blind, placebo-controlled study, adult HBO course as planned.
patients with Wagner grade 2–4 DFU were ran- In conclusion, although recent literature sur-
domized to receive sham pressurization (to 1.25 rounding the use of HBO for DFU has been lim-
ATA) or standard HBO. The primary outcome ited by suboptimal study design, this treatment
was the subjective assessment by a single vascu- remains a viable adjunctive treatment for patients
lar surgeon of whether the patient met criteria for with DFU. HBO can be used as an adjunctive
major or minor amputation after 12 weeks of treatment for Wagner 3 or greater DFU and
treatment. The study investigators found no sig- should be used in conjunction with other stan-
nificant differences in the percent of patients dard wound care treatment modalities including
meeting criteria for amputation between the two topical wound care, debridement, attention to
groups, and there was also no significant change glucose control, nutritional optimization, offload-
in ulcer width of surface area noted between the ing, revascularization when indicated, and treat-
groups. The investigators concluded that HBO ment of associated infection. For optimal
does not appear to reduce the indications for neovascularization and wound improvement,
amputation or facilitate wound healing in patients DFU patients may require multiple weeks of
with chronic DFU. Similar to the previous study, treatment with HBO.
this study did have significant limitations. Most
notably, the patients included in the study were
not required to be physically evaluated by the BO and Compromised Skin Grafts
H
vascular surgeon who determined the indication and Flaps
for amputation; the surgeon was instead provided
with clinical data and digital photographs While HBO is not indicated for the treatment of
obtained over the course of the study. Although healthy tissue in skin grafts or flaps, it may be
that surgeon provided a determination of whether useful in the salvage of flaps or grafts that are
compromised by decreased tissue perfusion or HBO and leeching resulted in a significant

local hypoxia [29]. When affected by prolonged increase in flap survival compared with use of
ischemia, skin flaps experience irreversible dam- leeching as a sole treatment.
age to the microcirculation [30]. The hyperoxy- The use of HBO in the management of com-
genation which occurs during application of promised grafts and flaps is most commonly lim-
HBO may result in increased viability of com- ited to the postoperative period, but HBO
promised flap or graft tissue, reducing the need preconditioning may also impact skin flap and
for additional surgical procedures and increasing graft survival. HBO preconditioning involves the
the potential for limb salvage [31]. HBO has been initiation of HBO prior to a planned ischemic
used for the treatment of compromised skin grafts insult in order to potentially reduce the sequelae
as well as ischemic random and free flaps [32]. of subsequent hypoxia [37]. The mechanism of
The mechanisms of action affecting the utility action of HBO preconditioning may involve
of HBO in the treatment of compromised skin induction of intracellular antioxidant enzyme
grafts and flaps include HBO-induced neovascu- systems [13]. HBO preconditioning may play a
larization, attenuation of inflammatory media- role in limiting the ischemic complications that
tors, and hyperoxygenation of ischemic tissue occur after reconstructive surgical procedures;
[33]. Post-ischemic tissue reperfusion is associ- however, at this time, much of the evidence sur-
ated with an increase in circulating neutrophils to rounding HBO preconditioning remains preclini-
vascular cell walls; the administration of HBO cal in nature [13].
reduces this neutrophil adhesion and the To summarize, based on the available litera-
ischemia- reperfusion injury associated with it ture, HBO should be considered as an adjunctive
[10]. The use of hyperbaric oxygenation may be treatment for skin grafts and flaps that exhibit
optimized when the treatment is initiated within a compromise due to arterial inflow, venous occlu-
short period of time (less than 1 week, and ideally sion, or both. When used to treat skin graft or flap
less than 48 h) after identification of graft or flap compromise, HBO appears to be most effective if
compromise [34]. Delays in recognition of flap it is initiated soon after the ischemic insult.
ischemia can result in irreversible tissue damage Although many HBO facilities are located within
that will not be ameliorated by use of HBO [35]. outpatient wound centers and do provide care to
As rapid identification of flap or graft ischemia is inpatients, the initiation of inpatient HBO treat-
critical, use of intraoperative perfusion monitor- ments should be considered for patients with
ing devices may be helpful in identifying early acutely compromised skin grafts or flaps in order
flap compromise so that HBO can be initiated in to optimize the effectiveness of this treatment. If
a timely fashion. Patients with acutely compro- HBO is indicated for an acutely compromised
mised skin grafts or flaps may benefit from twice- skin graft or flap but only outpatient HBO care is
daily HBO sessions in order to optimize tissue available, the treating physicians may consider
oxygenation. transfer of the patient to a facility that is able to
Although HBO is most often recognized as a accommodate the patient for inpatient hyperbaric
treatment for arterial ischemia after skin flap or treatments. Treatments may be administered
graft surgery, it can also be utilized as an adjunc- once or twice daily as indicated, and treatments
tive treatment for skin flaps complicated by are discontinued when flap viability is achieved.
venous occlusion. In an animal study, axial epi-
gastric skin flaps were performed on rats; the
flaps were then subjected to venous occlusion, HBO in Clinical Practice
while arterial inflow was left intact [36]. The ani-
mals were then randomized to receive HBO, Systemic HBO is administered while a patient is
leeching, or leeching and HBO. While the use of enclosed within a hyperbaric chamber. These
HBO alone was not effective in improving the chambers, composed of steel and acrylic compo-
venous outflow in this model, combined use of nents, are commonly located within outpatient
wound centers in the United States and are uti- enhanced patient privacy and reduced staffing
lized as an adjunctive wound healing modality. requirements compared with multiplace cham-
There are approximately 1300 hospital-based bers; in addition, monoplace chambers have a
hyperbaric facilities present in the United States smaller physical footprint than many multiplace
as of 2021 [38]. There are two main types of facilities, and some monoplace chambers are por-
hyperbaric chambers: monoplace and multiplace. table. The monoplace hyperbaric chamber is
Monoplace hyperbaric chambers (Fig. 28.1) can compressed with 100% oxygen; patients may be
accommodate one patient; multiplace hyperbaric intermittently administered compressed air to
chambers (Fig. 28.2) can accommodate multiple breathe via face mask to reduce the risk of oxy-
patients as well as caregivers, medical personnel, gen toxicity. The use of 100% oxygen enhances
and equipment. the risk of fire in the monoplace chamber; this
In the United States, monoplace chambers are risk is mitigated by careful patient preparation
the most commonly encountered hyperbaric and meticulous oversight by the chamber
treatment vessels in hospital settings. In the operator.
monoplace chamber, the patient remains enclosed In contrast, multiplace hyperbaric chambers
in the chamber for the duration of the hyperbaric are compressed with air. The use of compressed
treatment; hands-on medical care is not possible air instead of oxygen reduces, but does not com-
in the majority of monoplace chambers, and due pletely eliminate, the risk of fire in the multiplace
to this, patients must be clinically stable prior to chamber. Patients treated in multiplace hyper-
being treated in the monoplace chamber. baric chambers receive 100% oxygen via the use
Advantages of monoplace chambers include of vinyl hoods that are attached to a silicon neck
Fig. 28.1 Monoplace hyperbaric chamber

Fig. 28.2 Multiplace hyperbaric chamber. (Photo credit: Wikipedia.com)
ring to make an airtight seal. The larger, more place chambers in hospitals across the United
spacious nature of multiplace chambers is benefi- States.
cial for many claustrophobic patients, as the risk During hyperbaric treatments, patients sit or
of confinement anxiety is reduced in this setting. lie supine in the hyperbaric chamber and breathe
Additional advantages of multiplace chambers 100% oxygen for the duration of the treatment.
include the ability to treat multiple patients dur- Due to fire safety standards, patients treated in
ing each treatment session and the ability to per- the monoplace environment cannot bring books,
form hands-on patient care during the treatment. magazines, cell phones, or other personal belong-
Critical care, including use of mechanical venti- ings into the chamber with them. Monoplace
latory support, can also be accomplished more hyperbaric chambers commonly have a television
easily in a multiplace chamber than in a mono- monitor attached to the outside of the chamber;
place chamber. Patients who are critically ill or this allows the patient to watch television or a
hemodynamically unstable, including those with movie during each treatment, with sound avail-
necrotizing soft tissue infections, crush injuries, able inside the chamber through a built-in
and compartment syndromes, are best treated in a speaker. Patients may be allowed to bring per-
multiplace environment, as medical providers sonal material into a multiplace chamber with
can accompany these patients into the chamber them, but certain items (including many battery-
for the duration of the hyperbaric treatment to operated devices, matches, and other highly com-
provide necessary care. Due to the increased bustible material) are never permitted in any
costs associated with the staffing and operation hyperbaric environment due to the risk of fire. In
of these chambers as well as the larger physical the United States, the National Fire Protection
space requirements and increased relative com- Association (NFPA) sets fire safety codes for
plexity associated with their use, multiplace hyperbaric facilities that are adhered to by
chambers are less frequently found than mono- hospital-
based hyperbaric programs [39]. The
NFPA code provides specific recommendations may be limited due to logistical issues including
for hyperbaric facility construction as well as facility staffing limitations. Each wound healing
standards for patient safety and fire prevention. hyperbaric treatment is approximately 2 h in
With proper adherence to the NFPA code and duration. Pressurization is maintained at a treat-
knowledge and application of the basic tech- ment depth ranging from 2.0 atmospheres abso-
niques used to reduce the risk of fire in the hyper- lute (ATA) to 2.5 ATA; the treatment regimens
baric environment, the potential for fire in the are derived from the United States Navy recom-
hyperbaric environment is significantly reduced. pression tables and are generally not able to be
Despite this, not all hyperbaric facilities follow significantly modified due to the potential for
NFPA regulations, and there have been fatal fires adverse events including systemic breathing gas
in the United States and abroad involving hyper- toxicity. The HBO treatment course is typically
baric chambers. tailored to each individual patient. The number of
The use of traditional medical equipment and hyperbaric treatments required per patient varies
implanted devices in the hyperbaric environment based on the indication for treatment. Patients
poses unique challenges related to the inability of with acute or emergent treatment indications,
many modern medical devices (including such as necrotizing soft tissue infection or acute
intravenous pumps and ventilators) to withstand skin graft or flap compromise, may require ten or
the typical pressurization encountered in the fewer HBO treatments to achieve clinical
hyperbaric chamber. Most monoplace chambers improvement. Patients who are treated with HBO
are unable to accommodate patients who are for chronic conditions, such as DFU, may require
undergoing treatment with mechanical ventila- 40–60 daily HBO treatments for maximum clini-
tion or continuous intravenous infusions. Some cal effect. Some patients may end their treatment
implanted medical devices are unsuitable for use course earlier than expected based on a more
in the hyperbaric environment, due to fire or other rapid course of healing or symptom resolution.
safety concerns; many newer medical devices Interestingly, despite the lengthy time commit-
have not been tested under pressure and may ment and need to present to the hospital for daily
malfunction or experience structural failure when treatments, HBO has not been associated with
exposed to hyperbaric pressurization. Many decrements in patient quality of life [40].
pacemaker manufacturers have tested their
devices under pressure, and thus permanent pace-
makers are often not regarded as a contraindica- Adverse Effects of HBO
tion to hyperbaric compression. Other medical
devices, including insulin pumps and continuous When administered by trained professionals with
glucose monitoring devices, have not been exten- clinical oversight by a physician who specializes
sively tested under hyperbaric conditions; these in Undersea and Hyperbaric Medicine, adverse
devices are frequently not compatible for use in effects of HBO are rarely encountered. Most
the hyperbaric environment. adverse effects associated with HBO can be
Hyperbaric treatments are generally sched- avoided or mitigated with careful patient prepara-
uled on a daily basis; most hyperbaric chambers tion and attention to detail.
in the United States operate during weekday Middle ear barotrauma (MEBT) is the most
business hours only, but some facilities may offer common complication of HBO; MEBT occurs
weekend or after-hours treatments for emergent due to inadequate ear pressure equalization, often
conditions such as acute skin graft or flap com- due to eustachian tube dysfunction. Preventive
promise or necrotizing soft tissue infection. measures such as educating the patient on auto-
While a majority of hyperbaric patients receive insufflation techniques such as the Valsalva
daily treatments, patients with acute or emergent maneuver, are often used to reduce the risk of
hyperbaric indications may benefit from twice MEBT. Patients who are unable to equalize ear
daily treatment delivery, although availability pressures despite adequate education may require
use of topical or systemic decongestant medica- ment course is finished [46]. Due to the tempo-
tions. In some cases, tympanostomy tube place- rary nature of these visual changes, patients who
ment may be necessary. experience myopia as a consequence of hyper-
Systemic oxygenation can also induce hyperbaric oxygenation are often counseled to not pur-
activity of the central nervous system (CNS) chase new corrective lenses, as their vision will
resulting in oxygen toxicity; the exact mecha- revert back to baseline after the treatments are
nism of this is not well understood, but may be completed. Nuclear cataract formation after HBO
related to the presence of ROS that result in alter- has rarely been reported to occur as a conse-
ations in enzyme inhibition or brain metabolism quence of HBO, almost always in association
[41]. The risk of CNS oxygen toxicity is related with a prolonged course of treatment (greater
to both the partial pressure of oxygen inspired than 150 HBO treatments) [47, 48].
and the exposure time; the clinical presentation Not all patients are acceptable candidates for
involves tonic-clonic seizure activity that can treatment with HBO. Patients with underlying
occur with or without prodromal signs [42]. COPD or bullous lung disease are at increased
Seizures associated with CNS oxygen toxicity risk for pulmonary barotrauma, including pneu-
are rarely encountered in clinical practice; in a mothorax, which represents a potentially fatal
retrospective analysis of 2334 patients who complication of HBO. Fatal pulmonary edema
received HBO, the incidence of seizures was has been reported to occur in patients with
0.011% [42]. The risk of central nervous system impaired cardiac function (ejection fraction less
oxygen toxicity may be reduced by the use of than 40%), as HBO administration results in an
intermittent air breathing periods during each increase in pulmonary capillary wedge pressure
hyperbaric treatment. [49]. As previously discussed, patients with
In diabetic patients, HBO is associated with a implanted medical devices may be unable to
significant decrease in blood sugar concentra- safely receive HBO. The toxicities of some phar-
tions. The cause of this is not fully known; pos- macologic therapies may be exacerbated by
sible mechanisms include increased systemic exposure to hyperbaric oxygenation. Patients
glucose consumption or insulin production as with severe anxiety, claustrophobia, or impaired
well as increased tissue insulin sensitivity [43]. cognitive function may benefit from treatment in
Pre-treatment glucose values may correlate with a multiplace chamber instead of a monoplace, as
the presence of hypoglycemia during or after medical personnel can accompany them into the
hyperbaric treatment; in one study, a pre- former type of hyperbaric environment to pro-
treatment blood glucose concentration of 150 mg/ vide assistance during the treatment process.
dL was predictive of subsequent hypoglycemia Prior to starting a course of HBO, patients should
[44]. Due to the risk of hypoglycemia, diabetic be evaluated by a trained and experienced hyper-
patients who receive HBO are required to have baric medicine physician and nurse in order to
blood glucose levels checked prior to each treat- assess for these and other characteristics that
ment, and treatments are generally withheld if the could preclude them from safely receiving treat-
blood glucose value is below the hyperbaric facil- ment in the hyperbaric environment.
ity’s pre-defined threshold level.
Changes in visual acuity, most often affecting
distance vision, may occur as a side effect of Topical Oxygen Therapy
HBO. A myopic shift can be detected in almost
90% of patients who receive a standard course of Discussions of oxygen therapy for wound care
40 HBO treatments [45]. Patients may describe often include a mention of topical oxygenation.
having difficulties with distance vision and night- Topical oxygen therapy involves administration
time driving. Fortunately, these visual changes of oxygen via a bag, boot, or other device to a
are almost always temporary, and they resolve specific area of the body. This form of oxygen
over the ensuing weeks to months after the treat- therapy involves regional application of oxygen
to an extremity and does not involve systemic References

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Skin Grafting
29
IN: Functional Limb Salvage: The
Multidisciplinary Team Approach
Adaah Sayyed, Paige K. Dekker, Caitlin S. Zarick,

and Karen K. Evans
Introduction described in 1872 by Ollier and Thiersch [1].

Despite its initial use in facial reconstruction,
Skin grafting is a surgical technique in which skin grafting is commonly employed in soft tis-
skin from one region of the body is harvested sue reconstruction of defects such as deep burns,
from its local blood supply and transplanted to sores, large wounds, cancer resections, and
another location. As a result of being separated chronic ulcerations that are commonly encoun-
from its vascular bed, the viability of a skin graft tered in diabetic populations. This chapter will
relies on the development of new blood supply discuss the techniques and outcomes of skin
from the regional bed in which it is placed [1]. grafting, specifically STSG, in lower extremity
This technique is thousands of years old, origi- wounds resulting from diabetes and peripheral
nating in 2500–3000 B.C. by surgeons of the artery disease. Timely closure and healing are
Hindu Tilemaker Caste who used gluteal skin to critical in reducing the morbidity and cost associ-
recreate noses for those who suffered traumatic ated with chronic lower extremity wounds.
facial wounds. The focus of this chapter is split-
thickness skin grafting (STSG), a technique first
Categories of Skin Grafting
A. Sayyed The two major classifications of skin grafts are
Georgetown University School of Medicine,
Washington, DC, USA autogenous and tissue-engineered skin grafts.
e-mail: [email protected] Autogenous skin grafts are those transplanted
P. K. Dekker from a donor site and grafted onto a different site
Department of Plastic and Reconstructive Surgery, on the same individual. Autogenous skin grafts
MedStar Georgetown University Hospital, can be further divided into split-thickness and
Washington, DC, USA full-thickness skin grafts. Tissue-engineered skin
grafts are biologic cell-based dressings com-
C. S. Zarick (*) · K. K. Evans posed of live-cell constructs containing at mini-
MedStar Georgetown University Hospital, mum one layer of live allogeneic cells [2]. These
Washington, DC, USA are commonly used when traditional autogenous
Center for Wound Healing and Hyperbaric Medicine, dressings have failed or are deemed inappropri-
Washington, DC, USA ate, such as in patients unable to undergo anes-
e-mail: [email protected]; thesia for donor site harvesting. The take rate and
[email protected] healing rate of such grafts, however, are much

416 A. Sayyed et al.
lower than of autologous STSGs [3]. Most tissue- cases as they have decreased metabolic needs.
engineered skin grafts do not provide complete Intermediate-thickness STSGs provide the ideal
definitive skin coverage after one usage, and they graft for diabetic foot wounds, providing good
can also be more costly. A more complete discus- quality repair and resultant skin with sufficient
sion is presented in other chapters. elasticity and reduced retraction [4]. The most
common thickness used by the authors is
0.0012 in. The conservative approach to treating
Split-Thickness Skin Grafts chronic wounds entails frequent debridement and
dressing changes, along with topical solutions
Split-thickness skin grafts involve harvesting the such as collagenase ointments, antimicrobial
epidermis and varying portions of the underlying absorbent fiber sheets, saline, or iodine. The ben-
dermis, allowing the donor site to heal from epi- efit of STSG, however, is the significantly short-
dermal elements left behind. STSGs can be fur- ened healing time achieved when compared to
ther divided into thin (0.008–0.012 in.), conservative treatment. One study reported an
intermediate (0.012–0.018 in.), and thick (0.018– average healing time of 28 days with STSG ver-
0.030 in.) [4]. Advantages of STSGs include the sus 122 days in conservatively treated patients, as
large surface area coverage they provide while well as a decreased hospital length of stay and
using minimal donor skin that can be expanded overall reduced cost of care [3, 5].
via meshing techniques. Donor sites have the
ability to heal completely in 10–15 days and can
be reharvested at that time if necessary. Full-Thickness Skin Grafts
Disadvantages of this technique include the lim-
ited pliability and elasticity afforded by STSGs, Full-thickness skin grafts (FTSGs) require har-
resulting in increased contracture upon healing. vesting the entire layer of skin, including both the
Additionally, STSGs are fragile, lack hair, heal epidermis, dermis, and underlying adnexal struc-
with abnormal pigmentation, and lack a smooth tures such as sweat glands, hair follicles, and
texture. nerves [1]. Because FTSGs require full-thickness
STSGs are used in a variety of reconstructive harvesting, the donor skin takes longer to revas-
procedures. Indications for STSG use include cularize relative to STSGs, and often requires
cases when simpler methods of wound closure closure by local advancement of the skin or by
such as healing by primary closure, secondary secondary local flap placement.
intention, or negative pressure wound therapy do Benefits of FTSGs include their minimal
not suffice or are not possible. In patients with wound contraction and ability to provide good
large skin defects extending over the trunk or color, texture, elasticity, and thickness to match
extremities (not including joints), the increased the surrounding skin [1]. The aesthetic advan-
contractility of STSGs results in smaller areas of tages provided by FTSGs make them a prime
scarring. In addition, compared to large wounds choice in the repair of hand and facial wounds,
treated with standard local wound care dressings, such as facial defects resulting from skin cancer
STSG provides more stable coverage than the resections. Patients have reported increased satis-
scar created by secondary closure. STSG can also faction with the matching of texture and color
provide definitive coverage for wounds that provided by FTSGs [6]. Their minimal contrac-
closed partially in response to other therapies, or tion, pliable reconstructability, and improved
to improve healing of donor sites formed by other capacity to provide sensation and temperature
surgical procedures [4]. discrimination postoperatively also make FTSGs
STSGs are also indicated in cases of acute the preferred option in cases requiring grafting
skin loss (burns, infection, traumatic wounds) over mobile areas such as joints, palms, and fin-
and chronic skin loss (leg ulcers). Utilization of gertips [3]. They are used less frequently in com-
thinner grafts is particularly beneficial in these plex lower extremity wounds due to the poor host
29 Skin Grafting 417
environment, weight-bearing surfaces of the foot, tions begin to differentiate into afferent and
and often poor surrounding tissue quality. efferent vessels. Once complete, full circula-
tion is reestablished and blood flow is restored
to the graft [7].
Skin Graft Healing 4. The graft goes through a final maturation
phase, which can take over 1 year to com-
Four main phases comprise skin graft healing: plete. This phase involves changes in graft
pigmentation, flattening, and softening [8].
1. The plasmatic imbibition phase occurs within
the first 12–48 h. Fibrin attaches the graft to
the recipient bed over the first 24 h. The graft Pathologies Treated
gains up to 40% of its pregraft weight by
absorbing the wound exudate, becoming Many pathologies involving chronic skin loss in
edematous [1, 7]. This allows the graft to the lower extremities are able to be treated with the
remain moist and receive nutrients, maintain- use of STSGs. This chapter will focus specifically
ing graft vessel patency until revasculariza- on the use of skin grafts in the management of
tion is possible. The fibrin located beneath the complex lower extremity wounds, most notably
graft is progressively replaced with granula- due to diabetes and/or peripheral arterial disease.
tion tissue, resulting in the permanent attach-
ment of the graft to its recipient bed [1]. The
graft may appear pale or white during this Diabetic Foot Ulcers
ischemic phase. STSGs are able to survive up
to 4 days of ischemia [8]. Due to the propensity for extensive polymicro-
2. The inosculation and capillary ingrowth bial infections in patients with diabetic foot
phase occurs within 48–72 h, once proper ulcers, the need for a new skin barrier over these
apposition of the graft has occurred. A fine wounds is paramount. Skin grafting is a fast and
vascular network is established within the efficient method for creating this barrier. It pro-
fibrin layer created between the graft and vides pliable soft tissue and results in minimal
recipient bed. Blood vessels within the recipi- donor site morbidity while accelerating wound
ent bed grow capillary buds, which anasto- healing time. There is a common misconception
mose with pre-existing graft vessels in the that elevated hemoglobin A1c (HbA1c) levels in
dermis, creating open channels. The establish- patients with poorly controlled diabetes is a con-
ment of blood flow results in the graft turning traindication for skin grafting. It has been found,
pink, a general sign of probable graft survival however, that there is no difference in healed ver-
[7, 8]. sus failed skin grafts in patients with elevated lev-
3. The revascularization phase occurs within els of HbA1c, some with levels greater than 9%.
5–7 days. The most commonly endorsed the- In diabetic patients with an average HbA1c of
ory regarding graft revascularization proposes 8.7%, the mean time to heal was about 6.5 weeks
that after the inosculatory event, the definitive [9]. It is still ideal to have blood sugars well con-
vasculature of the graft includes the blood trolled in the perioperative setting immediately
vessels that were originally present within the before, during, and after surgery to ensure the
graft. The process of primary revasculariza- best chance for healing. Ideally, random blood
tion occurs when graft healing progresses nor- sugars around the day of surgery should be
mally. The graft initially has inadequate <180 mg/dL or lower.
reverse circulation, so the blood and fluids Another common misconception regarding
flowing into the graft become trapped, unable the use of STSG for diabetic foot ulcers involves
to return to the bed. Within 4–7 days post- perceived difficulties with graft healing on
graft, the newly established vascular connec- weight-bearing or plantar surfaces. Foot ulcers
resulting from neuropathy usually occur on the patent plantar artery. Other patient factors, such
plantar surface of the foot. The challenges of as plantar wound location, various methods of
reduced blood flow and difficulty offloading wound bed preparation, or presence of bacteria at
make chronic ulcers on plantar surfaces uniquely various culture time points, have not been shown
difficult to heal [5, 10]. There are low and compa- to have a significant relationship with wound
rable recurrence rates when STSGs are applied to healing [11]. A discussion of the assessment of
the plantar foot compared to other locations [10]. perfusion and revascularization methods is found
One study found that of 20 patients with STSG in Evaluation of Vascular Supply.
application to plantar surfaces, only one patient
required regrafting during a follow-up period of
2–8 years, and all patients resumed ambulation Presurgical Evaluation
during their follow-up period [10]. In addition to
providing a durable plantar surface, STSGs are Numerous variables account for the success or
also cost-effective, can be performed by most failure of STSG therapy in comorbid patients
wound surgeons (relative to free tissue transfer, with chronic wounds. Presurgical evaluation and
which requires a trained microsurgeon), and in optimization of these factors play a significant
some cases can be performed as an outpatient role in improving viability of skin graft therapy
procedure [10]. and resulting outcomes.
Peripheral Arterial Disease Evaluation of Vascular Supply
Peripheral arterial disease (PAD) and chronic In patients evaluated for treatment of lower
total vascular occlusions have increased in preva- extremity ulcers, it is crucial to assess for periph-
lence as cases of diabetes and chronic kidney dis- eral vascular disease prior to skin graft applica-
ease rise. Critical limb ischemia (CLI) with tion. Optimizing perfusion is the first step in
advanced wound presentation is a leading cause preparation of the wound for therapy. If distal
of nontraumatic lower extremity above- and pulses of the posterior tibial artery, dorsalis pedis
below-the-knee amputations [11]. artery, or peroneal artery are not palpable, vascu-
The goal in treating patients with PAD- lar status must be assessed further. Ideal methods
induced ischemic wounds is to provide a durable for evaluation include noninvasive vascular test-
protective barrier in order to prevent further ing, such as ankle brachial index (ABI), toe bra-
infection and limb loss. Similar to the treatment chial index, doppler waveforms, and pulse volume
algorithm for diabetic foot ulcers, wounds sec- recordings (PVR) [4, 5]. A handheld doppler can
ondary to PAD can also be treated with conserva- also help assess the vascular status but may not be
tive measures such as local wound care or STSG. accurate to diagnose peripheral arterial disease.
Adequate perfusion to the wound site plays a For adequate wound healing, an evaluation by a
key role in healing wounds secondary to PAD. vascular surgeon should be completed in order to
Literature discussing patients with CLI consis- ensure proper arterial flow and to perform any
tently reports that endovascular revascularization revascularization procedures needed.
and surgical procedures to improve distal extrem-
ity perfusion are both superior to medical man-
agement alone. Research assessing time to Infection Control
healing in patients with PAD treated with STSG
revealed that the most significant predictor of Infection control and establishment of a clean,
successful wound healing was a complete pedal granulating wound bed are paramount for suc-
arch, defined as a direct connection between a cessful STSG application. The first step in
patent dorsalis pedis artery and at least one other wound bed preparation is the eradication of
infected, nonviable tissue via serial debride- Other Considerations

ments while ensuring ample vascular supply to
promote epithelial advancement. Pre- and post- In addition to optimization of a patient’s vascular
debridement cultures should be obtained with supply and infection control, several other factors
each debridement in order to guide systemic must be addressed in order to maximize STSG
antibiotic therapy as well as to confirm that neg- success. Smoking negatively impacts wound
ative or scant growth is achieved prior to under- healing by reducing tissue oxygenation and sub-
going closure with STSG. Parenteral antibiotics sequently decreasing collagen synthesis [4].
are often unable to penetrate and eradicate bio- Smoking cessation should therefore be strongly
films which are often present in diabetic foot encouraged in patients considering wound clo-
wounds. Successful eradication of biofilms sure with STSG. Poor nutritional status can also
instead relies on aggressive, sharp surgical contribute to initial ulcer formation and persis-
debridement, which should be performed until tence; therefore, consultation with a dietician
healthy bleeding tissue at the base of the wound should be pursued in order to maximize nutri-
is observed [4]. Sharp debridement also provides tional status during the presurgical preparation
a 72-h window in which bacteria have increased period [5]. Lower extremity edema should be
susceptibility to antibiotics. Combination use of addressed with mechanical measures such as
STSG and antibiotics during this therapeutic limb elevation and compressive dressings or by
window has been suggested to improve wound managing the underlying cause of peripheral
healing [4]. edema in the patient [4]. In general, patients’
It has been suggested that bacterial loads medical comorbidities should be optimized to
between 105 and 106 organisms per gram may ensure the best chance for graft success. In some
negatively affect wound and skin graft healing [4, instances, however, wound closure may be
5]. Conversely, some studies suggest that identifi- needed prior to absolute optimization.
cation of more virulent organisms such as
Pseudomonas aeruginosa or Staphylococcus
aureus by preoperative wound culture swabs is Operative Techniques
more predictive of poor STSG outcomes than
quantitative analysis of infection load [12]. Once patient optimization is accomplished, the
Regardless of the method used to measure active next steps in care include wound bed debride-
infection, resolution of clinical infection is ment, STSG harvesting, meshing, and STSG
required prior to application of STSG [4]. application (Table 29.1).
After initial control of the infected wound,
patients will often be discharged from the hospi-
tal setting and followed as an outpatient until Wound Bed Debridement
their wound is ready for STSG application.
Local wound care is important during this As previously discussed, serial debridements are
period to ensure the wound bed stays clean, required to prepare the wound bed by eradicating
healthy, and granular. Often, patients receive infected, nonviable tissue while ensuring ample
negative pressure wound therapy (NPWT) with vascular supply to promote epithelial advance-
dressing changes twice weekly. This ensures a ment. In order to ensure that adequate debride-
clean and sterile dressing on the wound while ment and removal of the biofilm has been
building and increasing the granulation tissue in performed, the authors will often paint the entire
the wound bed. If NPWT is not being utilized, wound with methylene blue before each debride-
patients will commonly receive daily to weekly ment. Once the methylene blue is removed via
dressing changes in combination with offload- sharp debridement, it can be ensured that every
ing/immobilization and oral antibiotics if surface of the wound has been debrided
indicated. (Fig. 29.1). Sharp debridement is frequently
p erformed with hydrosurgical instruments, to the operating room multiple times while
curettes, rongeurs, and scalpels until healthy receiving antibiotics [10, 11].
bleeding tissue is reached. The wound is then Thorough hemostasis at the recipient wound
flushed with copious amounts of saline [4]. bed is imperative since hematoma formation
Patients undergo continued debridements until beneath the skin graft can inhibit neoformed cap-
the wound bed is deemed ready for STSG, which illaries, thereby halting graft incorporation.
is decided based on clinical evaluation of any Hemostasis can be achieved via meticulous han-
infection. Serial debridements are often done in dling of wound bed tissue as well as strategic
the in-patient setting if patients are to be brought electrocautery use throughout the procedure.
Topical thrombin provides fast reduction of intra-
Table 29.1 Basic operative steps involved in split- operative bleeding and can also be applied as a
thickness skin grafting (STSG) of a wound bed hemostatic agent for especially large diabetic
Wound bed debridement foot wounds [4].
1. Paint the wound with methylene blue Negative pressure wound therapy is often used
2. Sharply debride the wound using hydrosurgical as an adjunct to surgical debridement for wound
instruments, curettes, rongeurs, and scalpels
removing all the methylene blue bed preparation. In deep or unevenly contoured
3. Flush the wound with copious amounts of saline wound beds it can help to fill-in and even the sur-
STSG harvest face [3, 5]. NPWT also helps to increase granula-
1. Mark the harvest site for appropriate size of graft tion tissue to the wound bed. In patients
to be taken undergoing staged limb salvage procedures, the
2. Inject tumescent solution into the harvest site
resulting wounds created can be managed with
3. Lather the site with lubricant
4. Set power dermatome to the correct width and NPWT prior to definitive wound closure with
thickness and harvest the skin STSG [4]. NPWT assists in stimulation of granu-
Meshing lation tissue, removal of fibrotic tissue formation,
1. Select the appropriate mesher to the correct ratio and improved wound drainage [5].
(1.5:1 or 3:1) and mesh the skin graft. Dermis side
should be facing up during meshing
STSG application
1. Carefully transfer the skin graft to the recipient STSG Harvesting
bed, with the dermis side facing down
2. Secure the graft using skin staples or absorbable After the final debridement has been completed,
sutures the harvesting stage of the surgical procedure can
a b c
Fig. 29.1 The wound bed (a) is painted with methylene blue (b), which is removed using sharp debridements (c)
begin. A “classical” approach to harvesting the any skin preparation solution, such as betadine,
skin graft begins with donor site preparation [5]. and generously lathered with a lubricant. The
The donor site is often the primary cause of dis- most common lubricant is mineral oil but other
tress and pain in patients recovering from STSG; options could be surgical lubricating jelly,
therefore, care should be taken when deciding the chlorhexidine scrub, or hibiclens solution
ideal donor site for a given patient. Common (Fig. 29.3).
STSG donor sites include anterolateral regions of Various methods can be used to harvest STSG,
the contralateral or ipsilateral thigh or leg [5]. including an oscillating Goulian knife, a surgical
The size of the wound should be measured in knife, or a powered dermatome. Challenges of
order to determine the size of the graft that needs manual harvesting involve irregularities in the
to be harvested. One will also have to decide if donor site and skin graft. Due to this, power der-
the graft will be meshed or not. These factors will matomes are often the tool of choice due to their
determine the location of harvest as well as the harvest consistency and the adjustability in graft
size of the dermatome to be used. Once the size thickness and width offered [8]. The power der-
of the graft is determined, the authors will typi- matome should be set to the appropriate width
cally mark the area out on the harvest site of the and thickness. In cases of chronic wounds, an
thigh (Fig. 29.2a). The donor site is further intermediate-thickness STSG (0.012–0.018 in.)
prepped by injection of tumescent solution into should be obtained [4]. Lubricant should be
the harvest site in the subcutaneous layer applied to the dermatome as well to ensure no
(Fig. 29.2b). The benefits of tumescent solution skipping during harvest. The dermatome should
injection include pain control, hemostasis, and a be run at full speed during harvest with firm, even
firm surface for graft harvest. The typical tumes- pressure to the skin surface. Assistants can apply
cent solution that the authors use includes 1 L of traction to the donor site as well (Fig. 29.3).
lactated ringers, one ampule of epinephrine, and Following harvest, the donor site can be covered
30 cc of 1% lidocaine plain. A large spinal needle with an epinephrine- or thrombin-soaked sponge
can be used to inject the solution beneath the in order to minimize blood loss [8]. The authors
skin. The donor site should then be washed of will typically use a tumescent-soaked sponge.
Fig. 29.2 (a) A marker

is used to delineate the a b
donor site, then (b)
tumescent solution is
injected into the
subcutaneous layer of
the donor site
Fig. 29.3 Application

of lubrication jelly at the a b
donor site (a) and
subsequent harvesting
using a power
dermatome (b)
Fig. 29.4 Harvest skin

placed in the hand-
a b
powered mesher (a) and
the resultant meshed
graft (b)
The next step involves skin graft preparation

via meshing. This technique allows the graft to be
stretched so that it can cover larger surface areas.
Manual methods include using a scalpel to create
fenestrations or “pie-crusting” the graft. A hand-
powered meshing device (mesher) can also be
used (Fig. 29.4). Meshers apply numerous slits at
regular intervals in certain ratios. Higher ratios
result in a larger degree of graft stretching, but
also lead to longer healing times due to an
increased area requiring epithelialization [8].
Commonly used ratios for chronic wound grafts Fig. 29.5 Placement of the skin graft on the debrided
using a mesher include 1.5:1 or 3:1. The holes recipient site
created act as drainage sites to prevent blood,
fluid, or seroma collection between the skin graft then secured to the recipient site with either skin
and its recipient bed, which can result in graft staples or sutures, making sure to maintain mini-
failure [4, 8]. When meshing the dermal side of mal tension. Absorbable sutures like monocryl or
the graft should be placed upwards for ease of chromic are typically utilized to secure the graft,
application of the graft to the wound bed after since they do not require removal and dissolve
meshing. close to the same time that the skin graft becomes
adherent [8]. The authors will typically employ
4–0 monocryl in a running fashion around the
STSG Application wound edge.
After meshing is complete, the skin graft is care-

fully transferred to the recipient bed, making sure Postoperative Healing
to correctly orient the graft with the dermis side
facing down (Fig. 29.5). If placed with the epi- Various dressings and healing techniques can opti-
dermis side down, the graft will fail. The graft is mize outcomes during the postoperative period.
Donor Site Healing time, reduce donor site pain, and prevent hyper-
plastic scar formation [13]. The secondary donor
Donor sites should be dressed with a nonadherent site providing the thin STSG was found to epithe-
occlusive petrolatum gauze dressing covered by a lialize within 5 days without any detrimental
transparent film dressing, such as Tegaderm [3, functional or cosmetic effects [13].
5]. Some studies have also suggested the use of a
polyurethane membrane over the donor wound.
These donor site dressings can be removed after Recipient Site Healing
2 days and should be kept dry [5]. The authors
typically apply a nonadherent dressing, such as STSG dressings should provide maintenance of
xeroform, covered with an abdominal (ABD) pad moisture to encourage graft viability, compres-
or gauze and tegaderm. Patients are instructed to sion to prevent hematoma or seroma formation,
leave the nonadherent layer in place until it falls reduction of shear forces to prevent movement of
off on its own. The outer dressing should be the graft, and overall protection from the environ-
changed if saturated or soiled. The donor site will ment. Common postoperative dressings for the
take longer to heal and continue to bleed if the recipient site include bolster dressings or NPWT
nonadherent layer is frequently pulled off the [4]. The recommended polyurethane membrane
donor site. Once the site is healed, patients can for donor site coverage has utility for recipient
wash and moisturize the area regularly. Primary sites as well; it can be used in place of NPWT and
closure of donor sites was previously employed has been found to decrease operating room time
in instances where harvested grafts were thicker due to the lack of suture attachment, and it can
(for example 1:10,000) and thus healing times also assist with maintaining STSG hydration [5].
were longer. Today, the ability to harvest thinner Bolster dressings firmly secure the graft in
grafts, injection of bupivacaine at the donor site, place with nonadherent petrolatum gauze and
and biologic wound matrices have obviated the sterile plain sponges moistened with saline solu-
need for primary closure of donor sites in most tion. They can remain on the wound for 3 weeks
cases. postoperatively [4]. Options for postoperative
While donor sites often heal successfully, dressings to use with the bolster dressing include
patients should be counseled that donor site dis- gauze, silicone splints, fibrin glue, foams, and
comfort and pain are common [13]. Elderly other self-adherents [5]. A typical dressing for a
patients and patients with underlying diabetes STSG applied to the foot would include mepitel,
may experience a delayed or complete lack of an overlying sponge employed as a bolster, fol-
healing at the STSG donor site. Regrafting the lowed by a multilayer compressive dressing.
donor site has been proposed as a method to The alternative is the application of NPWT at
improve donor site healing while reducing asso- the recipient site. A nonadherent dressing is
ciated pain and improving cosmesis. This can be placed over the graft, followed by NPWT with a
achieved either by using a thin STSG from a sep- wound VAC typically set between 75 mmHg and
arate site, or by recycling unused skin graft rem- 125 mmHg of continuous pressure. The VAC
nants from the original donor site rather than should be left in place for 4–5 days postopera-
discarding them [13, 14]. Placement of any tively, after which it can be taken down. This is
excess STSG at the donor site helps facilitate followed by the placement of a nonadherent
healing by providing scattered “islands” of tis- dressing over the STSG to maintain moisture and
sue. Each island has its own reepithelialization prevent shearing [4, 5]. Studies have shown
potential and can improve overall epithelializa- numerous benefits of using NPWT postopera-
tion of the donor site [14]. The application of a tively including successful immobilization of the
thin STSG regraft on the donor site has been graft during the inosculation period in up to 97%
found to significantly shorten epithelialization of patients, improved graft take, reduced seroma
and hematoma formation, and improved epitheli- Complications and Revisions

alization and STSG quality in patients treated
with NPWT. Compared to conventional bolster While immense care is taken in preparing patients
dressings, NPWT post-skin grafts have been for lower extremity STSG procedures and caring
found to yield greater success rates for STSG, for them postoperatively, there are still certain
with approximately 80% less graft failure in circumstances in which complications arise or
NPWT patients compared to those treated with skin grafts fail. Possible complications include
bolster dressings only [12]. These benefits have infection, trauma, lack of wound bed/graft appo-
been attributed to increased oxygenation at the sition, seroma or hematoma, noncompliance, and
wound site, continuous removal of bacteria and swelling, and each of these complications delays
exudate, maintenance of a moist wound environ- healing time by disrupting the graft and interfer-
ment, and uniform pressure application over the ing with healing. Similarly, any patient requiring
entire grafted area [3–5]. revisional surgery can also be expected to experi-
All patients should be non-weight-bearing to ence delayed healing times [15]. Studies of post-
the extremity treated postoperatively. graft complication rates in diabetic patients have
Immobilization of the graft is critical to allow for reported rates ranging from 2.6% to 38% [15].
capillary ingrowth within the first 2–5 days of Faster healing times have also been correlated
inosculation. In patients with isolated STSG for with higher graft take percentage, with 100%
diabetic foot wounds, immobilization of the graft take healing about 3 weeks sooner than
affected lower extremity can be achieved using a patients with less than 95% graft take. Average
posterior splint or offloading boot to prevent time to healing is 5 weeks for non-complicated
movement during the healing phase [4, 5]. The healing in diabetic patients but can increase to
STSG is expected to become engrafted within 2 10–16 weeks in patients with complications [15].
weeks and fully healed in 4 weeks in nondiabetic
patients [5]. In diabetic patients, studies have
reported an average time to heal of 5 weeks with Factors Impairing Healing
a range of 3–16 weeks [15]. Strict adherence to
weight-bearing restrictions is crucial to STSG Pre-existing comorbidities in diabetic patients
success and clear expectations regarding postop- have been found to delay healing time further by
erative weight-bearing status should be commu- increasing postoperative infection risk and result-
nicated to the patient and his or her caretakers ing in an increased need for revisional surgery
throughout the perioperative period. An example when compared to nondiabetic patients. Graft
of a recipient graft on the tenth postoperative day failure in diabetic patients is also more common
can be seen in Fig. 29.6. in actively smoking patients and those who expe-
rience wound infections postoperatively [3].
There is mixed evidence regarding the effect of
wound size on time to healing. One study found
that wound size had no effect on time to heal
[15], but a separate study found that wounds
>80 cm2 were less likely to heal, with only a 52%
success rate when compared to a 74% success
rate in smaller wounds [3]. This finding may be
due to wounds with greater cross-sectional areas
having greater difficulty healing and requiring
amputation more often [3].
Tissue ischemia and edema are common con-
Fig. 29.6 Healing of the split-thickness skin graft on sequences of comorbidities such as PAD and
postoperative day 10 congestive heart failure, and significantly impair
wound healing postoperatively. The inability of tus. If both are optimized, regrafting can be
blood to reach the wound bed and skin graft attempted once more. Alternatively, in certain
results in inadequate supply of oxygen, nutri- circumstances the failed graft can be left in place
ents, and angiogenic factors, resulting in to act as a biologic dressing over the wound to
improper healing and graft failure. Edema cre- allow healing by secondary intention. Despite
ates a larger barrier for oxygen diffusion and measures taken to preserve the limb, some
reduces the clearance of metabolites, resulting in patients may ultimately require free tissue trans-
further tissue damage and impaired graft take. fer or major limb amputation [3].
Edema also reduces adherence of the skin graft
by creating shearing forces and a poor environ-
ment for granulation tissue formation [12]. Conclusion
Congestive heart failure was found to result in a
2.55 times higher risk of STSG failure and is The immense care and consideration that goes
predictive of poor healing in both diabetic and into preparing and treating patients with STSG is
nondiabetic patients [12]. made possible in large part through a multidisci-
The negative effects of fluid collection at the plinary team approach. A collaborative interpro-
wound site further support the need for compres- fessional team allows for streamlined and
sive dressings, NPWT, or bolster dressings post- effective treatment of otherwise complex, comor-
operatively. If compromised oxygen delivery to bid patients. Numerous medical consultations
wound tissues is of concern, hyperbaric oxygen should be requested as necessary to address
has been found to increase levels of free oxygen patients’ comorbidities preoperatively; these may
available in capillaries, positively impacting include but are not limited to members from
healing through collagen synthesis and cross- podiatric surgery, plastic surgery, vascular sur-
linking, angiogenesis, and fibroblast prolifera- gery, rheumatology, nephrology, cardiology,
tion. Hyperbaric oxygen therapy is indicated in medicine, wound care, nutrition, orthopedic sur-
patients requiring graft salvage secondary to skin gery, nursing, and physical therapy [4].
graft failure [4]. Postoperative coordinated care can be
achieved by proper delineation of the donor site,
recipient site, and date of the next dressing
Revisional Procedures change by the surgical team, allowing the entire
healthcare team to treat the patient appropriately.
Impending graft failure may appear as an overly Nurses involved in patient care should be made
black eschar or a porcelain white graft—find- fully aware of postoperative care management in
ings that are typically seen within 1–2 weeks of STSG patients. Team roles should also include
grafting. These findings may indicate only daily monitoring of the recipient site for bleed-
superficial necrosis with survival of the dermal ing, infection, and ischemia, with any change in
portion of the graft. If this is the case, the patient the wound resulting in immediate notification of
should be educated that after several weeks they the surgeons involved. Wound dressing changes
may notice superficial sloughing or necrosis, should occur according to surgeon preference
which will eventually be replaced by healthy tis- and explicit instructions should be communi-
sue [16]. cated to patients and caretakers prior to dis-
In cases of partial graft loss or graft failure, charge [8].
therapies are available to assist in promoting Lower extremity chronic wounds treated with
wound healing. Wet or moist saline-soaked gauze STSG are often delicate and complicated cases.
or dressing can be used to treat partial graft loss, Multidisciplinary care allows for the assembly of
allowing for secondary healing. In the case of complex and adaptive plans of treatment, helping
complete graft loss, the wound bed should be to ensure the best outcomes in terms of graft take
reassessed for infection and vascularization sta- and recovery.
Case Report thematous to yellow-tinged atrophic, shiny

A 73-year-old female with a past medical history plaque with overlying telangiectasias consistent
of type II diabetes mellitus, congestive heart fail- with NLD was noted.
ure, hypothyroidism, and necrobiosis lipoidica After establishing care, the patient was seen
diabeticorum (NLD) presented to the wound care by the wound care clinic, dermatology, and rheu-
clinic for evaluation of a chronic left lower leg matology to provide care for her left lower
ulcer. The patient experienced moderate-to- extremity wound. A consensus was made that the
severe “burning” pain with intermittent exacerba- etiology of the wound was likely multifactorial,
tions associated with the wound. The ulcer resulting from a combination of venous stasis and
occasionally drained significant amounts of fluid. early lipodermatosclerosis, recurrent wound col-
At the time the ulcer first appeared, the onization and infection, and diabetic components
patient’s legs were edematous, and her wound such as NLD and bullous diabeticorum that pre-
was assumed to be a venous ulcer secondary to vented the ulcer from healing. Treatment with
venous stasis insufficiency. It was initially treated oral and injectable steroids was begun, which for
using compression (Unna boots, ACE wraps) and some time helped to reduce the size of the ulcer,
topical wound care, including silver alginate and support the creation of skin islands, and stabilize
zinc oxide. The patient also underwent venous the wound. Approximately 9 months after the
ablation, which provided transient improvement, patient’s initial presentation to the wound clinic,
but the ulcer eventually grew in size despite the there was increased drainage and erythema of the
continued use of compression products. Of note, ulcer, with the wound bed measuring 15 × 12 cm.
a previous venous ulcer of the right leg improved In early 2019, the patient developed a malodor-
after the vein was removed. Due to her prior diag- ous, fibrogranular right heel ulcer as well, mea-
nosis of NLD and the presence of lesions bilater- suring 2.1 × 2 cm. Based on later biopsies of her
ally on her legs, the patient believed this wound wounds, dermatology ruled out pyoderma gan-
was caused by her NLD as well. New lesions grenosum as the etiology and recommended
appeared when the patient experienced stress, but against the use of steroids or other immunosup-
this was the first episode of wound ulceration. pressant therapies.
Topical steroids such as clobetasol and flutico- The patient underwent a total of 11 irrigation
noid were applied as standard treatment for NLD and debridement procedures of her bilateral
but were discontinued since they did not improve lower extremity ulcers over the course of 2 years
healing of the wound and there was concern for following her initial presentation to the wound
inhibition of healing. clinic. She underwent her first STSG applica-
At the patient’s first visit to the wound care tion nearly 2 years after her initial presentation.
clinic, notable vitals included hypertension and a The STSG was harvested from the patient’s left
BMI of 44. The patient’s diabetes was relatively thigh and applied to her leg wounds bilaterally,
well controlled, with a HbA1c of 6.2%. The with the left ulcer measuring 22 × 14 cm and the
patient’s HbA1c remained less than 6.5% right ulcer measuring 4 × 2 cm at the time of
throughout the course of her care. On physical application. The STSG was 1/10,000 in. thick
exam, she had 2+ pulses bilaterally in her lower and was meshed in a 3:1 ratio. The graft was
extremities and 2+ pitting edema at the dorsum of secured to the ulcers using Dermabond. Three
her left foot. She had normal range of motion in weeks following this application, the donor site
all four extremities. On her distal left lower appeared completely healed (Fig. 29.7a), and
extremity, there was a near circumferential and there was 95% flap take on the left lower extrem-
well-circumscribed ulcer measuring 22 × 10.2 cm ity (Fig. 29.7b) and 90% graft take at her right
with a clean base, areas of reepithelialization, lower extremity (Fig. 29.7c). Both grafts
and an erythematous rim. The wound had no appeared healthy, clean, well adhered, and well
odor, fluctuance, crepitus, warmth, or active perfused. Within 7 weeks, both grafts had fully
drainage. On her right anterior lower leg, an ery- healed.
Fig. 29.7 (a) Healing

of the donor site on
a b
postoperative day 22, (b)
healing of the left lower
extremity ulcer by
STSG, and (c) healing
of the right lower
extremity ulcer by STSG
Two months following STSG application, the are no financial disclosures, commercial associa-
patient began experiencing breakdown of her left tions, or any other conditions posing a conflict of
lower extremity skin graft with the formation of a interest to report for any of the above authors.
3.5 × 1.5 cm ulcer. Graft breakdown was believed
to be secondary to reduced ambulation, weight
gain, and worsening lymphedema. Her right lower References
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of split-thickness skin grafting to the plantar foot. J 15. Anderson JJ, Wallin KJ, Spencer L. Split thickness
Foot Ankle Surg. 2020;59(3):498–501. https://doi. skin grafts for the treatment of non-healing foot and
org/10.1053/j.jfas.2019.09.027. leg ulcers in patients with diabetes: a retrospective
11. Naz I, Walters ET, Janhofer DE, Penzler MM, Tefera review. Diabet Foot Ankle. 2012;3(1):10204. https://
EA, Evans KK, Steinberg JS, Attinger CE, Akbari doi.org/10.3402/dfa.v3i0.10204.
CM, Kim PJ. Outcomes of Split-thickness skin 16. Prohaska J, Cook C. Skin grafting. In: StatPearls.
grafting for foot and ankle wounds in patients with Treasure Island, FL: StatPearls Publishing; 2020.
peripheral arterial disease. Wounds. 2019;31(11): https://www.ncbi.nlm.nih.gov/books/NBK532874/.
272–8. Accessed 11 Sep 2020.
Local Flaps for Reconstruction
and Limb Salvage of the Foot
30
and Ankle
David Z. Martin and Gabriel Del-Corral
I ntroduction to Local Flap chances of a good outcome. The surgeon must

Reconstruction of the Foot think beyond the ankle-brachial index as an indi-
cator of adequate perfusion. Waveform analysis
Despite the challenges posed by the diabetic foot, and determining whether the flow is antero or ret-
local flap reconstruction of the lower extremity rograde into each of the six angiosomes inform
can be performed with success rates greater than the surgeon about the vascularity of the wound
90% in the appropriately selected patient. The and the availability of local reconstructive
success matches that of free flap reconstruction options. When the flow is inadequate, the surgeon
with lower overall reoperation rate [1]. must partner with the vascular interventionalist to
In order for local flap reconstruction to suc- ensure adequate perfusion. The six angiosomes
ceed, the surgeon must adhere to the basic prin- of the foot include the calcaneal, medial, and
ciples of reconstructive surgery. The foot is an plantar branches of the posterior tibial artery, the
unforgiving anatomic location. Ensuring a well- anterior perforating and calcaneal branches of the
vascularized wound with respect to the angio- peroneal artery, and the dorsal pedis artery origi-
somes and performing serial debridements prior nating from the anterior tibial artery [2].
to reconstruction are crucial to success. Similarly, Prior to flap repair, the foot must be free of all
a respect for the underlying bony pathology or devitalized tissue and infection. Debridement is
tendon imbalance will impact long-term success. fundamental and multiple debridements are typi-
Finally, flap selection will be impacted by vascu- cally required. Instituting a practice of debriding
lar status, tissues requiring coverage, and loca- to negative post-debridement qualitative culture
tion of wound. The value of good postoperative has been shown to improve success in local flap
care cannot be overstated. Designing a postoper- reconstruction of the foot at 90 days [3].
ative protocol that patients can reasonably follow Bone pathology and tendon imbalance should
and involving them in the care plan is vital. be assessed as part of the reconstructive plan.
Ensuring a well-vascularized limb as early as Osteomyelitis is managed surgically with post-
possible during limb salvage can increase the debridement cultures and pathologic margins
directing decisions regarding length of antibiotic
therapy. Major Charcot reconstructions or tendon
D. Z. Martin (*) · G. Del-Corral
Department of Plastic and Reconstructive Surgery, rebalancing may be delayed until after successful
Georgetown University Medical Center, wound reconstruction. However, planning for the
Washington, DC, USA management of these pathologies is important at
[email protected]

430 D. Z. Martin and G. Del-Corral
the time of closure to improve the chances of lateral foot. It is a type II Mathes-Nahai flap and
long-term functional limb restoration. it is a straightforward elevation. The donor site is
Once the wound has been adequately pre- typically closed primarily. The muscle itself can
pared, the vascular status optimized, and struc- be grafted or small defects left to heal
tural pathology assessed, flap repair can secondarily.
proceed.
Flap selection is based upon the location and Anatomy
size of the wound, the involved structures (bone, The ADM muscle originates from the calcaneal
tendon, nerve, or artery), and whether the tissue tuberosity. It travels along the plantar lateral
will be weight-bearing. aspect of the foot to the base of the fifth metatar-
Local flap reconstruction is generally reserved sal and then on to the lateral base of the fifth toe
for smaller defects. However, it can be combined proximal phalanx. The dominant pedicle is a
with skin substitutes and autografting to achieve branch off the lateral plantar artery proximally. It
broader wound coverage if the vital structures is used as a proximally based flap.
can be covered with the local flap. Wound closure
alone is not sufficient in functional limb restora- Surgical Technique
tion. Consideration must be given to the durabil- Flap elevation is typically performed under
ity of the reconstruction over time. regional anesthesia without tourniquet control.
Local foot flaps can be skin only, axial or per- Loupe magnification and a handheld doppler
forator based, or include intrinsic muscles. It is can facilitate identification of minor and major
often necessary to skin graft the donor site. pedicles. Surgical approach begins with a plan-
Keeping the donor site on a non-weight-bearing tar lateral incision along the course of the mus-
surface will improve the durability of the repair. cle (Fig. 30.1). Existing wounds may be
Intrinsic muscles are good choices when avail- incorporated into the incision plan. The subcu-
able to cover bone. The choice is typically based taneous fat pad is easily separated from the
upon the location of the wound. Commonly used muscle fascia on its superficial aspect. The ten-
intrinsic muscles of the foot include: Abductor don is released distally at the base of the fifth
digiti minimi (for lateral ankle and calcaneal cov- toe and dissection proceeds proximally. Suture
erage), abductor hallucis brevis (for medial mid- tagging of the tendon can aid dissection. The
foot, heel, and ankle coverage), extensor muscle is separated from the flexor digitorum
digitorum brevis (for anterior ankle coverage), minimi brevis medially. The muscle easily sepa-
and flexor digitorum brevis (for plantar heel cov- rates from the metatarsal dorsally. Ligation of
erage) [4]. minor pedicles can be done with bipolar cautery
When muscle is not needed or available, pedi- or ligation clips. The pedicles are identified
cled skin flaps can be useful. These include flaps along the medial border of the muscle.
based upon the following: first dorsal metatarsal
artery, lateral calcaneal artery, medial plantar
artery, and the reverse sural artery.
Finally, fillet toe flaps, random flaps, and tis-
sue expansion can be utilized to round out the
choices for local flap reconstruction of the foot.
Abductor Digiti Minimi Muscle Flap
The adductor digiti minimi (quinti) [ADM] mus-

cle provides a small but reliable flap for recon- Fig. 30.1 Incision is planned along the lateral glabrous
struction of the proximal to mid-plantar and junction. Fifth metatarsal base is outlined
30 Local Flaps for Reconstruction and Limb Salvage of the Foot and Ankle 431
Fig. 30.2 ADM proximally transposed

Fig. 30.4 ADM proximally transposed after release from
metatarsal base
a Mathes-Nahai type II, supplied by one major

proximal pedicle and minor distal pedicles. The
flap is primarily useful for reconstructions of the
calcaneus, medial malleolus, and medial mid-
foot. The muscle belly of the flap can be har-
vested with minimal morbidity and the scar is
hidden in a non-weight-bearing area. The small
muscle belly is ideal for closure of defects less
than or equal to 3–6 cm. Structural stability and
resistance to infection are the main advantages of
muscle flaps in comparison to fasciocutaneous
Fig. 30.3 ADM extended by releasing attachments to flaps when used for reconstruction of the sole of
metatarsal base while preserving vascular pedicle
the foot [6].
Dissection proceeds proximally as needed for Anatomy

length depending on the location of the wound The abductor hallucis muscle flap receives its
(Figs. 30.2, 30.3 and 30.4). The major pedicle is blood supply from both the dorsal and ventral
identified as a branch of the lateral plantar artery plantar system. The three main vessels are: the
at approximately the level of the proximal medial plantar artery, the deep branch of the
cuboid [5] (Fig. 30.3). Care is taken at inset to medial plantar artery, and the superficial branches
prevent kinking of the pedicle. Doppler and of medial plantar artery (Figs. 30.5, 30.6, 30.7
physical assessment can assure safe transposi- and 30.8). The lateral plantar artery is preserved
tion. The muscle can be inset with absorbable during flap harvest, conserving the blood supply
suture. Immediate skin grafting can be per- to the sole of the foot [7].
formed if needed.
Surgical Technique
The procedure is started with the patient under
Abductor Hallucis Muscle Flap general or spinal anesthesia. Tourniquet control
can be used, but it is not necessary. A ventral inci-
The abductor hallucis (ABH) muscle is usually sion is made along the medial aspect of the foot
used as a proximally based flap to cover defects towards the axis of the first metatarsal. The plan-
at the medial aspect of the foot. It is classified as tar fascia is incised from the medial and lateral
Fig. 30.5 Abductor hallucis muscle: elevation with per- Fig. 30.7 Flap inset and closure
forator from the medial plantar artery
border of the abductor hallucis. The insertion of

the abductor hallucis is identified at the calcaneal
tubercle. The muscle belly is dissected off the
base of the proximal phalanx of the hallux.
Supra-muscular dissection between the Abductor
Hallucis muscle and the Flexor Hallucis Brevis
tendon allows for complete exposure of the flap.
Muscular branches from the medial plantar artery
should be carefully preserved. The flap is then
rotated proximally and inset into the calcaneal
defect (Fig. 30.6). To prevent compression of the
pedicle, the calcaneal attachments/plantar fascia
can be released. If a greater arc of rotation is
needed, the flap can be raised as an island flap
allowing better rotation and more tissue bulk [8,
9].
The donor site can be covered with xenograft,
and negative wound pressure therapy. A split
thickness skin graft can be used 3 weeks later.
The patient should remain on weight-bearing
restrictions for 4 weeks until there is full incorpo-
ration of the graft (Fig. 30.7).
Fig. 30.6 Abductor hallucis muscle flap and calcaneal
defect
Fig. 30.9 A lazy S incision can be designed along the

axis of a line from the lateral malleolus to the first web
space
inserts into the extensor longus tendons of toes

2–4 and into the proximal phalanx of the hallux
via the extensor hallucis brevis muscle. The lat-
eral tarsal artery is the dominant pedicle entering
proximally under the muscle belly [11] as a direct
branch from the dorsalis pedis (DP) artery. It is a
Mathes-Nahai type II vascular supply [12].
Fig. 30.8 Latex injection. Abductor hallucis muscle with Surgical Technique
muscular perforator from the medial plantar artery The operation is performed with the patient in the
supine position under general or regional anes-
thesia. The EB muscle belly can be identified by
xtensor Digitorum Brevis
E having patients extend their toes preoperatively.
Muscle Flap A curvilinear incision is made along a line from
the lateral malleolus to the first dorsal webspace
The extensor digitorum brevis [EDB] muscle flap (Fig. 30.9). The lateral tarsal branch of the DP is
provides muscle coverage for anterior and lateral identified distal to the retinaculum along with the
ankle defects. Its donor site can be closed primar- motor branch of the deep peroneal nerve.
ily. Its harvest, however, results in incisions Dissection is performed between the extensor
within the dorsalis pedis [DP] angiosome which hallucis longus and extensor digitorum longus
can result in wound healing complications. To [EDL] (Fig. 30.10). Creating a plane, dissection
extend the EDB distal ligation of the DP artery is proceeds from medial to lateral elevating the
required. Care should be taken with this flap to EDL from the EB. Incising the extensor retinacu-
ensure adequate collateral circulation from the lum facilitates this elevation. Once the plane is
lateral plantar artery [4]. Its size makes it more developed, the EB tendon are divided distally and
appealing than other intrinsic muscle flaps for the flap is elevated distally to proximally. The
larger (5×7 cm) defects around the ankle and cal- lesser vascular pedicles are ligated, preserving
caneus [10]. the lateral tarsal artery and deep peroneal nerve
(Fig. 30.11). The arc of rotation can then be
Anatomy extended by ligating the DP distal to the pedicle
The Extensor Brevis (EB) muscle originates from (Fig. 30.12) [12]. The donor site is closed primar-
the tendocalcaneal ligament of the lateral foot. It ily. The ED muscle belly can be grafted.
Fig. 30.12 If more length is needed the DP artery is

ligated distal to the pedicle and the arc of rotation is
increased. Muscle is shown over the lateral malleolus
Fig. 30.10 A plane is developed between the EHL and

EDL. Dissecting medially to laterally the EDL is dis-
sected off the EB muscle
Fig. 30.13 Calcaneal wound with osteomyelitis.

(Courtesy Paul J Carroll, DPM)
Although typically used as a proximally based

flap, there are reports in the literature of using ret-
rograde flow through the DP artery to provide
muscle coverage to the forefoot [13].
Flexor Digitorum Brevis Muscle Flap
The flexor digitorum brevis [FDB] is a proxi-

mally based muscle flap. It is typically used to
cover calcaneal defects. It is a Mathes-Nahai type
II flap. Because it is a muscle flap, it is well suited
for the management of osteomyelitis (Fig. 30.13).
Fig. 30.11 The EB tendons are released distally and the Although the donor site is closed primarily, skin
flap is elevated, ligating the distal pedicles and preserving grafting is typically used to cover the muscle
the lateral tarsal artery
after inset.
Fig. 30.14 Flap elevation through plantar midline with Fig. 30.15 Flap inset. (Courtesy Paul J Carroll, DPM)
transposition. (Courtesy Paul J Carroll, DPM)
Anatomy
The flexor digitorum muscle originates from the
medial process of the calcaneus and inserts into
the middle phalanges of toe two, three, four, and
five via tendons. The plantar fascia lies immedi-
ately superficial to it and the muscle is bordered
medially by the abductor hallucis and laterally by
the abductor digiti minimi. The lateral plantar
artery is dominant. The artery enters within the
proximal one third of the muscle [14].
Surgical Technique
Fig. 30.16 Primary closure of donor site with integra
Flap elevation is typically performed under grafting of muscle. (Courtesy Paul J Carroll, DPM)
regional anesthesia without tourniquet control.
Loupe magnification and a handheld doppler can
facilitate identification of minor and major pedi- and elevating the lateral plantar artery are tech-
cles. A midplantar incision is made with dissec- niques that can extend the reach of this flap [15].
tion performed to the plantar fascia (Fig. 30.14). If the lateral plantar artery is included in the flap,
The fascia is longitudinally incised and elevated care must be taken to ensure the dorsalis pedis
medially and laterally exposing the muscle belly pulse is preserved.
of the flexor digitorum brevis. The fascia can be
included in the flap if additional bulk is needed.
The muscle is exposed distally until the tendons First Dorsal Metatarsal Artery Flap
are identified. The tendons are divided and the
flap is dissected distally to proximally. The flap is The first dorsal metatarsal artery (FDMA) flap
dissected off the quadratus plantae which lies has been useful in the reconstruction of the
deep to the flap. Care is taken to preserve the per- defects on the dorsomedial side of the distal foot.
forators from the medial and lateral plantar arter- The initial report of the FDMA flap was pub-
ies. The muscle is rotated into position lished by McCraw and Furlow in 1975 [16].
(Fig. 30.15). The donor site is closed with perma- Ishikawa later described the distally based
nent monofilament suture and muscle can then be FDMA flap that was used to reconstruct the
grafted (Fig. 30.16). Disoriginating the muscle defects of the great toe, as well as the first ray
defects [17]. The vascular branching pattern branch assumes a more superficial course after
allows for multiple variations of the flap includ- piercing the metatarsal ligament and frequently
ing adipofascial and fasciocutaneous in reverse, connects with the medial plantar artery [18].
propeller-type, and proximal transposition
options (Fig. 30.17). Surgical Technique
The operation begins with doppler ultrasound for
Anatomy identification of the first dorsal metatarsal artery
The first dorsal metatarsal artery originates from and dorsalis pedis artery. A vein finder or a tour-
the dorsalis pedis or the deep plantar artery. The niquet without exsanguination can be used to
course of the first dorsal metatarsal artery (FDMA) delineate the venous network. Dissections pro-
has three variations relating to its orientation with ceed by incising a skin island directly over the
respect to the first dorsal interosseous muscle audible perforator. The flap is then elevated in the
belly. In 10% of cases it can course superficial to subfascial plane until identification of the distal
the muscle. In the majority of cases, the artery segment of the first dorsal metatarsal artery.
passes under the muscular arch formed by the The dissection now proceeds, proximally, until
tibial head of the first dorsal interosseous muscle identification of the proximal pedicle. Careful
and runs adjacent to the first metatarsal bone. The transection of all fascial attachments surrounding
tibial head can be easily divided and the artery can the pedicle follows to minimize the risk of venous
be easily dissected in this space. No intramuscular congestion and flap failure. If a larger arc of rota-
dissection is needed. Multiple cutaneous perfora- tion is needed, resection of the EHB muscle can
tors can be identified between the heads of the be performed to allow for a tension-free flap inset
first and second metatarsals. The FDMA distal [19]. The flap can be rotated up to 180°, making
this flap useful to cover defects of the dorsum of
the toe or webspace or defects exposing tendons
on the distal dorsum of the foot [20] (Fig. 30.18).
The donor site can be closed primarily or with
the assistance of a skin graft or skin substitute.
Immobilization of the foot is recommended for 1
week with a posterior splint for support.
After this period, the patient can be transi-
tioned into a walking boot until the incision is
completely healed. Custom inserts and shoe gear
can be useful in maintaining an even distribution
of weight across the foot and decrease pressure
over the flap site.
Lateral Calcaneal Artery Skin Flap
The lateral calcaneal artery (LCA) skin flap is a

durable and reliable method of reconstructing the
posterior heel and calcaneus of small and medium
sized defects. Alternative methods of reconstruc-
tion in this area include free tissue transfer or
skin grafting depending on the patient and wound
conditions. This flap was described in detail in
Fig. 30.17 First dorsal metatarsal artery flap: latex injec-
tion flap outline 1981 by William Grabb and Louis Argenta [21].
Fig. 30.19 Lateral calcaneal artery flap after incision

prior to dissection
Fig. 30.18 First dorsal metatarsal artery flap: flap eleva-

tion at the level of the dorsalis pedis artery
Anatomy
Fig. 30.20 The proper plane for elevation is best found
The lateral calcaneal artery skin flap is a proxi- through the posterior incision at the periosteal level
mally based neurovascular skin flap that includes
the lateral calcaneal artery, lesser saphenous
vein, and sural nerve. The LCA is a branch of malleolus. The base can start just proximal to
the peroneal artery. It arises at the level of the the malleolus (Fig. 30.19). For posterior
lateral malleolus between the Achilles and pero- defects, the flap extends distally towards the
neal tendons. It travels distally into the foot giv- plantar heel for a distance of approximately
ing rise to several smaller branches and 8 cm. The distal posterior incision can be made
terminating at the base of the fifth metatarsal down to the periosteum to identify the proper
(Fig. 30.21) [22]. plane (Fig. 30.20). Once the flap is released dis-
tally, the dissection can proceed proximally.
Surgical Technique Care is taken along the anterior border where
The procedure is performed in the lateral decu- branches of the calcaneal artery and the sural
bitus or prone position. This can be done under nerve are continuing into the foot. The flap is
regional or general anesthesia, with or without elevated making sure to retain the LCA in the
tourniquet control. The patency of the artery is flap which runs deep to the subcutaneous tissue
assessed preoperatively with handheld doppler (Figs. 30.21 and 30.22). It is dissected proxi-
or angiography. After proper wound bed prepa- mally until an adequate arc of rotation is
ration, the flap can be designed. The base of the achieved to reach the defect in a tension-free
flap extends from the lateral border of the manner (Figs. 30.23 and 30.24). The donor site
Achilles to the posterior border of the lateral typically requires skin grafting.
Fig. 30.21 In well-vascularized feet the flap can be Fig. 30.24 Posterior rotation of the flap
extended by curving the flap design onto the foot and pre-
serving the LCA and sural nerve as it curves distal to the
lateral malleolus Medial Plantar Artery
The medial plantar artery flap was first described

by Shanahan et al. in 1979, as a rotational skin
flap isolated on the medial plantar artery for cov-
erage of plantar defect. The medial plantar flap is
a fasciocutaneous flap (Mathes-Nahai Type B)
that overlays the instep area between the first
metatarsophalangeal joint (MTPJ) and the calca-
neus (midline of heel). The midline and the
navicular tuberosity are lateral and medial limits,
respectively.
This flap is composed of glabrous skin that is
ideally suited for reconstruction of weight-
bearing portions of the foot, such as the heel. The
flap can also be harvested as a neurotized flap of
Fig. 30.22 The flap is then elevated distal to proximal
protective sensation of the heal or as a free flap
for distant defects. Free flap reconstruction using
the medial plantar artery has been described for
sensate for finger pulp reconstruction [23, 24].
Anatomy
The skin flap is supplied by the medial plantar
artery, a branch of the posterior tibial artery,
which is one of the two terminal branches of the
tibial–peroneal trunk. The medial plantar artery
is the smaller of the two terminal branches of the
posterior tibial artery, the other being the lateral
plantar artery. The medial plantar nerve travels
with the pedicle and it is a terminal branch of the
posterior tibial nerve. The flap (12 × 6 cm maxi-
mum) can be islanded and pedicled on these ves-
Fig. 30.23 Anterior rotation of the flap sels to cover defects on the heel. Another variation
is the distally based medial plantar artery flap pletely elevated (Fig. 30.26). The abductor hal-
which is supplied by retrograde blood flow lucis muscle can be divided in order to increase
through the medial plantar artery [25]. the arc rotation of the flap (Fig. 30.27). Venous
insufficiency can result as the venae comitantes
Surgical Technique are quite small. To lessen this possibility, a super-
The procedure is performed under general or spi- ficial vein (if encountered) can be harvested and
nal anesthesia. A doppler ultrasound is used to preserved with the flap [27]. The main trunk of
map the perforator over the medial plantar artery the medial plantar nerve should be preserved to
and the posterior tibial artery behind the malleo- avoid sensory loss over the distal foot (Fig. 30.28).
lus. A straight line connecting this point and the Donor site closure proceeds with the use of a full
plantar aspect of the first metatarsal space denotes
the midaxis of the flap (Fig. 30.25). This line is
divided into three equal parts. The perforator usu-
ally emerges in between the middle and distal
third and the flap is centered over the perforator.
The distal border should be kept 2 cm behind the
metatarsal heads in order to avoid the weight-
bearing area [26].
The operation proceeds by making an incision
along the medial border of the flap. Elevation of
the flap now proceeds in the subfacial level and Fig. 30.26 Medial plantar flap: flap dissection
below the plantar aponeurosis. The neurovascular
bundle now lies in between the flexor digitorum
brevis (FDB) muscle laterally and abductor hal-
lucis (AbH) muscle medially. Each muscle is
retracted in the opposite direction to expose the
pedicle and the medial plantar nerve. Sometimes,
it is recommended to add a portion of the adduc-
tor hallucis and flexor digitorum brevis muscles
along with the flap.
The pedicle can now be identified distally and
divided to allow for proximal dissection. The dis-
section should remain in the subfacial level and
continue to the level of the calcaneal tuberosity.
The remaining of the lateral incisions can now be Fig. 30.27 Medial plantar artery flap pedicle dissection
(red arrow). Medial plantar nerve dissected with flap for
made after pedicle elevation and the flap is com- flap neurotization (black arrow)
Fig. 30.25 Medial plantar artery flap: skin markings (red Fig. 30.28 Superficial dissection of the medial and lat-
line) eral plantar nerves (arrows)
thickness skin graft or partial thickness graft. The

patient remains non-weight-bearing for 14 days
until the graft is completely healed [28].
Reverse Sural Artery Flap
The reverse sural artery flap is presented as an

alternative flap for small to medium size defects
when free flap procedures hold a higher risk. The
reverse sural artery flap was first described by
Masqualet in 1992 [29]. It was first depicted as a
random flap based on the superficial flow of the
sural artery. Traditionally, it has been used for
sensate reconstruction of lateral malleolar and
heal defects [30]. The distally based superficial
sural artery flap is one of these neurocutaneous
flaps, and its circulation depends on anastomosis
of peri-sural vasculature with distal perforators of
the peroneal artery near the lateral malleolus.
Anatomy
The proximally based sural artery flap is a fas-
ciocutaneous, Mathes-Nahai type I flap (one
dominant pedicle). The anatomic structures
composing the flap are the sural artery, superfi-
cial and deep fascia, sural nerve, and saphenous
vein. Both the sural artery and short saphenous
vein originate from the popliteal artery and vein,
respectively. The superficial sural artery arises
from the popliteal artery in 65% of the cases,
from the medial sural artery in 20%, and from
the lateral sural artery in 8.3% [31]. In most
cases, the artery descends into the lateral malleo-
lus, and in less than 30% of the cases it fades
distally into the distal third of the leg. It has a
constant distal anastomosis with septocutaneous
perforators from the peroneal artery and poste- Fig. 30.29 Reverse sural artery superficial anastomosis
through septocutaneous perforators from the peroneal
rior tibial artery (5 cm above the lateral malleo- artery
lus), which will supply a reverse-flow flap
(Fig. 30.29). It is important to avoid raising the
flap too far distally, as this could potentially position with proper padding can be used for
affect the arterial and venous structures needed flap elevation. A vein finder can be used to mark
to preserve retrograde flow. the superficial saphenous vein network. The
flap markings are as follows. A straight line is
Surgical Technique drawn connecting a point 1.5 cm posterior to
The procedure is performed under general or the lateral malleolus and the cleft formed by the
spinal anesthesia. Prone or lateral decubitus gastrocnemius muscle. This is the longitudinal
Fig. 30.30 Reverse sural artery flap: flap markings. The

pivot point is marked 5 cm from the lateral malleolus. The
vascular axis of the flap is between the midpoint of the
malleolus and the lateral edge of the Achilles tendon
axis of the sural nerve and the vascular pedicle.

The end of the distal dissection is marked with
a transverse line 5 cm above the lateral malleo-
lus. This is the pivot point of the flap, proximal
to the most distal perforators from the peroneal
artery. A doppler can be used to mark the course Fig. 30.31 Subfacial flap elevation. Medial sural vessels
of the peroneal artery perforators at the lateral (blue arrow)
malleolus.
The flap is then outlined and centered over
the pedicle. A tear drop configuration can be level (Fig. 30.31). Muscular perforators from
used to assist in later closure of the proximal the gastrocnemius are visualized and ligated.
defect (Fig. 30.30). An incision is made in the The incision in a lazy S fashion is then carried
proximal border of the flap directly where the distally. The underlying pedicle is elevated with
sural nerve and vessels can be identified at the a width of approximately 2–3 cm, including the
midaxis of the flap. The dissection now pro- deep fascia [32]. The adipofascial cuff that
ceeds from proximal to distal in the subfacial remains around the pedicle should not be vio-
Fig. 30.33 Flap design based upon a first metatarsal

head wound
Fillet Flap of Toe
The fillet flap of the toe is a versatile flap, easy to

raise, and adheres to the “spare parts” principle
of plastic surgery. It can be used to close distal
dorsal, plantar, and forefoot wounds, as well as
Fig. 30.32 Adipo-facial sleeve with preservation of the
sural nerve, artery, and short saphenous vein provide durable coverage for adjacent toes espe-
cially at the metatarsal phalangeal joint. It
requires intact forefoot perfusion to be successful
lated and the vascular structures should not be [35].
skeletonized (Fig. 30.32). The tourniquet is
deflated, and the circulation in the flap is Anatomy
checked. The flap is then transposed distally and The fillet flap of toe is based upon the dual perfu-
sutured to the receptor site. Our preference is to sion of the medial and lateral digital arteries.
connect the defect and donor incisions and avoid Depending on the perfusion of the foot it can be
a subcutaneous tunnel. The tear drop shape of based upon one or both arteries. Typically, there
the flap allows for easy inset and direct visual- are associated wounds involving the toe that dic-
ization of the pedicle [33]. Donor site closure tate the design of the flap.
proceeds in primary fashion if the defect is less
than 4 cm. When closure is not possible, a skin Surgical Technique
graft is preferably used. Venous supercharging This procedure can be performed under local or
has also been found to be beneficial, as described regional anesthesia. Incision placement is based
by Herlin et al [34]. This is indicated especially upon the intended destination of the flap. For
for medial malleolus defects where it is easy to dorsal foot wounds, the incision is placed dor-
perform an anastomosis using the great saphe- sally and for plantar wounds, the incision is
nous axis, unlike the heel or Achilles’ region placed plantarly. The incision extends distally to
which has a dearth of superficial veins. High- the nail fold (Fig. 30.33). The nail fold, germi-
risk patients, such as the elderly, smokers, those nal, and sterile matrixes are excluded from the
with peripheral artery disease, diabetics, and flap and left adherent to the distal phalanx.
those with signs of venous congestion, should Depending on the length of flap needed, the inci-
undergo flap delaying in two stages to avoid sion can be carried medially and laterally around
postoperative vascular complications. the nail and connected distally at the hyponych-
Fig. 30.34 Flap elevated with preservation of both digi- Fig. 30.36 Transposition of flap for coverage. Flap is
tal arteries trimmed and inset
minor flap tip necrosis. The flap design is vari-

able based upon the location of the wound and
condition of the toe.
Random Skin Flaps
Local rotational and advancement flaps have

been well described in the plastic surgery litera-
ture. There is a role for these flaps in limb salvage
as well. Unlike other parts of the body where flap
length: width ratios can exceed 3:1 and 4:1, in the
Fig. 30.35 Degloved toe, discarded foot, maintaining a 1:1 ratio is advised
(Figs. 30.37, 30.38, 30.39, 30.40, 30.41, 30.42,
ium. The incision is made full thickness to the 30.43 and 30.44). These flaps can be very sensi-
periosteum and the toe bones are then degloved tive to tension and atraumatic tissue handling is
back to the metatarsal joint. Depending on the needed to decrease the risk of delayed wound
intended use, the flap can be elevated with dou- healing.
ble or single pedicles. The flap can be elevated
with [36] or without tourniquet control. The ten-
dons can either be included with the flap or prox- Tissue Expansion
imally transected. Once the flap has been
elevated and the phalanges degloved, the toe can Internal tissue expansion of the lower extremity
be disarticulated with a scalpel (Figs. 30.34 and is known to carry a higher complication risk than
30.35). The flap edges can be inspected for expansion of other areas of the body [37]. It is
bleeding. Flap inset can then be performed typi- generally not feasible in the foot and ankle. In
cally with permanent suture (Fig. 30.36). The certain circumstances the technique of external
flap can be tailored during inset. Care should be tissue expansion can be applied to achieve
taken to not skeletonize or disrupt the pedicle delayed primary closure of a wound. The suc-
during this dissection. Flap dimensions of cessful application of external tissue expansion
4–5.5 cm have been described in literature [36]. can result in full thickness coverage over tendon
Local wound care is usually sufficient to manage and bone leaving an incisional scar more durable
Fig. 30.37 V-Y advancement flap. (Courtesy John S. Fig. 30.39 V-Y advancement flap. Place sutures to mini-
Steinberg, DPM) mize distal flap tension. Notice focal blanching at suture
locations. (Courtesy John S. Steinberg, DPM)
than a skin graft. Multiple techniques have been

described in literature including stapling rubber
bands in a crisscross pattern across a wound [38]
and commercially available products that apply a
constant 1.2 kg tension to skin anchors placed
around a wound [39]. Given the relatively inelas-
tic nature of the tissues in the foot, particularly in
the presence of inflammation and edema, the role
of tissue expansion in the authors’ limb salvage
practice is limited, but recurring. Generally,
wounds that can almost be primarily approxi-
mated are best suited for this technique. External
tissue expansion can be synergistically paired
with negative pressure wound therapy. Larger
defects with significant gaps between the wound
Fig. 30.38 V-Y advancement flap. After incising through edges are better served with alternative forms of
the skin, cut down through fascia. Avoid any undermining. reconstruction when available.
(Courtesy John S. Steinberg, DPM)
Fig. 30.40 V-Y advancement flap. Complete healing.

(Courtesy John S. Steinberg, DPM)
Fig. 30.41 Rotational flap. When possible avoid inci-

When using the constant tensioning device on sions over high pressure areas like the metatarsal heads.
the foot, several principles should be followed. If (Courtesy John S. Steinberg, DPM)
the skin edges are adherent to the wound bed,
they will need to be undermined to allow advance- Early removal (between 24 and 72 h) is preferred
ment of the expanded tissue. The skin needs to be to limit additional wounding. When the device is
protected from the monofilament band spanning removed it may be necessary to revise skin edges
between the skin anchors. Without this, linear at the time of delayed primary repair. Despite
areas of necrosis may occur along the course of these limitations, external tissue expansion can
the band. The stapled anchors and tension band serve as a valuable instrument in the limb salvage
can cause irritation and wounds themselves. surgeon’s toolbox.
Fig. 30.44 Rotational flap. Complete healing. (Courtesy

John S. Steinberg, DPM)
Fig. 30.42 Rotational flap. After incising along the arc of
the flap, undermining is performed until the flap can freely
rotate into position. (Courtesy John S. Steinberg, DPM)
Conclusion
Local flap reconstruction of the foot is an important

component of any limb salvage service. The proce-
dures tend to be straightforward and mostly can be
done under ankle block anesthesia making it safer
for the patient with multiple medical comorbidities
than other more complex forms of reconstruction.
It is critical that the surgeon take a holistic approach
prior to entertaining any of these procedures.
Medical management, vascular assessment, and
wound bed preparation are prerequisites for any
planned flap procedure in the lower limb.
Acknowledgment The authors wish to thank Zachary

D. Martin BA (candidate) for his assistance in the cadaver
lab.
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Free Tissue Transfer in Diabetic
Limb Salvage: Lessons Learned
31
and Best Practices for Functional
Salvage
Paige K. Dekker, Kevin G. Kim, Kenneth L. Fan,

and Karen K. Evans
Introduction ropathy, and microvascular occlusive disease that

developed secondary to diabetes resulted in
Reconstruction of lower extremity defects using impaired healing, compromising the viability of
free tissue transfer (FTT) first occurred in 1973 FTT and thereby making diabetic patients poor
when abdominal and groin flaps were used for candidates for this reconstructive modality [7–9].
coverage of distal lower extremity defects [1, 2]. Various studies have since failed to demonstrate
Flap failure rates were initially as high as 40–50% increased incidence of small vessel disease or
[3] but continued advancements in microsurgery endothelial proliferation in patients with diabetes
technique, surgical microscopes, and surgical [10–13]. Furthermore, our research and others’
instruments have led to success rates as high as have maintained that free flap reconstruction can
98–99% [4, 5], making FTT a highly reliable be performed with high success rates in the dia-
reconstructive modality in various clinical sce- betic population [7, 9].
narios. FTT is now recognized as a mainstay While FTT is not always a viable option, it
reconstructive option for lower extremity recon- offers several benefits over major limb amputa-
struction, yielding flap success rates up to 92% tion in appropriate patients. First, major amputa-
[6] and limb salvage rates of 83–84% [6, 7]. tion of one lower extremity increases the risk of
Contrary to previous beliefs, diabetes and contralateral amputation: nearly 50% of patients
peripheral vascular disease are not contraindica- who undergo amputation will undergo a second
tions to microsurgical free flap reconstruction. amputation of the contralateral limb within two
Previous thinking held that hyperglycemia, neu- years [9, 14–16]. Second, major limb amputation
has been shown to be associated with increased
mortality. Patients with diabetes and chronic
P. K. Dekker · K. G. Kim lower extremity wounds have a 5-year mortality
Department of Plastic Surgery, MedStar Georgetown of 43–55% [17–19] but mortality may increase to
University Hospital, Washington, DC, USA as high as 74–78% in patients who ultimately
e-mail: [email protected]; kgk31@rwjms. require amputation due to increased cardiovascu-
rutgers.edu
lar demand [17, 19, 20]. Oh et al. demonstrated a
K. L. Fan · K. K. Evans (*) statistically significant increase in 5-year survival
MedStar Georgetown University Hospital, for diabetic patients undergoing FTT for lower
Washington, DC, USA extremity reconstruction relative to patients
e-mail: [email protected]; undergoing above-ankle amputation (86.8% ver-
[email protected] sus 41.4%, respectively; p < 0.001) [7].

450 P. K. Dekker et al.
While FTT is a successful and reliable recon- (3) exhibit exposed joint or neurovascular struc-
structive modality for diabetic patients with tures [9, 21]. Another primary indication for FTT
lower extremity defects, several perioperative is for reconstruction of areas of the foot or leg in
strategies can optimize success. Importantly, ischemic angiosomes where there is minimal in-
diabetic patients undergoing FTT generally
line blood flow. In this regard, FTT acts as a vas-
require more debridements, have longer healing cular bypass adding vascularized tissue to
times, and have higher rates of re-exploration, ischemic wounds. Importantly, diabetes, periph-
flap failure, and local complications when com- eral vascular disease, and elderly age are not
pared to non-diabetic patients undergoing FTT absolute contraindications for FTT; however,
[9, 21]. A carefully orchestrated multidisciplinary patients with these comorbidities do require spe-
approach involving reconstructive, podiatric, cial perioperative considerations as discussed
orthopedic, and vascular surgeons as well as further below [21]. Importantly, FTT is contrain-
close collaboration with infectious disease, endo- dicated in patients who lack a suitable recipient
crinology, hematology, and nutrition colleagues vessel and caution should be taken in diabetic
is essential to optimizing free flap outcomes in patients receiving dialysis [9]. Patients with end-
this patient population [21]. This chapter will dis- stage renal disease often have diffuse vessel cal-
cuss the indications for FTT as well as strategies cification and impaired wound healing, while
to optimize outcomes in the preoperative, intra- patients on dialysis are at increased risk of both
operative, and postoperative stages of care for thromboembolic events and hematoma formation
patients with diabetes who are undergoing lower [28–30].
extremity reconstruction with FTT.
Preoperative Evaluation
Indications and Optimization
The reconstructive ladder is traditionally used to The preoperative stage should focus on three
help guide the stepwise progression through tasks: (1) evaluating whether the patient is a good
reconstructive modalities. Free flap reconstruc- candidate for FTT, and if so, (2) early and aggres-
tion was considered when primary closure, skin sive optimization of underlying comorbidities as
grafts, and local flap options were exhausted well as (3) preparation of the wound bed for
[22]. However, certain authors advocate for a FTT. Each of these steps requires multidisci-
reconstructive elevator rather than a reconstruc- plinary collaboration from both a surgery and
tive ladder [23, 24]. Primary closure is often pre- medicine standpoint, which may include special-
cluded by the lack of soft tissue domain [9]. ist expertise from podiatric and reconstructive
Robust soft tissue is required for ambulation, and surgery to cardiology, hematology, and hematol-
skin grafting is precluded by exposed tendon and/ ogy, among others. Our management algorithm is
or bone [9, 25, 26]. Local flaps have limited reach depicted in Fig. 31.1.
and may not always be a reliable reconstructive In addition to this multidisciplinary approach,
option, particularly in distal third defects with patients must have a clear understanding of the
repetitive trauma [27, 28]. As surgeons seek to reconstructive timeline as well as postoperative
attain superior functional and aesthetic outcomes, expectations and guidelines in order to maximize
FTT is often the first choice for reconstruction the chance of reconstructive success. To that end,
[21]. counseling the patient and his or her caretakers
Keeping the aforementioned points in mind, should occur throughout the preoperative period.
indications for microsurgical free tissue transfer Ensuring a clear understanding of postoperative
for reconstruction of lower extremity defects weight-bearing and ambulation progression are
include those that (1) are large (>2–3 cm), (2) particularly important, as failure to comply with
involve concurrent bone or muscle loss, and/or rehabilitation protocols can lead to flap failure.
31 Free Tissue Transfer in Diabetic Limb Salvage: Lessons Learned and Best Practices for Functional… 451
Fig. 31.1 Multidisciplinary approach to preoperative workup for free tissue transfer reconstruction
Medicine than three times likely to experience wound

dehiscence and patients with a hemoglobin A1c
Preoperative evaluation of the patient should greater than 6.5% are more than three times as
include obtaining a thorough history that cap- likely to undergo wound dehiscence and/or reop-
tures all pre-existing medical conditions in order eration [31]. In addition to setting a target glu-
to allow for early and aggressive optimization. In cose level of less than 200 mg/dL, it is also
patients with diabetes, tight glycemic control in important that glucose levels are maintained in a
the perioperative period is essential: patients with narrow range throughout the perioperative period,
blood glucose levels above 200 mg/dL are more as patients who display wide variability in
g lucose levels are at increased risk of reoperation Table 31.1 Components of a thorough thrombophilia
screening panel
[31]. Close collaboration with endocrine special-
ists and patient education regarding the impor- CBC
PT, PTT
tance of perioperative glucose control are
Factor V Leiden G1691A genotype
essential to achieving these targets.
Prothrombin G20210A genotype
Surgical trauma induces a hypermetabolic Homocysteine level
state mediated by multiple endocrine pathways, Factor VIII level
which relies on adequate nutritional stores. Antiphospholipid antibody testing
Nutritional screening should therefore be included Antithrombin III activity
as a routine aspect of any preoperative workup Protein C activity
[32]. Retrospective review of patients undergoing Protein S activity
MTHFR polymorphisms (A1298C and C677T)
free flap reconstruction at our institution suggests
PAI-1 4G/5G QST
that a preoperative albumin level above 2.7 g/dL
CBC complete blood count, MTHFR methylenetetrahy-
within 30 days is a reasonable target for patients drofolate reductase, PAI-1 plasminogen activator inhibitor
undergoing FTT, as levels below this value were 1, PT prothrombin time, PTT partial thromboplastin time,
associated with slower healing times and QST quantitative sensory testing
decreased overall flap healing rates (personal Adapted from Defazio MV, Hung RWY, Han KD, Bunting
HA, Evans KK. Lower Extremity Flap Salvage in
communication with Karen K. Evans, 2020). Thrombophilic Patients: Managing Expectations in the
Smoking cessation, or at the very least Setting of Microvascular Thrombosis. J Reconstr
decreased use leading up to surgery, can reduce Microsurg. 2016. doi:10.1055/s-0035-1571249
the risk of impaired wound healing, infection,
partial flap loss, and need for revision surgery genotypes for factor V Leiden G1691A and pro-
[33]. We typically encourage patients to quit or thrombin G20210A as well as testing for the
otherwise abstain from tobacco use for at least A1298C and C677T polymorphisms of the
four to eight weeks prior to surgery. MTHFR gene and lastly for the 4G/5G polymor-
Patients should also be screened for inherited phism of the plasminogen activator inhibitor-1
or acquired traits that may predispose them to (PAI-1) gene [36]. Implementation of this hyper-
thrombosis. Patients with underlying hyperco- coagulability testing protocol in our preoperative
agulability are at increased risk of microvascular workup algorithm revealed that 61% of patients
thrombosis and subsequent flap failure with high undergoing FTT for lower extremity reconstruc-
rates of nonsalvageability [34–36]. In our insti- tion may have at least one thrombophilic trait
tution, we employ a preoperative hypercoagula- and that 20% of patients were found to have
ble workup for all patients undergoing FTT three or more separate diagnoses [36].
including a thrombophilia panel and thorough Patients with known or newly detected
history taking to assess for any personal or fam- thrombophilia should receive a hematology
ily history of hypercoagulability [36]. As part of consult in order to assist with preoperative risk
this history taking, patients should be asked stratification as well as have perioperative anti-
about any personal or family history of clotting coagulation regimens optimized based on their
disorders, autoimmune disease, purpura fulmi- level of thrombosis risk. We consider hemato-
nans, miscarriage, blood clots, or use of blood logic (hypercoagulable traits identified with
thinners [36]. Components of a thorough throm- thrombophilia panel), acquired (history of
bophilia panel are outlined in Table 31.1 and venous thromboembolism, myocardial infarc-
include a complete blood count (CBC), pro- tion, cerebrovascular accident, malignancy,
thrombin time (PT), partial thromboplastin time miscarriage(s), and/or use of blood thinners),
(PTT), homocysteine and factor VIII levels, test- and intraoperative (thrombosis, anastomotic
ing for antiphospholipid antibodies, and measur- revision, vascular calcifications) risk factors to
ing activity levels of protein C, protein S, and stratify patients into low, moderate, and high-
antithrombin III. Testing should also include risk groups [34]. We use this risk stratification
to guide intraoperative and postoperative anti- sue, requiring thorough physical exam. The vas-
thrombotic therapy as outlined in Fig. 31.2. cular supply defining the six foot and ankle
Implementation of this risk-stratified anticoagu- angiosomes should guide the vascular exam, as
lation algorithm at our institution resulted in this not only allows the surgeon to predict the
significantly lower rates of total and partial flap viability of a newly placed free flap but it also
loss in the risk- stratified group compared to allows the surgeon to plan for optimal placement
non-stratified controls (total flap loss 3.0% ver- of surgical incisions since adequate blood flow
sus 19.0%, p = 0.06; partial flap loss 10.0% ver- on either side of the incision is necessary for opti-
sus 37.0%, p = 0.025) [34]. Several studies mal healing. Furthermore, vascular exam and
investigating patients undergoing free flap sur- imaging assist in the coordination with a vascular
gery have found 0% salvageability rates in the surgeon for preoperative revascularization proce-
setting of postoperative thrombosis, regardless dures, if necessary, to ensure that areas targeted
of anticoagulation protocol [34, 35]. Taken for reconstruction have adequate blood supply. In
together, these findings reiterate the risk of non- patients with diabetes and/or peripheral vascular
salvageability in thrombophilic patients who disease, using the six angiosomes as a framework
develop thrombosis postoperatively and rein- to guide directional assessment of blood flow can
force the potential benefits of a risk-stratified ensure that (1) surgical incisions will not com-
anticoagulation protocol. promise blood flow to a given area of the foot and
(2) that vascular bypass procedures will actually
revascularize ischemic angiosome(s) [25, 37].
Vascular Arterial examination can be performed via
palpation of pulses, ankle-brachial indices,
Flap success is highly reliant on adequate arterial handheld doppler, catheter arteriography, or
supply and venous drainage of the transferred tis- computed tomographic (CT) angiography [38].
Fig. 31.2 Risk-stratified anticoagulation protocol for Tefera E, Evans K. Lower Extremity Free Tissue Transfer
patients undergoing free tissue transfer. ASA acetylsali- in the Setting of Thrombophilia: Analysis of Perioperative
cylic acid, LMWH low molecular weight heparin, POD Anticoagulation Protocols and Predictors of Flap Failure.
postoperative day, PTT partial thromboplastin time. J Reconstr Microsurg. 2019;35(04):270–286. doi:10.105
(Adapted from DeFazio M, Economides J, Anghel E, 5/s-0038-1675145)
We employ arteriography for all patients under- Podiatric and Orthopedic Surgery
going FTT. Conventional arteriography uses
less intravenous contrast than CT angiography All patients should undergo biomechanical
and provides more meaningful clinical data examination in order to identify any mechanical
[38]. Routine use of this imaging modality in factors that may be contributing to wound devel-
our institution identified arterial pathology in opment and recurrence. This portion of the pre-
67.8% of patients undergoing FTT for lower operative workup is particularly important for
extremity reconstruction [38]. In the same patients with diabetic neuropathy, as impaired
series, diabetes was associated with the need for protective sensation, proprioception, balance,
endovascular intervention as well as findings of and muscle strength in these patients can lead to
stenosis or occlusion on angiography [38]. increased plantar pressure, prolonged stance
These findings highlight the utility of this imag- times, weakened dorsiflexion, and claw toes [41,
ing modality not only in diagnosing peripheral 42]. Gait alterations in these patients may lead to
vascular disease but also in guiding recipient changes in skeletal structure and muscle func-
vessel selection and facilitating timely endovas- tion, as well as loss of flexibility in the joint and
cular intervention [38]. Achilles tendon [42]. Reduced flexibility in the
Insufficient venous outflow resulting in flap Achilles tendon impairs foot dorsiflexion, which
congestion and delayed thrombosis is a leading can lead to Charcot development and subsequent
cause of re-exploration and flap loss; thus, plantar ulceration [43]. For this reason, we rou-
venous studies are also a key component of pre- tinely address equinus gait with Achilles tendon
operative workup [4, 39]. Venous studies can lengthening, which has been shown to reduce
identify venous insufficiency as well as venous wound recurrence by up to 94% in this popula-
anomalies that may predispose patients to venous tion [44]. This procedure should be supplemented
congestion with subsequent thrombosis and flap with additional measures to address other biome-
failure. While there are many options for venous chanical abnormalities, including, but not limited
imaging, including CT venography, magnetic to, external fixation for bony reconstruction in
resonance (MR) venography, and catheter patients requiring Charcot reconstruction as well
venography, we recommend venous duplex as appropriate corrective footwear [42].
ultrasound because of its superior safety and
efficacy profile relative to alternative imaging
modalities. Importantly, duplex ultrasound is Surgical
noninvasive and does not require contrast, which
is particularly beneficial in diabetic patients who The next preparatory step entails achieving a
often have comorbid renal insufficiency. clean wound bed via serial surgical debridement
Utilization of venous duplex ultrasonography in of all infected or devitalized tissue, senescent
patients undergoing lower extremity free flap cells, and biofilm [25, 45]. Aerobic and anaerobic
reconstruction at our institution detected venous cultures should be obtained prior to and after
insufficiency in 39% of patients and deep vein debridement and should be collected deep to the
thrombosis requiring anticoagulation in 6.78% wound surface [45]. Culture-driven antibiotic
of patients [40]. These findings highlight the therapy should be given in conjunction with sur-
utility of duplex ultrasound in detecting proxi- gical debridements and should be maintained
mal deep venous thrombosis as well as venous until negative cultures are achieved, at which
reflux, making it a helpful tool in determining point the patient is ready for further reconstruc-
whether the deep venae commitantes versus the tion from an infectious standpoint. Please refer to
superficial saphenous system should be used as Chap. 13 of this text (“Debridement of the
the recipient veins for a given patient’s free flap Diabetic Foot and Leg”) for further information
reconstruction. on this topic.
Intraoperative Optimization may be altered in the vasculopathic population.

Musculocutaneous flaps are harvested by elevat-
Anesthesia ing the skin and underlying muscle. These flaps
are well vascularized and offer more bulk than
Close collaboration with the anesthesiologist is fasciocutaneous flaps, making them more resis-
important, as they manage several factors capable tant to infection and more helpful for coverage of
of optimizing flap outcomes. Perioperative anti- defects requiring obliteration of dead space [47].
coagulation is of particular importance in free Chimeric flaps can be helpful for patients with
flap procedures because flap viability is so criti- tendinous or bony defects. For example, a chime-
cally dependent on flap perfusion. As previously ric anterolateral thigh (ALT) with rolled fascia
stated, hematology should be consulted to help lata free flap can be used to reconstruct defects
devise an optimal anticoagulation regimen for that require tendinous reconstruction [48].
any patient with underlying thrombophilia. In Chimeric flaps that include vascularized bone
general, patients should be given aspirin or sub- can be helpful for reconstruction of defects with
cutaneous low-molecular-weight heparin for bony involvement [49].
antithrombotic prophylaxis. We also typically In addition to flap composition, one must also
administer 5000 U of heparin just prior to flap consider the aesthetic and functional needs of the
inset and vessel anastomosis. site that is being reconstructed. The subunit prin-
Normothermia (average temperature > 37 °C) ciple of the foot described by Hollenbeck et al.
should be maintained throughout the surgery, as provides a helpful framework when determining
lower temperatures have been associated with which free flap best suits the unique needs of a
increased risk of perioperative complications particular area of the foot or ankle [50]. Heel
including recipient site infections [46]. ulcers (subunit 5) require reconstruction with a
Vasopressors can be administered as needed for flap that will provide both bulk and durability,
hypotension as their use does not significantly making either the vastus lateralis (VL) or ALT
increase the risk of complications, reoperation, or good options (Case 31.1) [25, 50]. The dorsum of
flap failure [46]. the foot (subunits 3 and/or 4) requires a different
reconstructive approach, as use of a bulky flap
could prevent the patient from fitting into shoes.
Flap Choice Instead, one must rely on flaps with thinner pad-
dles such as the superficial circumflex iliac artery
One of four flap compositions can be utilized for (SCIP) flap (Case 31.2), medial sural artery per-
the vast majority of lower extremity reconstruc- forator (MSAP) flap, or fasciocutaneous ALT
tions: fasciocutaneous, muscle only, musculocu- flap [25, 50]. Functional morbidity is also a key
taneous, or chimeric. Fasciocutaneous flaps, consideration in flap donor site, particularly in
which are harvested by elevating the skin along patients who may require future amputation. The
with its underlying deep fascia, offer several ben- free rectus flap and the latissimus dorsi flap are
efits including preservation of underlying muscu- not preferable options as it is important to retain
lature as well as being thin, pliable, and amenable upper body and core strength for transfers should
to tissue expansion [47]. Large fasciocutaneous an amputation be required in the future.
flaps (>8 cm) may require skin grafts at the donor
site [47]. Typically, we avoid fasciocutaneous Case 31.1 Vastus Lateralis Free Flap
flaps if subcutaneous tissue is too thick. In these A 45-year-old male with a past medical history
instances, we use a muscle flap with overlying significant for type I diabetes mellitus, peripheral
skin graft. Revision procedures including artery disease, left below-knee amputation
debridement and repeat skin grafts for partial (BKA), right-sided weakness secondary to cere-
skin graft loss are not uncommon as blood supply brovascular accident, and right fifth ray partial
amputation initially presented with right foot Purulence was expressed from the wound at the
wounds. On exam, the patient was afebrile (37.1) bedside and cultures were sent. Broad-spectrum
with stable vitals (HR 99, BP 128/72). Exam of intravenous antibiotics were initiated, and the
the right foot revealed a wound with expressible patient was admitted for surgical management of
purulence on the lateral aspect of the fifth meta- his wounds.
tarsal as well as a wound on the dorsomedial The patient underwent two rounds of surgical
aspect of the first metatarsal shaft and head. debridement down to fascia in the operating room
Necrotic skin was noted on the plantar aspect of (Fig. 31.4). The patient also underwent arterio-
the foot, spanning across all metatarsal heads gram and subsequent percutaneous transluminal
(Fig. 31.3). Labs were significant for a hemoglo- angioplasty of the right anterior tibial artery. The
bin A1c of 8.8%. X-ray of the foot was negative patient was discharged home on the tenth day of
for gas in the extremity but was concerning for hospitalization with home health nursing and
cortical erosion of the talus and navicular bones. wound care instructions.
Fig. 31.3 Plantar (a)

and lateral (b) surfaces a b
of the right foot on
initial presentation
Fig. 31.4 Plantar (a)

and medial (b) surfaces a b
of the right foot
following two rounds of
surgical debridement
Approximately one month later, the patient

was re-admitted for debridement, length-
preserving transmetatarsal amputation (which
was especially important given the patient’s con-
tralateral BKA), tendon Achilles lengthening
(TAL), and microsurgical free flap. We proceeded
with our management algorithm as outlined in
Fig. 31.1 prior to FTT:
• Multiple debridements were performed and

cultures were obtained in order to achieve a
clean wound bed prior to FTT. Cultures grew
Candida albicans but this was ultimately
attributed to secondary colonization. Targeted
antimicrobial therapy was administered lead-
ing up to FTT.
• As described above, vascular surgery was
consulted and arteriogram was performed dur-
ing the patient’s initial hospitalization.
Arteriogram revealed multiple areas of ste-
nosis and occlusion of the anterior tibial
artery, which was treated with endovascular
Fig. 31.5 Right foot after length-preserving transmeta-
revascularization. The posterior tibial artery tarsal amputation and anterior tibial donor site
was also noted to have an occlusion without preparation
distal reconstitution.
• Vascular surgery was also consulted for
venous studies. Venous duplex was performed
twelve days prior to FTT and findings were
significant for (1) no evidence of reflux, (2) no
visualized perforators, and (3) no visualization
of the small saphenous vein from the junction
to the proximal calf.
• Hypercoagulability studies revealed that the
patient was weakly positive for lupus antico-
agulant and also had low protein S levels.
These findings did not necessitate further
workup with hematology or specialized intra-
operative management.
• Endocrinology was consulted for optimiza- Fig. 31.6 Harvested vastus lateralis free flap
tion of blood glucose levels. At the time of the
patient’s initial admission, the patient’s hemo- The descending branch of the lateral circumflex
globin A1c was 8.8% and he had glucometer femoral artery was anastomosed to the recipient
readings as high as 294 mg/dL the day before anterior tibial artery in an end-to-side fashion,
FTT. The patient was a non-smoker. followed by two venous anastomoses which
were performed in an end-to-end fashion using
After TMA and percutaneous TAL were per- a venous coupler. The patient was noted to have
formed (Fig. 31.5), a vastus lateralis free flap extensive calcifications in the recipient and
was harvested from the right thigh (Fig. 31.6). donor site arteries; therefore, the arterial anasto-
mosis was performed in an inside-to-outside Case 31.2 Superficial Circumflex Iliac Artery
fashion. After flap inset, a split-thickness skin Perforator Free Flap
graft (STSG) was harvested, meshed, and A 62-year-old female with a past medical his-
affixed to the flap with staples (Fig. 31.7). The tory significant for right hallux rigidis presented
patient was discharged 17 days after FTT. At approximately three weeks after undergoing
ten-month postoperative follow-up, the patient’s right metatarsophalangeal joint fusion with 5/10
flap donor and recipient sites were well healed pain around the surgical site. The patient
and the patient was full weight-bearing with a reported that she had completed a full 10-day
custom molded orthosis (CMO)/ankle-foot course of antibiotics postoperatively. The patient
orthosis (AFO) on the right lower extremity and was afebrile (36.6). Examination of the surgical
a prosthetic device on the left lower extremity site revealed intact sutures and erythema and
(Fig. 31.8). skin sloughing around the incision. Incisional
Fig. 31.7 Medial (a)

and dorsal (b) views of a b
the flap immediately
after microvascular
anastomosis and skin
grafting
Fig. 31.8 Final

postoperative
appearance
dehiscence probing to hardware was noted dis- • Vascular surgery was consulted in order to
tally (Fig. 31.9). There was no purulence. X-ray evaluate blood flow to the distal extremity.
of the foot showed generalized soft tissue swell- This exam was particularly in this patient,
ing consistent with postoperative changes. who was a current smoker. Arteriogram
Intravenous antibiotics were initiated and the revealed three-vessel runoff to the patient’s
patient was admitted for surgical management foot and venous duplex studies revealed (1)
of her wound. no evidence of reflux, (2) no evidence of deep
or superficial vein thrombosis, (3) no visual-
ization of the distal small saphenous vein due
to dressings/drainage, and (4) no visualization
of perforators.
• The patient underwent multiple debride-
ments and cultures were obtained in order to
achieve a clean wound bed prior to proceeding
with FTT. Infectious disease was consulted
for management of targeted antimicrobial
therapy.
• Hypercoagulability studies were all nega-
tive with the exception of minimally elevated
anticardiolipin antibodies and minimally ele-
vated protein C levels. No further hematology
workup was required.
Once it was determined that the patient was

ready for definitive closure, a SCIP flap was har-
vested from the patient’s left thigh (Fig. 31.10).
The right thigh was not used as a donor site due
to the presence of intertrigo on this side. The
superficial circumflex iliac artery perforator was
anastomosed to a side branch of the dorsalis
Fig. 31.9 Right foot wound prior to free flap closure
Fig. 31.10 Harvested

superficial circumflex
iliac artery perforator
(SCIP) free flap
pedis artery in an end-to-end fashion, followed well as a minor revision procedure to remove a
by two venous anastomoses: the superficial cir- portion of the flap that was growing pubic hair
cumflex iliac vein was anastomosed to a deep (Fig. 31.12). At six-month postoperative follow-
vein of the anterior tibial artery and a superficial up, the patient was healing well (Fig. 31.13).
saphenous vein tributary was anastomosed to the In general, thigh-based flaps can be relied on
saphenous vein. Both venous anastomoses were as the workhorse flaps for lower extremity recon-
performed in an end-to-end fashion using a struction. At our institution, the most commonly
venous coupler. A small piece of bilaminar utilized flaps are the ipsilateral ALT flap or VL
wound matrix was used for coverage at the proxi- flap, both of which are based on the descending
mal end of the flap-skin interface in order to min- branch of the lateral femoral circumflex artery
imize tension on the pedicle (Fig. 31.11). Five [25]. Both of these flaps offer the benefits of
months after free flap reconstruction the patient upper body and core strength preservation, low
underwent flap debulking with liposuction as donor site morbidity, and long pedicles that are
Fig. 31.11 Dorsal (a)

and dorsolateral (b) a b
views of the patient’s
right foot after free flap
inset with bilaminar
wound matrix to limit
pedicle compression
Fig. 31.12 Dorsal (a)

a b
and dorsolateral (b)
views of free flap after
debulking procedure
Fig. 31.13 Flap

appearance at six-month
follow-up
large in diameter [25, 51–53]. The ALT flap can in order to perfuse the flap. End-to-side anasto-
be taken with or without underlying muscle, mosis not only preserves distal blood flow to the
making it a good choice for defects requiring less limb but it also reduces the risk of recipient ves-
bulk, while the VL is a useful option for defects sel vasospasm and allows the surgeon to com-
requiring a thicker paddle. The SCIP and MSAP pensate for vessel mismatch [60–62]. We prefer
flaps are two other options that can be useful for to use a longitudinal slit arteriotomy, as opposed
reconstruction of defects that require thin paddles to excising the vessel wall with scissors, as the
for coverage. Limitations of the SCIP flap include former minimizes intimal trauma and allows for
a short, small caliber pedicle while limitations of even further control of vessel size mismatch
the MSAP flap include tedious muscle dissection [61, 63]. Utilization of longitudinal slit arteri-
and susceptibility to vein damage given the large otomy with end-to-side anastomosis in highly
caliber of tributaries [54, 55]. The gracilis flap is comorbid patients undergoing free tissue trans-
another thigh-based option but is often not used fer for lower extremity reconstruction at our
because of short pedicle length. institution has yielded excellent long-term limb
salvage (83.5%) and flap success (93%) rates
[63]. We generally gently palpate an area with-
Vessel Anastomosis out calcium to make our incision. Two large
Acland clamps are used to prop the vessel up.
Microvascular anastomosis can be particularly The donor vessel is cut at a 60-degree angle. A
challenging in the diabetic patient population, toe stitch is performed and tied down. The heel
as these patients often have comorbid peripheral stitch is left untied with a micro clip on it to
vascular disease, atherosclerosis, and or diffuse allow for visualization of each bite. The more
calcifications which can cause recipient and difficult side is sutured first in a running inter-
donor vessels to become stiff, fibrotic, and frag- rupted fashion. Then the heel stitch is tied down.
ile [25, 56]. These vessels are susceptible to In patients who have diffusely calcified donor
traumatic injury and intimal damage during and recipient vessels, use of an end-to- side
microsurgical anastomosis, increasing suscepti- interpositional saphenous vein graft eliminates
bility to thrombosis and other surgical compli- outside-to-inside suturing which can dislodge
cations [25, 57, 58]. These patients also often calcific plaques and increase the risk of anasto-
have limited vascular supply to the lower motic failure [25, 58, 63]. For severe calcifica-
extremity; therefore, the optimal anastomosis tions, a cardiac needle on 7-0 Prolene can be
technique is one that allows for preservation of used to perform the microsurgical anastomosis.
distal blood flow [25, 59]. End-to-end anasto- Inside-to-outside suturing with a saphenous
mosis is therefore not ideal in these patients as it vein interposition graft tacks fragile intima up
requires a major recipient artery to be sacrificed and minimizes disruption [25, 58, 63].
Flap Inset sue transfer, there is considerable variability

with respect to the timing of initiation and fre-
After the microsurgical anastomosis and removal quency of such protocols. A recent systematic
of all vessel clips, a Cook-Swartz implantable review found that the vast majority of studied
Doppler probe can be placed on the vein in order protocols included 48 h of bedrest after surgery
to allow for continuous monitoring of anasto- followed by initiation of a dangle protocol on
motic patency. In the lower extremity, limited postoperative day three [66]. Patients were typi-
domain can cause venous compression during cally allowed to start weight-bearing at the con-
inset. Therefore, it is critical to use the implant- clusion of the dangling protocol barring any
able doppler to monitor the vein during inset. A concomitant orthopedic injuries that would pre-
ViOptix Tissue Oximeter can also be placed on clude this [66]. The importance of patient coun-
skin-based flaps after closure to monitor postop- seling and education bears repeating at this
erative flap perfusion. We have found that supple- stage, as failure to comply with weight-bearing
mentation of clinical observation with these and ambulation progression can lead to flap
additional monitoring tools allows for more failure.
timely and accurate identification of possible flap
compromise.
Conclusion
Postoperative Optimization Preparing for free tissue transfer reconstruction

requires coordinated care among various medical
Flap Monitoring and surgical specialties. Free tissue transfer is a
highly reliable reconstructive option for patients
The most common causes for flap re-exploration with diabetes, but optimization of blood sugar
include pedicle (particularly venous) thrombosis and other underlying comorbidities prior to sur-
and hematoma formation [4]. Not surprisingly, gery is essential to flap success. Thigh-based
shorter time to re-exploration is associated with flaps can be used for the vast majority of lower
increased rates of flap salvage [4]. For this rea- extremity defects and end-to-side anastomosis
son, postoperative flap monitoring is an essential allows for preservation of distal vascular supply.
component of flap success. The vast majority of In the postoperative period, frequent flap checks
flap complications necessitating urgent re- and adherence to weight-bearing and ambulation
exploration will arise within the first 48 h after protocols are key to flap success.
surgery; therefore, inpatient monitoring is typi-
cally recommended for 3–4 days postoperatively
[4, 64]. Hourly flap checks are recommended for References
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Advanced Plastic Surgical
Reconstruction Options
32
in the Lower Extremity
John M. Felder and Joon Pio Hong
Introduction infrastructure to support complex reconstructive

efforts.
For microsurgeons, diabetic foot reconstruction This chapter is geared toward the surgeon who
represents an opportunity to provide substantial already has a strong grasp of these complex
quality of life and mortality benefits to an often issues. Advanced reconstructive techniques pro-
neglected patient population. However, free tis- vide microsurgeons additional tools to tackle
sue transfer in diabetics is among the most chal- challenging and complex cases, as well as tools
lenging for a variety of reasons, with a higher risk to reduce the morbidity of reconstruction. A
of failure than in many types of microsurgery. broad palette of options allows the surgeon to be
The multifactorial nature of the disease and the flexible and create elegant solutions that are best
inevitable presence of multiple significant medi- suited to the unique circumstance of the patient.
cal comorbidities mandate that reconstruction be Examples of advanced techniques include
approached in the context of a multidisciplinary “supermicrosurgery” (anastomosis involving
team. Even with a team approach, questions as vessels <0.8 mm in luminal diameter), perforator
basic as indications for salvage may be difficult to perforator anastomoses, superthin flaps, flow-
to answer, and much of the literature surrounding through flaps, and other techniques. Advanced
microsurgical reconstruction focuses on flap suc- reconstruction requires the surgeon to be able to
cess rates rather than the more complex questions shift perspectives away from classic dogma when
of proper patient selection and meaningful out- needed to choose the actual best option for the
comes. Presenting scenarios vary widely in given scenario. Unfamiliar principles such as
regard to wound types, underlying bony and vas- working with small vessels near the zone of
cular abnormalities, functional abilities and injury may actually provide the simplest, quick-
demands of the patient, complicating medical est, and least morbid reconstruction to the patient
diseases, social resources, and availability of without jeopardizing outcomes. However, judi-
cious use of both old and new principles will be
required to obtain consistently excellent out-
J. M. Felder
Division of Plastic Surgery, Department of Surgery, comes across the spectrum of problems encoun-
Washington University in St. Louis School of tered in this challenging field.
Medicine, St. Louis, MO, USA
J. P. Hong (*)
Department of Plastic Surgery, Asan Medical Center,
University of Ulsan, Seoul, South Korea

468 J. M. Felder and J. P. Hong
Patient Population and Selection of the patient. For instance, younger and highly
active patients with extensive osteomyelitis or
Ninety percent of diabetic foot reconstructions arthropathy in which salvage would require
can be accomplished by simple techniques, and sacrifice of the critical bony architecture of the
only roughly 10% require complex flap recon- foot will have better function with a transtibial
struction [1]. Patients needing microsurgical amputation. However, elderly diabetic patients
reconstruction are often those that have failed have difficulties putting on a prosthesis without
traditional wound care or reconstruction and
support. In many cases their neuropathy has
therefore are at high risk for amputation. already limited their hand and finger coordina-
Presenting patients are typically middle-aged tion. In addition, they suffer from diabetic reti-
to elderly, although younger patients with severe nopathy. Thus, counterintuitively, salvage to
diabetes are becoming more common as the maintain limb length for independent transfers
global epidemic mounts. Obesity, neuropathy, and minimal weight bearing is of benefit to pre-
poor glucose control, peripheral vascular dis- serve independence (Fig. 32.1). Unfortunately,
ease, osteomyelitis, cardiovascular disease, kid- patients who are much older but very active and
ney disease, and visual and mobility impairment who are highly motivated to pursue salvage
are common. Thus, patient selection typically may at times be too frail to withstand complex
begins within a pool of patients that are tradi- surgery, hospitalization, and a prolonged period
tionally considered poor candidates for complex of healing and rehabilitation. The variations are
or lengthy surgeries. Because of this, proper endless, such that seasoned judgment is
patient selection is paramount. Unfortunately, required.
because the comorbidities listed above (and the Obesity is problematic in terms of limiting
critical details of each—e.g., where exactly is flap selection to mostly muscle flaps and increas-
the osteomyelitis or PVD) may occur in a count- ing the difficulty of surgical dissection. It also
less number of individual combinations, useful tends to increase donor site complications such
algorithms to guide patient selection do not as seroma, dehiscence, and fat necrosis. Finally,
exist. increasing obesity tends to be associated with
The surgeon therefore must consider the perti- poorer rehabilitation and ambulation potential.
nent contributions of each of these complicating Poor glucose control has been independently
factors to create a plan with any likelihood of associated with dehiscence in lower extremity
success. This ability can only be gained through diabetic wound closures; thus, involvement of
experience and multidisciplinary collaboration. It internists and/or endocrinologists is critical [2].
is also advisable that the surgeon be familiar with Sensory neuropathy does not affect surgical suc-
the principles and practice of amputation surgery, cess rate and is not a contraindication to salvage,
so that the role of properly performed amputa- but increases the risk of ulcer recurrence [3] and
tions can be included in the decision-making late reconstructive failure. Motor neuropathy is
process. of increasing significance for rehabilitation as
The foremost consideration in patient selec- involvement moves proximally from the foot into
tion is the current and anticipated level of func- the leg.
tion of the patient. While some scenarios are Osteomyelitis is a frequent indication for
clear-cut, such as coverage of a limited area of microsurgical coverage but presents a wide
bone exposure in a younger and active patient, spectrum of considerations depending upon the
most require careful evaluation to determine if location of the involved bone(s). Skeletal defor-
an attempt at salvage will be in the best interest mities of the foot (e.g., Charcot arthropathy)
32 Advanced Plastic Surgical Reconstruction Options in the Lower Extremity 469
a b c
d e
Fig. 32.1 Determining candidacy for salvage may be caneal bone at base. The patient had undergone a failed
complex. Counterintuitively, less functional patients may attempt at partial calcanectomy with primary closure. (b)
be indicated for salvage. A 78-year-old wheelchair-bound Radiographs demonstrate a fractured residual calcaneus
diabetic female with ESRD presented with osteomyelitis with osteomyelitis. (c) Wound following debridement,
after failed attempts at partial calcanectomy and closure. antibiotic therapy, and negative pressure wound therapy.
Although extensive calcaneal osteomyelitis with a large Note the granulation from the calcaneal bone, which is an
soft tissue should prompt consideration for amputation in indicator of good blow flow. (d, e) Stable result at 2 years
ambulatory patients, in this elderly, debilitated patient, post-op after coverage with a free vastus lateralis flap and
salvage was indicated to preserve length for independent glabrous skin graft from the instep. Anastomosis was end-
transfers. (a) Wound at presentation with desiccated cal- to-side (ETS) to the posterior tibial vessels
a b c
Fig. 32.2 Underlying biomechanical abnormalities and onstrating extensive osteomyelitis of the midfoot. In this
extent of infection must be considered before proceeding case, salvage would not have been appropriate despite the
with salvage. (a) A small wound of the midfoot appears small wound. Below knee amputation was undertaken and
favorable for salvage. (b) X-ray demonstrating Charcot the patient returned to ambulation in 8 weeks
arthropathy. (c) Magnetic resonance imaging (MRI) dem-
may further complicate the feasibility or advis- requiring microsurgical reconstruction.

ability of salvage (Fig. 32.2). It is useful to con- Classically, in diabetics, this is at the level of the
sider the foot in thirds, with osteomyelitis and leg trifurcation vessels and is relatively amenable
deformities of the forefoot, midfoot, and hind- to vascular intervention (Fig. 32.3). However, the
foot being progressively less feasible for sal- high prevalence of associated physical, medical,
vage, as destruction of bony architecture (either and social comorbidities such as age, renal fail-
by infection/debridement or bony collapse) in ure, and tobacco abuse mean that in reality, vas-
critical weight bearing joints will lead to a non- cular disease can be diffuse and very problematic
functional foot. For these reasons, it is impor- distally in the leg and foot. Milder PVD may be
tant to have a collaborative relationship with simply an obstacle in recipient vessel selection,
orthopedic surgeons, who may be able to extend but severe PVD associated with tissue loss repre-
the indications for salvage with antibiotic spac- sents a stage of disease that is much more diffi-
ers, fusions, tendon transfers, and external cult to treat and associated with high limb loss
fixation. rates independent of flap success. A close collab-
Associated peripheral vascular disease (PVD) orative relationship with vascular surgery is
is more the rule than the exception for cases critical.
a b
c d
Fig. 32.3 Peripheral vascular disease is a complicating and underwent incision and drainage with hallux amputa-
factor in diabetic foot reconstruction that is at play more tion. (c, d) Angiography demonstrated chronic total
often than not. Diabetics typically present with trifurca- occlusions of the anterior and posterior tibial arteries in
tion level (infrapopliteal) disease. (a, b) A 54-year-old the mid-leg. (e, f) The occlusions of the anterior tibial and
diabetic woman presented with a plantar forefoot ulcer- posterior tibial arteries were treated with balloon angio-
ation leading to first metatarsophalangeal joint infection plasty, resulting in 3 vessel runoff
e f
Fig. 32.3 (continued)
Pre-operative Surgical Evaluation disease. The realistic success rate of microsurgi-

cal diabetic foot reconstruction is markedly lower
Preoperative Counseling than in most other applications of microsurgery.
Even in successful cases, it is the rule rather than
Patients requiring microsurgical reconstruction the exception that minor complications such as
are often those that have failed traditional wound areas of delayed wound healing will occur.
care or reconstruction and therefore are at high Because of the frequent presence of advanced
risk for amputation. In most cases, patients medical comorbidities, the surgeon must con-
should be frankly counseled that they may be at sider patient safety to a greater degree than in
the point of facing amputation if salvage is unsuc- most other applications of microsurgery. Safety
cessful, and that diabetic foot infections them- requires a thorough medical workup, as detailed
selves are a marker for increased risk of mortality. below.
Patients should understand that the wound is a Finally, the surgeon must keep in mind that
serious warning bell, and that even successful healing from microsurgical reconstruction of the
reconstruction is not to be taken lightly. Patients diabetic foot generally means a 6–12 week
should be realistically counseled about the sur- period of non-weightbearing on the foot.
geon’s success rate in challenging cases such as Therefore, patients should be evaluated for will-
in the presence of advanced peripheral vascular ingness to undergo a lengthy period of non-
weightbearing, as well as for noncompliance. Assessment for peripheral vascular disease is

Patients expected to be noncompliant with post- paramount. Femoral, popliteal, and pedal pulses
operative activity restrictions are not candidates should be palpated. Pencil Doppler examination
for reconstruction. of blood flow to the foot is the cornerstone of vas-
cular examination and should be performed in all
cases, even when a pulse is palpable. Specific
Preoperative History effort should be made to determine whether flow
is antegrade or retrograde in both the dorsal and
A history of any prior wound or surgery (includ- plantar systems, via selective occlusion of arter-
ing amputations) of either lower extremity should ies [4].
be sought. A history of prior vascular interven-
tion is critical to obtain. Specific attention should
be paid to determining the patient’s level of Preoperative Studies
ambulatory function. Previous history of throm-
bophilia, stroke, unexplained miscarriages, or X-ray examination of the foot should be per-
venous diseases should be sought. Specific atten- formed in all cases to assess for osteomyelitis or
tion must be paid to use of anticoagulants and biomechanical deformities such as Charcot neu-
recommendations obtained for perioperative roarthropathy that may impact reconstruction.
anticoagulant therapy. Many patients will be anti- MRI may be useful when the presence of osteo-
coagulated either for cardiac reasons or owing to myelitis is uncertain, or when `the exact extent of
lower extremity vascular surgery. osteomyelitis will have implications for salvage
(Fig. 32.2). X-ray images often will also reveal
valuable information regarding the extent of arte-
Preoperative Examination rial calcification within the foot and ankle
(Fig. 32.4).
The wound is assessed carefully by measuring its When free flap reconstruction is being planned,
size and depth and is then photographed. A metal- and unless there are multiple palpable pulses, tra-
lic probe is used to assist in the evaluation of the ditional angiography should be obtained rather
depth of the wound. If the probe touches bone, than computed tomography or magnetic reso-
there is an 85% chance that osteomyelitis is pres- nance imaging. Traditional angiography provides
ent. If tendon is involved, the infection is very superior visualization for recipient vessel plan-
likely to have tracked proximally or distally. Note ning and avoids artifacts caused by vessel calcifi-
the presence and extent of cellulitis and differen- cation, which is frequent in this population
tiate from dependent rubor. Antibiotic therapy (Fig. 32.4). When pulses are palpable and there is
should be initiated after deep cultures are per- low concern for significant arterial calcification,
formed [1]. such as in younger diabetic patients, CT angio-
A critical error to avoid is to simply consider gram is an adequate screening examination that
the wound itself. Instead, the surgeon must con- has the added benefit of being able to visualize
sider the extent of the underlying disease pro- perforators (e.g., anterolateral thigh, circumflex
cesses at play (vascular, bony, neuropathic, iliac) and assist with planning the flap harvest. If
osteomyelitis). Plastic surgeons are often called abnormalities are noted on the CT angiogram,
upon to treat wounds. However, plastic sur- then formal angiography should be pursued.
geons may not be used to the idea that a funda- Ultrasound to exclude the presence of active
mental, progressive, underlying change of the deep venous thromboses is advisable [5].
foot is going on and must be evaluated and Duplex ultrasound should be used to map recip-
treated as a whole in order to obtain meaningful ient vessels for perforator to perforator type
success. anastomoses [6].
Fig. 32.4 Arterial

calcification is a a b
common complication
factor in diabetic foot
reconstruction and can
lead to technical
difficulties with
anastomosis, as well as
signal a more advanced
state of disease. Plain
radiographs should be
assessed for the presence
and extent of vascular
calcifications. (a)
Calcification of the first
dorsal metatarsal and
digital arteries can be
seen. (b) Extensive
calcifications of the
anterior tibial, posterior
tibial, dorsalis pedis, and
lateral plantar arteries
can be seen
In addition to standard preoperative laboratory anesthesia. Internal medicine or endocrinology

testing, nutrition labs (albumin, prealbumin) are should be involved preoperatively for tight peri-
important to obtain. Hemoglobin A1C may help operative glycemic control. Nephrology may be
define whether the patient is likely to be compli- needed for co-existing kidney disease, dialysis,
ant. In the setting of osteomyelitis, baseline and and adrenal insufficiency. Operative planning
subsequent ESR/CRP are useful to help tailor the may need to account for hemodialysis schedules,
length of antibiotic therapy and determine suit- which can also affect administration of blood
ability for delayed bony procedures such as products and antibiotics. Infectious diseases
fusion or arthroplasty. Microbial cultures are consultation is recommended for all patients,
mandatory prior to reconstruction. given the frequent need to consider drug interac-
Anemia is common, due to chronic disease, tions, extended courses of intravenous antibiot-
kidney disease, and other comorbidities. ics, and microbial antibiotic resistance. Vascular
Transfusion may be needed when Hgb < 10 for surgery should be consulted for angiography
cardiac reasons or if blood loss is anticipated and, frequently, for preoperative vascular
(e.g., in anticoagulated patients). intervention.
Preoperative Consultations Preparation for Reconstruction
Appropriate interdisciplinary consultations are Before consideration of reconstruction, it is

essential for patient safety. Safety profiles for imperative to achieve adequate debridement. All
lengthy surgery should be determined by col- necrotic material, foreign material, and microor-
leagues in internal medicine, cardiology, or ganisms must be removed while delicately spar-
ing intact tissue to maintain substrate for healing. 60% of angioplasties may be occluded within
Cultures should be taken before and after debride- 2–3 months, capitalizing on the window of
ment and used to guide antibiotic therapy. Flap reperfusion shortly following an angioplasty is
reconstruction should be delayed until negative important.
post-debridement cultures are obtained. Negative Another factor to consider is the healing
pressure wound therapy, with or without fluid potential of the surrounding tissues in the setting
instillation, can be helpful in managing the of PVD. Even with a healthy flap, failure may
wound between debridements [1]. occur if the surrounding tissues are inadequately
In cases where vascular disease has impeded perfused. In this scenario, two adjuncts may be
healing, vascular intervention should be pur- helpful. The first is preoperative hyperbaric oxy-
sued before debridement and reconstruction. gen therapy (HBOT). HBOT may be begun
The periwound tissues must be capable of toler- immediately following reperfusion surgery
ating debridement and healing to the flap. If vas- while awaiting demarcation of viable tissues.
cular intervention is required, the patient should The goal is to reach a TCP02 of 40 mmHg, which
be referred to a vascular surgeon who special- has been shown in multiple studies to promote
izes in distal revascularizations, as bypass sur- angiogenesis from the surrounding tissues into
gery is clinically still superior to endovascular the flap.
revascularization. Ideally, this is the same per- The second option is to employ aggressive
son who performed the preoperative arteriogra- debridement according to angiosomes. This is
phy. Angiosome-specific reperfusion is not necessary in well-perfused limbs. However,
preferable when possible because this generally in the setting of severe PVD manifesting as a
provides better options for flap recipient vessels wound within a defined angiosome, the entire
adjacent to the wound. When impossible, then ischemic angiosome surrounding the wound
revascularization should target the best outflow should be resected, such that the remaining sur-
available [7]. rounding angiosomes are all adequately perfused
After successful bypass surgery, it then takes for healing. This requires judgment and confi-
4–10 days to maximize the periwound tissue oxy- dence on the part of the surgeon, as the wound
gen level. If angioplasty is performed, then it may may be significantly enlarged as a result. Failure
take up to 30 days for tissue oxygen saturation to to completely debride the ischemic angiosome
reach maximal levels. Definitive debridement can result in tissue edges that will not heal to the
and aggressive wound care should follow as soon flap or result in marginally perfused tissue that is
as signs of revascularization occur, such as new susceptible to infection, which can also be a
granulation and so forth. Wet gangrene, ascend- source of late flap failure.
ing cellulitis, and necrotizing fasciitis demand Partial foot amputation should be considered
immediate debridement. when approaching more extensive cases of tissue
Timing of reconstruction in relation to revas- loss or osteomyelitis. This is because good bio-
cularization is critical when pursuing the super- mechanical function is the goal of reconstruction.
microsurgery or perforator to perforator This is a frequent scenario in the forefoot, and
approach. Use of smaller recipient vessels near to flaps can often be combined with partial foot
the wound may be dependent upon the continued amputations (such as the transmetatarsal amputa-
patency of a recent angioplasty. Because up to tion) for meaningful salvage (Fig. 32.5).
a b
d e f
Fig. 32.5 Forefoot wounds with involvement of the toes recurrence. (d) Conversion to a TMA was performed, and
in patients with peripheral vascular disease (PVD) should the first ray amputation defect covered with a gracilis flap
be considered for conversion to a transmetatarsal amputa- anastomosed end-to-end to the first dorsal metatarsal
tion (TMA), with flap coverage if needed. This provides a artery and subcutaneous vein. The gracilis muscle flap
stable, definitive level of amputation that is functional for was chosen rather than a skin flap because the patient
ambulation and does not risk the formation of future toe required angioplasty for reperfusion of the foot. Muscle
wounds with progression of PVD. (a–c) The patient from flaps provide a larger capillary bed and lower outflow
Fig. 32.3 after revascularization and debridement with resistance, which may assist with maintaining patency of
first ray resection. Although perfused, the toes have sig- vascular interventions. (e, f) Stable, healed TMA at 1 year
nificant wounds with tendon exposure that would require post-op. The patient returned to ambulation without assis-
complex coverage. They are at significant risk of wound tive devices and had no recurrence of wounds
Algorithmic Approach includes the bony architecture, specialized gla-

to Reconstruction brous skin, protective sensation, vascular perfu-
sion, and thin contour that allows footwear.
Although diabetic foot wounds can be complex Diabetic foot wounds can present with an end-
with many reconstructive considerations, a sim- less variety of involvement of each of these com-
ple 3-step algorithm is a good starting point for ponents [8]. This chapter will focus on common
the advanced microsurgical approach. The algo- examples, organized by forefoot, midfoot, hind-
rithm assumes the operator is comfortable with foot, ankle, and massive wounds. The examples
any flap type and focuses on choosing the best considered will be exclusively those that require
reconstruction for the particular defect based on microsurgical reconstruction. It should be recog-
three factors: nized by the reader that local flap alternatives
may exist and be preferable in some of the sce-
1. Consider the wound and the reconstructive narios discussed, but their inclusion is beyond the
requirements. scope of this chapter [9, 10].
2. Review angiography or other vascular imag-
ing (e.g., ultrasound) and commit to a choice
of recipient vessels, using the best-available Forefoot Wounds
vessels.
(a) If there is no significant PVD and high- The forefoot is a relatively privileged area in that
quality vessels are available adjacent to significant bony sacrifice can be made while pre-
the wound, these should be chosen prefer- serving good function. This is important, as many
entially, regardless of their size, to forefoot wounds that reach the point of requiring
decrease operative morbidity. free tissue transfer for salvage will involve osteo-
(b) If severe PVD is present or no suitable myelitis. However, the forefoot also has the sig-
small vessels are adjacent to the wound, nificant downside of being the area most affected
major recipient vessels should be chosen by peripheral vascular disease. Thus, patients
regardless of their distance from the with good blood flow are often high priority can-
wound. didates for salvage despite osteomyelitis and soft
3. Choose the flap based on: tissue loss. Conversely, patients with the same
(a) The appropriate pedicle length from the wound and significant PVD are generally poor
chosen recipient vessels to the wound and candidates for salvage.
(b) The reconstructive requirements of the Generally, acral forefoot wounds such as toe
wound (e.g., thick/thin skin, weight bear- infections or osteomyelitis of the toes can be
ing or not, dead space, outflow resis- treated with limited amputation of the involved
tance, etc.) digits, or fillet flaps. We have reported recon-
struction of toe or webspace defects with super-
The following sections deal with each of these thin flaps (e.g., superficial circumflex iliac artery
considerations in turn. The presented cases will perforator—SCIP, posterior interosseous artery
also emphasize this algorithm. perforator—PIA) connected to the digital ves-
sels (Figs. 32.6 and 32.7) [11, 12]. Use of these
techniques must be carefully considered against
ypes of Wounds and Defect-
T the more traditional options of toe amputation
Specific Considerations or fillet flap due to the reliability of these tradi-
tional procedures for resolution and prevention
The foot is a specialized weight bearing structure of recurrence. However, the goal of “advanced
and enough of its critical components must be reconstruction” is to be able to provide new
intact if functional ambulation is the goal. This solutions that are function-sparing and more
a b c
d e f
Fig. 32.6 An example of “advanced reconstruction” is to artery end-to-side and superficial vein. Let me know your
utilize low-morbidity free flaps to prevent even minor lev- thoughts. (b) The wounds after debridement. (c, d) A
els of amputation, such as toe amputations. Flaps can be superficial circumflex iliac artery perforator (SCIP) flap
used in combination with simpler methods such as local was used to reconstruct the great toe defect, with end-to-
flaps when appropriate. (a) A 65-year-old diabetic male side arterial anastomosis to the digital artery and end-to-
presented with chronic osteomyelitis of the first toe and end venous anastomosis to a superficial vein. A fillet flap
small defects of the first and second toes. After debride- was used to close the second toe defect. (e, f) Final
ment, a SCIP flap was used to reconstruct the first toe. appearance
second toe, fillet flap was used. Free flap used Digital
elegant than ablative techniques. And so, if the providing dorsal foot reconstruction and is a
surgeon is capable of performing such recon- workhorse in this regard (Fig. 32.8). Other fas-
structions with minimal morbidity, we advocate ciocutaneous flaps elevated at the suprascarpal
their use. plan (e.g., ALT) also work well (Fig. 32.9).
Dorsal forefoot wounds, such as those with Combined wounds of the toes and dorsal foot
exposed tendon or bone, generally result from should be strongly considered for transmetatarsal
infection or unintentional injury and subsequent amputation (TMA). An excellent indication for a
debridement. Dorsal or medial/lateral foot flap is for dorsal foot coverage to allow salvage of
wounds are the most favorable for reconstruction, a transmetatarsal amputation with intact plantar
as many options exist for flap coverage, and soft skin (Figs. 32.5 and 32.10).
tissue coverage alone generally suffices, without Plantar wounds of the forefoot are either sim-
the need for any specialized considerations. The ple or highly problematic. These tend to occur as
anterior tibial vascular system is easily accessible pressure ulcers related to altered weight bearing
throughout the dorsum of the foot, for use as con- patterns in the diabetic foot. Biomechanical
venient recipient vessels. The SCIP flap excels in changes such as tendon contracture or arthropa-
a b d
e f
Fig. 32.7 This case demonstrates use of supermicrosur- exposure of toe extensor tendons, ankle extensor tendons,
gery for toe salvage as well as superthin flap for achieving and tibial bone. (g) The toe wounds were reconstructed
thin contour at the ankle. (a, b) A 62-year-old male with a with a posterior interosseous artery (PIA) free flap anasto-
history of diabetes and smoking presented after a chemi- mosed end-to-side to the second toe digital vessel, with
cal burn involving the distal leg, medial ankle, dorsal fore- venous anastomosis to a superficial vein. (h) A suprascar-
foot, and medial first MTP joint. (c, d) Initial attempts to pal ALT flap was used to cover the ankle and leg defect. (i)
manage the burns with excision and grafting failed, due to In cases where anticoagulation cannot be held, it can be
a failure to consider the vascular status of the limb. The beneficial to loosely inset the free flap so that bleeding can
wounds converted to wet gangrene. (e) Angiography dem- drain from beneath the flap as seen here. The patient is
onstrated a short segment chronic total occlusion of the then returned to the operating room on postoperative day
proximal popliteal artery, which responded to angioplasty. 5–7 for definitive closure when bleeding risk has passed.
The patient was placed on aspirin, clopidogrel, and hepa- (j, k) Healed flaps at 3 months post-op with good contour
rin by vascular surgery following the angioplasty. (f) The for footwear
wounds following revascularization and debridement with
g h
i j k

a b c
d e
Fig. 32.8 The SCIP flap is a workhorse in diabetic foot side on the posterior tibial artery. Both wounds were
reconstruction and excels at providing thin coverage for reconstructed on the same day all at once. This case shows
the dorsal foot. A 55-year-old female presented with bilat- the importance of orthoplastic thinking and approach. The
eral diabetic foot wounds, including (a) a dorsal foot follow-up at 3 years shows good function and coverage.
wound with dry gangrene of the toes on the right and (b) (c) The right foot wound was treated with first and second
a posterior ankle wound on the left with exposure of the toe amputation, followed by debridement of the dorsal
Achilles tendon and an equinus contracture. Again the foot wound and coverage with a SCIP flap. (d, e) the left
cases you shared with me were beautifully done using a ankle wound was treated with open lengthening of the
superthin ALT. Here is a case for the chapter if you decide Achilles tendon to treat the contracture and immediate
to use them. A 55-year-old female patient with bilateral coverage with an ALT flap. (f, g) Healed result at 3 years
DM foot. Right foot with exposed tendon and necrosis of demonstrating good function and coverage. This case
the toes. Covered with SCIP flap by end to side on the shows the importance of the orthoplastic thinking and
dorsalis pedis artery. Left foot with chronic ulcer that approach, respecting biomechanical abnormalities as well
ended in tightening of the Achilles and tendon exposure. as soft tissue coverage
One stage Achilles lengthening and ALT free flap end to
f g
thy combine with loss of protective sensation and that are severe enough to threaten the foot even
susceptibility to tissue injury caused by periph- with biomechanical correction (e.g., extensive
eral vascular disease. The result is a callous or osteomyelitis, extensive soft tissue loss, and par-
ulcer that then becomes infected, frequently lead- ticularly those associated with PVD) require
ing to osteomyelitis of the metatarsophalangeal advanced reconstruction.
joints. It is critical to seek the underlying biome- Reconstruction of plantar forefoot wounds is
chanical mechanism for these wounds and cor- indicated because, if successfully reconstructed,
rect it. Most commonly, this is an equinus normal ambulation can be restored. Unfortunately,
contracture of the Achilles tendon, and Achilles they are also highly challenging to reconstruct
tendon lengthening must be performed along with free tissue transfer. This is because they are
with reconstruction, or else early recurrence is the furthest from accessible large vessels at the
certain [13, 14]. Metatarsophalangeal joint resec- ankle, and management of recipient vessels and
tion, metatarsal head resection, or even in situ pedicle length become challenging. “Workhorse”
metatarsal neck osteotomy may be required to flaps must have a very long pedicle (12+ cm) to
remove infection or pressure points and are well- reach from the posterior tibial vessels at the ankle
tolerated biomechanically. Those wounds that to the plantar ball of the foot (Figs. 32.11, 32.12
can heal with biomechanical correction and tradi- and 32.13). Conversely, the use of short-pedicle
tional wound care are considered simple. Wounds flaps such as the SCIP can be limited by absence
a b
c d
Fig. 32.9 The suprascarpal ALT is an alternative option to performed in patients with diabetes. However, in cases
provide thin dorsal foot coverage for larger wounds. A where the wound encompasses the entire distal angiosome,
41-year-old diabetic man presented with wet gangrene it may be appropriate. (d) The use of drains is critical when
stemming from a plantar ulcer beneath the fifth MTP joint. reconstruction with superthin skin flaps is performed. The
(a) He underwent amputation of the second-fifth toes and thin flaps are very vulnerable to injury by pressure from
extensive dorsal foot debridement, removing much of the underlying fluid collections. In this case, despite the use of
dorsalis pedis angiosome. (b) Diagnostic angiogram dem- closed-suction drainage, a seroma formed that threatened to
onstrated 3 vessel runoff to the foot. (c) A suprascarpal ALT compromise the proximal flap integrity. The flap recovered
flap was used for reconstruction, with end-to-end anasto- with prompt drainage. (e–g) Healed and stable result at
mosis to the distal anterior tibial artery. End-to-end anasto- 1 year post-op. The contour was appropriate for normal dia-
mosis to major vessels of the leg and foot should rarely be betic shoes without any revision surgery
e f g
a b
Fig. 32.10 Dorsal foot coverage with a thin flap to allow dorsal skin for bone coverage. (b) Result at 6 months post-
TMA closure is a strong indication for a free flap, because o p following coverage with SCIP flap. Terminal distal
the TMA level of amputation is highly functional for vessels were used as recipients: the flap artery was anasto-
ambulation. The SCIP flap excels in this context. This flap mosed to the first dorsal metatarsal artery (FDMA) and
has the advantage of thin, pliable coverage, with minimal the superficial circumflex iliac vein (SCIV) to the medial
pedicle dissection. (a) A 55-year-old active diabetic man marginal vein, within 1 cm of the wound edge. The patient
presented with a necrotic dehiscence of a TMA site, with returned to ambulation at 6 weeks post-op
adequate plantar skin for weight bearing, but inadequate
of suitable recipients immediately adjacent to the Strategies to combat these challenges include
wound, particularly in the presence of concomi- use of flaps with very long pedicles, components
tant PVD. Further, thin flaps such as the SCIP that adequately address dead space, and compo-
have lower capacity for dead space obliteration nents such as thick skin or fascia to add durability
and weight bearing durability. Partial resection of for weight bearing. Flaps such as the partial
metatarsals and phalanges is commonly neces- medial rectus (Fig. 32.11), TDAP (thoracodorsal
sary in the setting of osteomyelitis and creates artery perforator) (Fig. 32.12), and radial forearm
significant dead space within the wound that (Fig. 32.13) can be harvested with very long ped-
must be addressed. icles to provide reliable long-term inflow from
a b
d e
Fig. 32.11 Reconstruction of plantar forefoot wounds is intervening tissue without tunneling. In this case, the par-
the most challenging scenario in diabetic foot reconstruc- tial medial rectus flap was chosen to allow length exten-
tion but is indicated because of the possibility of restoring sion of the inferior epigastric pedicle by dissection into
a foot with normal function. (a) An ischemic neuropathic the muscle. Rectus fascia was included to add durability
diabetic plantar forefoot ulcer caused by equinus contrac- to the weight bearing surface of the foot. The flap was
ture and severe PVD. The patient was status post remote anastomosed end to side to the distal extent of the bypass
popliteal to posterior tibial artery bypass but developed graft. A trough was created along the medial glabrous
stenosis of the bypass origin and progression of intra- junction of the foot for the pedicle to lay in. (c) Options
pedal disease. Angioplasty of the bypass origin was perfor coverage of the exposed pedicle include skin grafting
formed to restore inflow. (b) In the setting of ischemia, directly onto the pedicle. Skin undermining to allow clo-
robust flow from the ankle is desirable. A flap with a very sure should not be performed in the setting of PVD. (d, e)
long pedicle is needed, and the surgeon must manage the Outcome at 3 years post-op
a b c
d e f
Fig. 32.12 The thoracodorsal artery perforator (TDAP) perforator to assist in dead space obliteration while still
flap provides another option for plantar forefoot coverage. maintaining a thin flap at the skin level. (d) The flap was
The TDAP flap has the advantages of thick skin and a long anastomosed end-to-end to the medial plantar vessels
pedicle for reach to the forefoot. (a) This defect resulted beneath the abductor hallucis. The medial plantar vessels
from squamous cell carcinoma excision in a diabetic man can be considered minor vessels in patients without PVD
without PVD and resulted in exposure of the second- and are appropriate for end-to-end anastomosis. The sub-
fourth metatarsal heads in a critical area of weight bear- cutaneous tissue and fascia beneath the glabrous junction
ing. An incision is designed along the glabrous junction to incision are removed in a 1 cm swath to create room for
allow inset of the pedicle between the recipient vessels at the pedicle. An implantable Doppler probe is placed
the ankle and the wound in the distant plantar forefoot. (b) around the recipient vein. The glabrous junction incision
The TDAP flap is designed centered preferentially around is carefully and loosely closed unless or until the venous
the most distal perforator in order to achieve maximal signal is lost. In this case, sutures in areas that were too
pedicle length. (c) Although not necessary for perfusion, a tight to close were placed loosely and then tied at the bed-
small portion of the muscle can be included around the side on postoperative day 7. (e, f) Healed flap at 6 months
the posterior tibial vessels at the ankle. Generally (Fig. 32.12). Skin edges should never be under-
speaking, the pedicle cannot be completely cov- mined in patients with PVD. Tunneling of flap
ered by the flap, and it is necessary to create a pedicles on the dorsal and lateral foot is possible,
trough between the anastomosis and wound and although risky from the point of view of venous
cover the flap vessels with skin graft, biologic compression. Tunneling of flap pedicles on the
matrices, or carefully planned chimeric compo- plantar foot is not generally possible.
nents of the flap (Fig. 32.11). In patients with Severe plantar forefoot wounds also present
normal blood supply and good tissue quality, the a challenge for salvage of the partial foot with a
skin edges of the trough can occasionally be transmetatarsal amputation. This is because
undermined enough to close over the pedicle integrity of the distal plantar skin is necessary
without tension, although this must be done to close a traditional TMA that will withstand
carefully while listening for loss of venous
the weight bearing demands of the foot.
Doppler signal. More often, we place sutures Because the TMA is a highly functional level of
loosely and delay closure to 1 week post-op at the amputation, attempts to salvage a TMA with
bedside, once the pedicle has had time to fibrose distal plantar reconstruction are warranted
and develop resistance to compression (Fig. 32.14) [15].
a b c
d e f g
Fig. 32.13 Reconstruction of plantar forefoot wound of the PVD. The distal venous arch of the foot was arteri-
with long-pedicle free flaps—radial forearm flap. (a, b) A alized end to side to the radial artery to improve flow to
diabetic man with neuropathy and severe PVD presented the ischemic toes. (e, f) Healed flap at 2 months. The
with a lateral plantar forefoot ulcer and dorsal toe wounds. patient initially dehisced his flap due to inattention in the
(c) After revascularization, a radial forearm flap was early postoperative period. A total contact cast was then
designed to cover the plantar and critical dorsal defect at used to allow delayed healing. (g) Upon resumption of
the first metatarsophalangeal joint capsule. (d) The flap ambulation, the ulcer began to recur due to uncorrected
was harvested with a very long pedicle to reach the plantar prominence of the third and fourth metatarsal heads.
forefoot through a trough cut into the medial glabrous Attention to biomechanics with adequate bony resection
junction. Anastomosis was performed end to side to the before reconstruction would have prevented this compli-
posterior tibial artery at the ankle. Anastomosis to major cation. The ulcer resolved with Achilles tendon
vessels at the ankle was performed because of the severity lengthening
a b c
d e f
Fig. 32.14 Use of flaps with long pedicles for plantar and therefore a TDAP flap was chosen with a long pedicle
forefoot reconstruction: when plantar coverage is needed created by intramuscular dissection. The pedicle had ade-
to salvage a TMA, the TDAP is a good choice because of quate reach for anastomosis to the PTA vessels. The
its thick skin and long pedicle. (a) Salvage of a TMA patient did not have ischemic disease, and so the incision
defect with significant plantar tissue loss. (b) Initially, to accommodate the pedicle could be undermined and
reconstruction was performed with a SCIP flap to the dis- closed gently over the pedicle without creating compres-
tal FDMA vessels. (c) The flap covered the distal bone sion. (e, f) Healed SCIP/TDAP on left allowed return to
stumps, but provided inadequate coverage of the plantar normal ambulation without assistive devices (the patient
surface, with a need for skin grafting that broke down with also had reconstruction of a complex TMA defect on the
weight bearing. (d) Distal recipient vessels in the plantar right with a latissimus myocutaneous flap)
forefoot (e.g., for another SCIP flap) are relatively poor,
Midfoot Wounds are defects limited to soft tissue that result from
infection or trauma, with the underlying skeletal
Dorsal wounds of the midfoot, as with the fore- structure intact. Instances of underlying skeletal
foot, are favorable for reconstruction, with few abnormality that can be corrected to preserve
functional implications. Coverage should be thin, ambulation (e.g., treatment of Charcot arthropa-
so as to allow for fitting into footwear. The SCIP, thy with triple arthrodesis) are also good indica-
PIA, and suprascarpal ALT flaps (Figs. 32.8 and tions for soft tissue reconstruction [16–18].
32.9) are excellent options here. Finally, occasionally, salvage in the setting of
Plantar midfoot wounds frequently result from biomechanical abnormalities and infection may
biomechanical abnormalities such as Charcot be reasonable if the goal is not ambulation, but
arthropathy and must be carefully evaluated for length preservation for transfer (Fig. 32.15).
underlying cause before considering reconstruc-
tion (Fig. 32.2). Uncorrectable Charcot (or simi-
lar biomechanical abnormality) will create a high Hindfoot Wounds
likelihood for recurrence of the ulcer. Infected
Charcot arthropathy (osteomyelitis) should Hindfoot generally refers to the plantar heel, as
prompt strong consideration for amputation, as dorsal and lateral defects at this level will be of
removal of bones of the midfoot generally leads the ankle. Defects are commonly the result of
to worsening biomechanical abnormalities that neuropathic ulceration and infection. Plantar heel
affect ambulation negatively. Scenarios where reconstruction has the opposite positive and neg-
salvage is most indicated for the plantar midfoot ative considerations as forefoot reconstruction.
a b
c d
Fig. 32.15 Reconstruction of severe midfoot defect. (a) have been a more functional result. (b) Anastomosis was
A nonambulatory, wheelchair-bound, morbidly obese dia- to the terminal perforating branch of the peroneal vessels,
betic female with leukemia, a contralateral BKA, and with resection of the remaining intervening angiosome of
ankle varus deformity resulting from chemotherapy- the wound. (c) The gracilis flap was chosen due to the
induced peroneal neuropathy presented with a complex need for obliteration of extensive dead space, and an ETE
lateral midfoot wound resulting from osteomyelitis of the anastomosis was performed given the terminal position of
fifth metatarsal. Reconstruction was indicated only in an the vessels with respect to the wound angiosome. (d) With
attempt to preserve limb length for independent transfers. a healed wound and a brace, the patient was able to use the
For an ambulatory or healthier patient, amputation would leg for transfer in and out of a wheelchair
Blood supply is most likely to be preserved or the angiosome concept, two angiosomes may
accessible, while bone sacrifice is of high func- need to be debrided, resulting in a very large
tional consequence. Thus, osteomyelitis of the defect. The success rates of heel reconstruction
calcaneus requiring significant bony resection, are markedly higher when at least one of the
regardless of vascular status, should prompt native vessels (PT or peroneal) is intact. When
strong consideration for amputation, as ambula- only the AT artery is intact, reconstruction has a
tory function will be compromised (Fig. 32.16). high chance of failure. Surgeons must examine
Exceptions, again, are patients who are mini- the preoperative angiogram with these consider-
mally or nonambulatory and require maximal ations in mind before deciding on reconstruc-
limb length preservation for independent transfer tion [20].
(Fig. 32.1). In ambulatory patients where the
extent of calcaneal osteomyelitis is limited and a
limited partial calcanectomy can be performed Ankle Wounds
that will preserve functional ambulation, salvage
is indicated. Generally, an attempt at reconstruction should
Isolated wounds of the medial, lateral, and always be made for ankle wounds. Good options
posterior heel without osteomyelitis are generally for bony fusion procedures or long-term antibi-
excellent indications for reconstruction otic spacer placement make even infected
(Fig. 32.17). For wounds of the plantar heel, con- arthropathy of the ankle relatively salvageable
sideration should be given to using a flap with compared to the midfoot or plantar heel. Easy
thicker skin, such as gluteal and thoracodorsal access to three distinct recipient vessel systems
artery perforator flaps, or flaps from the circum- provides a hospitable environment for free tissue
flex scapular system. Muscle can be used to cover transfer. Thin skin coverage is the ideal recon-
the heel, and conforms well, but has the propen- struction at the ankle, and flaps such as the SCIP,
sity to atrophy, allowing the calcaneal tuberosity suprascarpal ALT (Figs. 32.7, 32.8), suprascarpal
to erode through the flap with time. A useful tech- SIEA (Fig. 32.18), PIA, distal lateral arm
nique is to resect the tuberosity of the calcaneus (Figs. 32.19 and 32.20), and radial forearm
when approaching plantar heel reconstruction in (Fig. 32.21) fit the defect requirements nicely.
order to prevent this delayed erosion [19]. Muscle flaps are an alternative that provide thin
Reconstruction of heel wounds in the isch- coverage by atrophy.
emic foot is a challenging scenario with a higher Common scenarios requiring coverage at the
failure rate than elsewhere in the foot. The heel ankle are posterior defects involving the Achilles
is a watershed area, which normally has a dual tendon (Figs. 32.8, 32.17, 32.18 and 32.20), ante-
supply from the posterior tibial and peroneal rior defects related to failed arthroplasty or fusion
arteries. However, in advanced PVD, the ante- procedures (Fig. 32.21), and lateral ankle defects
rior tibial artery may be the only supply to the related to vascular (frequently venous) disease or
foot. Therefore, when debriding according to prior surgery (Fig. 32.19).
a b
Fig. 32.16 Patients who are strong ambulators but have graphs of the foot demonstrate advanced osteomyelitis of
extensive osteomyelitis of the calcaneus should be the calcaneus, with cortical disruption and multiple areas
strongly considered for below knee amputation, regard- of cystic degeneration of the calcaneus. (c) MRI T1
less of the wound size or vascular status. (a) A 46-year-old images show avascular necrosis of the majority of the cal-
diabetic man with a 2 year history of a chronic plantar caneus. (d) MRI T2 images show osteomyelitis of the
heel ulcer with osteomyelitis developed extension of the entire calcaneus that is confluent with the plantar heel
infection to the Achilles tendon with acute abscess forma- wound. The patient went on to have an Ertl BKA and
tion. The wounds are shown after incision and drainage. regained the ability to run using a prosthetic within
Many options exist for flap coverage. (b) Plain radio- 3 months
a b
c d
Fig. 32.17 Defects of the non-weightbearing hindfoot chronic posterior heel wound. (b) Defect following
are very favorable for salvage, as only skin coverage is debridement. (c, d) Stable coverage with ALT flap with
required. (a) A 74-year-old ambulatory diabetic man with ETS anastomosis to PTA
history of prior TMA presented with acute infection of a
a b
Fig. 32.18 Coverage of the ankle with ultrathin skin donor sites unfavorable, an ultrathin superficial inferior
flaps. (a) A 61-year-old obese female with a history of epigastric artery (SIEA) flap was chosen and raised in the
diabetes and smoking presented with a chronic would of subdermal plane just deep to the SIEV. (c) Healed flap at
18 months duration after surgical repair of a ruptured 3 months with satisfactory contour match to the thin skin
Achilles tendon. (b) Because obesity made other skin flap of the ankle
a b
Fig. 32.19 Thin skin coverage options for ankle defects. behind the fibula for lateral ankle wounds. (a) Chronic
Lateral ankle wound resulting from chronic venous dermati- venous stasis wound with surrounding zone of scarring. (b)
tis. In chronic cases, the zone of scar tissue surrounding the Design of distal lateral arm flap using very thin skin overly-
wound may encompass the local perforating vessels, making lateral epicondyle. (c) Flap pedicle in situ adjacent to
ing perforator-to-perforator anastomosis undesirable. The radial nerve, demonstrating generous length of pedicle. (d)
distal lateral arm/forearm flap is a useful very thin alterna- Exposure of the peroneal vessels behind the fibula. (e)
tive to the SCIP, with a long pedicle to reach outside the Completed end-to-side anastomosis to the peroneal vessels.
zone of scarring. The peroneal vessels can be easily accessed (f, g) Healed flap with satisfactory contour to lateral ankle
a b
c d
Fig. 32.20 The lateral arm flap can provide thin coverage (b) The forearm was the only anatomical area with a rea-
for the ankle in morbidly obese patients. (a) A 53-year-old sonable skin thickness match to the posterior ankle. A dis-
morbidly obese diabetic female with a BMI of 56 pre- tal lateral arm flap is elevated. (c, d) Healed flap at
sented with a chronic Achilles wound of 7 years duration. 3 months post-op with appropriate contour to the ankle
a b c
Fig. 32.21 Anterior ankle wounds are often favorable for ment and placement of antibiotic cement spacer. (c) Stable
reconstruction because bony fusion or arthroplasty proce- coverage with radial forearm flap. The radial forearm flap
dures can address osteomyelitis. (a) A morbidly obese was chosen rather than the SCIP because of the multiply
diabetic man presented with a chronic, draining anterior reoperative field, with heavy scarring, which made anasto-
ankle wound with osteomyelitis following failed arthro- mosis well outside the zone of injury preferable. The
plasty and multiple attempts at closure with biologic patient returned to ambulation in a brace with the antibi-
matrices and skin grafting. (b) Defect following debride- otic spacer left in place
Massive Wounds cle flaps such as the latissimus may be the best
option to provide coverage (Fig. 32.22). If skin
Massive wounds generally result from necrotiz- flaps are used, then several flaps may be neces-
ing infection or abscess and may cross anatomi- sary, and these can be performed to separate
cal areas, for instance, from the plantar foot up to recipient vessels, or “stacked” as flow-through
the proximal leg. These wounds often occur in flaps (Fig. 32.23). However, our experience has
the setting of poorly controlled diabetes and non- been that in the case of circumferential wounds
compliance. Candidacy and methods for recon- of the lower leg with circumferential disruption
struction must be selected on an individual basis of the lymphatic system, skin flap reconstruc-
considering the extent of pathology, functional tions are more prone to chronic edema than mus-
status of the patient, and likelihood of compli- cle flap reconstructions (Figs. 32.23 and 32.24).
ance with a complex reconstructive effort that All of these factors should be considered when
may take months to heal. At times, necrotizing approaching Step 1 of our algorithm above:
soft tissue infection leaves a mostly skin-level
defect that is amenable to salvage even if mas- • “Consider the wound and the reconstructive
sive. In the setting of massive wounds, large mus- requirements.”
a
b
e f
Fig. 32.22 Massive wounds often result from gas gan- the medial forefoot. (c, d) Coverage was achieved with a
grene or necrotizing fasciitis. (a, b) A 37-year-old man split-latissimus dorsi muscle with a distal skin paddle.
with Prader-Willi syndrome and type II diabetes devel- The transverse branch of the muscle covered the proximal
oped gas gangrene resulting from an infected hallux ulcer. leg wound. The descending branch of the muscle covered
The resulting defect included exposure of the anterior the ankle and dorsal foot. (e, f) 8 months postoperative
compartment tendons in the distal leg, ankle, and dorsal demonstrating stable coverage with satisfactory contour
foot, as well as a first metatarsal ray amputation defect of for shoe wear
a b
d e
Fig. 32.23 Massive wounds and the choice of fasciocu- mucor infection and potentially due to nonadherence of
taneous versus muscle flaps for coverage of infected ten- the fasciocutaneous flap to the underlying infected ten-
dons. An undiagnosed diabetic man presented with a dons. A muscle flap might have had better adherence to
necrotizing infection due to mucormycosis. (a, b) Radical the tendons for eradication of infection. (d, e) The patient
debridement resulted in circumferential wounds with was lost to follow-up and returned several months later
extensively exposed tibia and tendons. (c) The wound was with healed but very swollen flaps. These photos are after
reconstructed with “stacked” ALT flaps and skin grafting. 1 week of compression therapy. Early and sustained post-
The first flap was anastomosed end-to-side to the anterior operative compression therapy might have prevented the
tibial artery, and the second flap end-to-end to a flow- edema seen here, especially in the context of a circumfer-
through vessel of the first flap. There was initially satis- ential wound with loss of the superficial venous drainage
factory contour. The patient developed an abscess beneath system. A muscle flap would likely have been less prone
the flaps several weeks out from surgery, due to persistent to develop edema and would have been a better option
Fig. 32.24 Coverage of massive wounds and the choice flap anastomosed end-to-side to the posterior tibial vessels.
between fasciocutaneous and muscle flaps for large wounds (e) By 8 weeks post-op, the flap and skin graft had excellent
with infected tendons. (a, b) A 64-year-old diabetic man pre- contour. There was no occurrence of infection beneath the
sented with a severe, circumferential venous stasis ulcer with flap, which had good adherence to the infected tendons. There
exposure and infection of multiple tendons. (c, d) Following was no notable edema despite the known presence of venous
radical debridement with preservation of longitudinal struc- stasis disease. This contrasts favorably to the outcome with
tures, the wound was covered with a latissimus dorsi muscle fasciocutaneous flap for a similar situation in Fig. 32.23
Recipient Vessel Selection recipients, particularly in the setting of

PVD. Duplex ultrasound has lately become a fre-
Recipient vessels in the ankle and foot include quently employed and useful technique for
the anterior tibial, posterior tibial, and peroneal assessment of minor vessels as recipients for e.g.,
vascular systems. Detailed knowledge of the “supermicrosurgery” using flaps such as the
anatomy of each is critical to successful opera- SCIP that have small caliber and short pedicles.
tive planning, particularly in the presence of vas- The ultrasound generally should be performed by
cular disease where anatomy is abnormal. the surgeon him/herself, who must be an experi-
Readers are referred to the excellent article by enced operator of the equipment.
Attinger on angiosomes of the foot and ankle for In general, for any critical defect, major ves-
a detailed review of vascular anatomy and its sels are a preferred solution due to their reliabil-
assessment [4]. ity, anatomic consistency, and long-term patency.
Selection is straightforward in diabetics with “Traditional” workhorse type flaps require large
minimal or no vascular disease, such as very caliber vessels for anastomosis. Major vessels
young patients. However, in the more common should never be used when in-line flow to the
scenario of concomitant peripheral vascular dis- vessel is absent or cannot be reestablished by vas-
ease, recipient vessel selection is often the most cular surgery. The downside of using major ves-
challenging and critical facet of reconstructive sels comes into play in the distal foot, where
planning. intervening tissue between the major vessels at
Recipient vessels of the foot and ankle can be the ankle and the distal defect becomes a problem
broken down into “major” and “minor” vessels, with respect to pedicle placement. This may
which anatomically roughly correspond to “prox- require sacrifice of intervening skin (making the
imal” and “distal.” Major systems include the wound worse in the case of flap failure), or
tibial vessels at the ankle, and the peroneal ves- unconventional treatment of the pedicle, such as
sels in the leg behind the fibula (the peroneal ves- skin grafting the pedicle itself (Fig. 32.11). As
sels are infrequently used). Minor systems well, closure over the anastomosis to major ves-
include perforators of major vessels, distal sels often produces compression of the veins,
branches of the major systems, such as the first which creates other considerations for flap inset.
dorsal metatarsal artery (FDMA) (Fig. 32.25), Minor vessels are generally useful when
medial and lateral plantar systems, digital vessels attempting to minimize the morbidity of recon-
(Figs. 32.6 and 32.7), intrinsic muscle pedicles, struction with the “supermicrosurgical” approach.
peroneal vessels at the ankle (Fig. 32.15), and Minor vessels are an excellent option in the set-
intact collateral vessels in the setting of PVD. It ting of normal vascular anatomy, or mild to mod-
is strongly recommended to obtain formal angi- erate PVD. Minor vessels, for those experienced
ography for recipient vessel planning in all cases with supermicrosurgery, are best used for fore-
[21]. In addition to anatomical information, angi- foot/toe defects, dorsal foot defects, ankle
ography gives information on the consequences defects, or salvage of partial foot amputations.
of potential vessel sacrifice—for instance, even if Minor vessel anastomosis is generally with end-
a palpable pulse of the dorsalis pedis is present, to-end technique. The most common example is
end-to-end anastomosis to this vessel may be use of the SCIP flap with anastomosis to distal
devastating to a foot with an occult occlusion of vessels (Figs. 32.10 and 32.25). This approach
the posterior tibial artery, where the plantar pedal has benefits in that small vessels are present
circulation is dependent on retrograde flow from within or immediately adjacent to the wound, and
the dorsal system. Formal angiography suffices their preparation requires minimal or no dissec-
for vessel selection if one of the major systems is tion of the foot outside of the wound (Figs. 32.5,
to be used. However, for the minor vessels, angi- 32.6, 32.7 and 32.8). This minimizes surgical
ography alone may not give the spatial informa- trauma to the foot. It also potentially shortens
tion needed to accurately locate suitable operative time, as both flap pedicle dissection are
a b c
f
e
Fig. 32.25 Use of the first dorsal metatarsal artery using the “scratch test” to look for bright red bleeding. At
(FDMA) system as recipient vessels. These vessels are 1 week post-op, the flap is viable. However, one can see
ideal recipients for reconstruction of open TMA defects. that nursing staff mistakenly made repeated scratches.
(a, b) A diabetic man underwent guillotine TMA for nec- Only one scratch is necessary, and it can be encouraged to
rotizing infection. The green Acland clamp is on the bleed repeatedly with mechanical agitation. (e, f)
FDMA. (c) A SCIP flap was used for reconstruction, with Demonstrating healed flap at 8 weeks post-op. The wrin-
end-to-end anastomosis to the first dorsal metatarsal kled skin is due to the use of compression wrapping,
artery and subcutaneous vein. (d) The flap was monitored which facilitates rapid healing
more rapid (using flaps with short pedicles), and artery, then vein grafting to the intact major sys-
recipient vessel preparation is rapid, as only a tem may be necessary and is preferable to the use
short length of small vessels needs to be isolated. of minor collateral vessels for substantial defects.
In contradistinction to major vessels, minor ves- Alternatively, when possible, a distal vascular
sels can be used when in-line flow is absent; e.g., bypass can be performed by vascular surgery and
when supplied via collaterals, so long as there is anastomosis can be to either the bypass vessel or
strong pulsatile outflow from the vessel. The the distal reconstitution of, e.g., the posterior tib-
downside of using minor vessels is their anatomic ial artery that the bypass targets (Fig. 32.26).
inconsistency in the setting of PVD, and the ana- Muscle flaps provide the lowest outflow resis-
tomical limits imposed by finding appropriate tance, and so should be used preferentially when
vessels near enough to the wound when using using highly diseased major recipient vessels that
flaps with very short pedicles. It is essentially required significant angioplasty or bypass to serve
mandatory to use preoperative duplex ultrasound as targets. Skin flaps with limited vascular beds
to confirm the presence and exact location of create resistance to outflow, which may contribute
usable vessels when taking this approach, as tra- to thrombosis of vessels that are already tenuous
ditional pencil Doppler examination with surgi- and have been freshly injured by angioplasty or
cal exploration can be very misleading [22]. The bypass anastomosis.
anatomy of blood supply to minor vessels in the With all of the above in mind, the second step
setting of PVD may be markedly distorted, with of our algorithm should be considered as
abnormal collateral channels taking unpredict- follows:
able courses. Review angiography or other vascular imag-
In the setting of significant PVD, we consider ing (e.g., ultrasound) and commit to a choice of
the use of major vessels the safest option. Salvage recipient vessels, using the best-available
in these cases is a difficult prospect, and vessels vessels.
with the most reliable and robust flow should be
used, to add substantial tissue and vascularity to • If there is no significant PVD and high-quality
the foot and to simplify the already challenging vessels are available adjacent to the wound,
variable of recipient vessel selection. Optimization these should be chosen preferentially, regard-
of major vessels should always be performed by less of their size.
vascular surgery prior to the flap. Pulsatile vessels The supermicrosurgery approach with
are ideal, but anastomosis to severely atheroscle- small adjacent recipient vessels and thin
rotic vessels is a common scenario and does not skin flaps with short pedicles minimizes
affect success rates provided that in-line flow is operative length and morbidity.
present and technique is meticulous. We always • If severe PVD is present or no suitable small
employ end-to-side anastomotic technique when vessels are adjacent to the wound, major
utilizing major recipient vessels, as all diabetics recipient vessels should be chosen regardless
can be expected to have progression of peripheral of their distance from the wound.
vascular disease over time; maintaining multi- Flaps with long pedicles or vein grafting
vessel inflow is therefore critical. When major may be necessary.
vessels are not available adjacent to the wound, • Critical or “high stakes” defects may shift the
such as in the case of a dorsolateral foot defect in decision in favor of major recipient vessels
a single-vessel leg fed by the posterior tibial and highly reliable workhorse flaps.
a b
d e f
g h i
Fig. 32.26 Flaps may be used in conjunction with a dis- the distal bypass vessel. Access to the forefoot from the
tal vascular bypass when no other options for salvage are medial ankle is via a trough along the glabrous junction.
available. In this case, muscle flaps should be used to pro- The implantable doppler is placed on the recipient vein,
vide additional outflow for the bypass and assist with proximal to the venous anastomosis (proximal to coupler
maintaining patency. (a, b) A diabetic man with severe in picture). (f) The serratus muscle flap was chosen
PVD and long-segment chronic total occlusions of the because it has a long pedicle for reach from the ankle to
anterior tibial, posterior tibial, and peroneal arteries the forefoot and because the muscle provides a large out-
underwent guillotine TMA for a gangrenous forefoot flow bed (with low resistance) for the bypass. (g) Closure
wound. The remaining foot was poorly vascularized and over the 3 anastomoses was not possible at the conclusion
the plantar flap was insufficient for closure of the TMA. of the case, and so the anastomoses were covered tempo-
(c) A popliteal to posterior tibial artery bypass was per- rarily with a biologic matrix (Integra Bilayer matrix), and
formed to restore flow to the foot. (d) The distal bypass then later with a full thickness skin graft. (h, i) Stable
vessel was then the only available recipient option for a result at 3 months
free flap. (e) Flap anastomosis is performed end-to-side to
Flap Selection adjusted by choosing more proximal or more

distal perforators to supply the skin island, to
A wide variety of flaps are applicable to diabetic achieve either a shorter or longer pedicle length.
foot reconstruction, and their selection and appli- The surgeon should also not be afraid to shorten
cation is limited only by the surgeon’s imagina- the pedicle of a flap if doing so allows a better
tion and the constraints imposed by vascular inset. It is better to have a smaller vessel caliber
disease. with an unkinked pedicle inset, then to have a
A review of every flap is beyond the scope of longer pedicle with redundancy. Smaller vessel
this chapter, and multiple examples are provided caliber does not affect flap success rate in our
in the included case presentations. However, experience.
pearls and pitfalls relating to flap selection are After choosing a flap with the appropriate
presented below. Flaps are considered as “work- pedicle, other characteristics of the flap can be
horse” and “supermicrosurgical.” Workhorse considered to match the wound requirements
flaps are all muscle flaps, and skin flaps such as and vascular situation. Among the workhorse
the anterolateral thigh (ALT), TDAP, or radial flaps, it is important to realize that atherosclero-
forearm that are based on larger vascular sys- sis differentially affects certain flap pedicles.
tems; generally with 2 mm or greater caliber ves- Generally, flaps harvested from the lower
sels. Supermicrosurgical flaps are those with extremity are the first to be affected, and the
vessel calibers of 1 mm or less and include flaps ALT pedicle is the most prone to atherosclerosis
such as the SCIP or PIA. among workhorse flaps (the same applies to the
We typically begin the process of flap selec- vastus lateralis muscle flap). The flap can be
tion by first committing to a choice of recipient used despite the presence of atherosclerosis in
vessels and then choosing a flap based on its ped- the pedicle, but considerable anastomotic tech-
icle. This is because recipient vessels are often nical difficulty may be encountered if both the
not normal or even absent in diabetics with PVD flap and the recipient vessel are atherosclerotic.
and so the particular anatomy of remaining ves- In this situation, some authors advocate the use
sels is a constraining factor in planning the recon- of an interposition vein graft at the anastomosis
struction. A flap with an appropriate pedicle [23]. Among lower extremity workhorse flaps,
length to allow a straight/unkinked lie of the the gracilis pedicle, based on the medial femoral
pedicle and appropriate vessel size for anastomo- circumflex, tends to be relatively spared from
sis to the intended recipient vessels should be vascular disease. The gracilis is a highly useful
chosen. The particular flap (there are usually flap in the foot, being highly reliable in its per-
multiple possibilities depending on the recon- fusion, having good caliber vessels for anasto-
structive requirements of the wound) is then cho- mosis to either major or minor recipients, and
sen based on the combination of its pedicle also a short enough pedicle length to allow
characteristics and tissue characteristics. In the direct coverage of the anastomosis with the
era of supermicrosurgery, the mantra of “bigger muscle flap itself (Fig. 32.5). The sural arteries
vessels and longer pedicle length are better” is also tend to be spared in diabetic PVD, which
therefore no longer always true. A flap with a makes the medial sural artery perforator
short pedicle and smaller vessels may very well (MSAP) flap a tempting choice. However, the
be the most advantageous if appropriate recipient use of this flap must be considered carefully, as
vessels are available next to or within the wound, its donor site is the basis for the posterior flap of
whereas a longer pedicle with larger diameter the below knee amputation (BKA) which is a
vessels is favorable for distant recipient vessels very realistic eventual prospect for many in this
and severe PVD. patient population. Additionally, closure of the
In some perforator flaps, such as the ALT donor site of this flap creates compression or
and TDAP, pedicle length can sometimes be tightness of the leg, which may be problematic
for venous drainage of the flap. For these rea- tion minimizes surgical injury to the remaining
sons, we do not employ the MSAP in diabetic foot. The SCIP contours very well to convex
foot reconstruction. defects and provides rapid skin-to-skin healing
The chest vessels are typically the last to be (Figs. 32.6, 32.8, 32.10, 32.25 and 32.27).
affected by atherosclerosis and for this reason However, as previously discussed, the flap does
the latissimus, serratus, and other derivatives of have some limitations, including: the necessity
the thoracodorsal system are particularly useful of appropriate recipient vessels adjacent to or
in the setting of PVD. This system offers the within the wound, the thin nature of the skin
ability to cover large areas and use chimeric that may be less durable for weight bearing
components including muscle, skin, and bone. surfaces, and its minimal ability to treat dead
Downsides of the latissimus flap are the potential space. The pedicle of the SCIP flap can also be
to create weakness of the shoulder girdle that calcified in the setting of severe PVD such as
may be relevant in transfers (or crutch walking) that seen in ESRD. In the setting of PVD, when
for temporarily or permanently nonambulatory the flap is anastomosed to abnormal collateral
patients. This has not been proven, but is worth or other distal vessels, the viability of inflow
considering. This can be avoided by using the from these vessels may be uncertain in the long
transverse partial latissimus flap [24], which sac- term, particularly if angioplasty is used to
rifices some of the area of the flap but preserves achieve adequate inflow prior to surgery. When
function and maintains the advantage of healthy using the SCIP flap, it is important to include
flap vessels. Specific pitfalls of the latissimus the superficial circumflex iliac vein (SCIV) or
and its derivatives are the need to consider pedi- superficial inferior epigastric vein (SIEV) as
cle coverage. The usable segment of the thora- the venous drainage for the flap, rather than
codorsal pedicle extends well proximal to the solely on the vena comitante of the flap.
proximal border of the muscle, so that the mus- Isolated use of the perforator vena comitante
cle does not overlap the anastomosis. This is par- has been associated with partial flap necrosis in
ticularly relevant in the foot and ankle, as our experience, whereas use of the superficial
opposed to the leg. There is little soft tissue lax- subcutaneous venous system provides consis-
ity in the foot to close over an anastomosis, and tent venous drainage. The SCIV is directly
the length of the pedicle is such that the muscle subdermal in the lateral portion of the SCIP
itself cannot be positioned over the anastomosis flap, and then penetrates the Scarpa’s fascia
without creating redundancy and a risk for kink- medially. Most of the flap drainage comes from
ing. Thus, when using the latissimus on the foot the lateral association of the vein with the skin.
or ankle, the surgeon should make preparations To maintain a thin flap, it is necessary to keep
for pedicle coverage. This can at times be done the vein with the flap laterally (where it is in
by including a propeller-type island of skin in the subcutaneous layer) and then separately
the proximal muscle [25]; however, this is inad- dissect the vein from the medial portion of the
visable in obese patients. Other options include flap (where the vein changes to the subscarpal
harvest of serratus muscle for pedicle coverage, layer). The posterior interosseous artery (PIA)
skin grafting of the pedicle, or use of a biologic flap is an alternative to the SCIP flap. It is also
matrix for temporary pedicle coverage followed very thin, with an even shorter pedicle, which
by delayed skin grafting. may be desirable in certain scenarios
The SCIP flap is currently enjoying a surge (Fig. 32.7). As compared to the SCIP, the
of popularity for diabetic foot reconstruction. venous drainage is more straightforward, being
The flap can be harvested and completed very reliably drained by the perforator vena comi-
quickly, which is an important consideration tante. Donor site morbidity is minimal,
for minimizing operative time in sick patients although esthetically less desirable than the
[26, 27]. The minimal recipient vessel dissec- SCIP donor site.
a b
Fig. 32.27 The SCIP flap is popular in diabetic foot infection. (b) 10 weeks following reconstruction with
reconstruction because it is thin and contours well to con- SCIP flap. The patient had a congenitally absent dorsalis
vex defects. Its short pedicle with small-caliber vessels pedis, and the flap was anastomosed to a dorsal foot small
allows use of minor recipient vessels near the wound. (a) perforator artery and subcutaneous vein
First ray amputation defect resulting from diabetic foot
Our general advice on use of the SCIP flap in small-vessel vascular anatomy is inherently
the diabetic foot is that it is an excellent option abnormal. Published literature from authors
for diabetics without severe PVD, in which only experienced with SCIP reconstruction has iden-
skin coverage is required without significant tified concomitant PVD and history of prior
need for dead space obliteration. In this setting, amputation as the only two significant predictive
it provides a rapid and simple solution with min- factors for flap failure [28]. Use of essentially
imal reconstructive morbidity. Use of the SCIP the terminal portion of a diseased vascular sys-
flap in patients with severe PVD should be tem for inflow has the twin disadvantages of
approached more carefully. In this setting, recip- unpredictable inflow and skin healing to poten-
ient vessel mapping with ultrasound and flow tially diseased surrounding tissues. Many sur-
velocity measurements is critical, as normal geons who use SCIP flaps in the setting of PVD
routinely utilize hyperbaric oxygen therapy risk of seroma or abscess formation. Although
(HBOT) as an adjunct. In many health systems, the efficacy of particular flap types for coverage
this is a difficult proposition with regard to logis- of osteomyelitis as a global issue probably has
tics and insurance coverage. more to do with adequate bony debridement and
The SCIP can be used in cases of PVD and host factors than with flap choice, it has been
is used by the authors. However, attention to our experience nonetheless that muscle is very
the details noted above is critical. Ultrasound effective for adhering to bone and providing
mapping of recipient vessels with flow veloc- rapid tissue healing, which seems to be helpful
ity measurements, consideration for pre- and in the setting of infection. When extensive ten-
postoperative use of HBOT, and enough expe- don coverage is necessary, flaps lined with fas-
rience with supermicrosurgery to allow flexi- cia on their undersurface, such as the
bility in decision-making. The chosen minor fasciocutaneous ALT, are more prone than mus-
recipient vessel must have strong pulsatile cle to have delayed adherence to the underlying
flow, not impaired flow, in order for the flap to tendons and allow fluid collections to form. This
be successful; this is where ultrasound map- is because the undersurface of fascia is poorly
ping with flow velocity becomes useful. vascularized and because muscular fascia is, by
Additionally, the surgeon must respect the design, relatively inflexible. Whereas this may
angiosomes of the foot and ankle and realize be desirable in areas where tendon excursion is
that in the setting of PVD, the wound may be a critical such as hand reconstruction, it repre-
declaration of failure of the entire angiosome. sents a considerable risk in the diabetic foot
Thus, the entire angiosome may need to be population where rapid resolution of wound and
resected to properly prepare the defect, such infection is the paramount consideration
that the defect edges will have sufficient per- (Figs. 32.22, 32.23 and 32.24). Muscle also has
fusion to heal to the flap [28]. the advantage of thin coverage after atrophy has
With regard to the longstanding question of taken place, which allows return to normal foot-
whether muscle or fasciocutaneous flaps are wear. Finally, muscle flaps also have a larger-
preferable, this remains subject to debate. We volume vascular bed which equates to greater
suggest not viewing this question as binary—it outflow and lower outflow resistance. This is an
has subtleties that need to be considered. important consideration in situations where the
However, it is the authors’ recommendation that risk of arterial thrombosis is high (such as in the
muscle flaps still be frequently employed as an case of severely calcified recipient vessels with-
option, even in the setting of “advanced recon- out normal intima or when vein grafts are used),
struction.” Diabetic foot reconstruction is com- or in instances where the flap is critical to main-
plex, and efforts to improve outcomes should be tain the patency of a vascular bypass or angio-
utilitarian. Simplifying flap factors can remove plasty. A larger outflow bed and lower outflow
one more element of difficulty from the equa- resistance may add to the durability of vascular
tion. Several other factors make muscle flaps interventions such as angioplasty or bypass, as
very useful. Muscle is the best substrate for con- compared to smaller skin flaps or the native dis-
forming to irregular contours and filling dead eased microvasculature which have a high resis-
space, which is often a concern in more grave tance to flow (Figs. 32.26 and 32.28).
wounds (which frequently are those requiring In contrast, fasciocutaneous flaps of the foot
free tissue transfer). Muscle adheres more rap- are more likely to require revisions for contour
idly to the underlying tissue bed, reducing the issues [29], particularly in the setting of obesity,
a b c
d e f
Fig. 32.28 The benefits of muscle flaps for contour and thrombosis at the anastomosis to a heavily calcified ves-
in vasculopathy. (a) A diabetic gentleman presented with sel. (c, d) Threatened toes should be amputated because
a severe dysvascular foot wound stemming from a plantar calcific changes of small vessels on X-ray suggest micro-
fifth MTP joint ulceration with septic arthritis and dorsal circulatory impairment that will result in new wounds
foot extension. Tissue perfusion is visibly compromised, with minor trauma to tenuously perfused toes. The serra-
with impending necrosis of several toes. His X-rays are tus flap was chosen because of its long vascular pedicle
shown in Fig. 32.4 and demonstrate diffuse, severe calci- that allows reach from the ankle to the forefoot, and its
fications of the pedal arteries. Severely calcified distal relative thinness. The pedicle can be partially closed over
arteries on X-ray suggest that finding useable recipient and the remainder skin grafted. The serratus was also cho-
vessels near the wound will be unlikely. (b) Angiogram sen because flaps from the chest tend to have less calcifi-
demonstrated single-vessel runoff via the anterior tibial cation of their pedicles than flaps from the lower extremity
artery, with severe disease of the plantar circulation. or abdomen. When the recipient vessel in the foot is
Because of the severity of the PVD and vascular calcifica- known to be severely calcified, it is preferable to choose a
tion, major vessels (the anterior tibial at the ankle) were flap with a vessel that will not be calcified in order to
chosen as recipient vessels. For the same reason, a muscle avoid anastomosing calcified vessel to calcified vessel. (e,
flap was chosen to provide lower resistance to outflow f) Healed result at 3 months. The muscle flap already has
through the anastomosis and minimize the risk of arterial satisfactory contour and will continue to undergo atrophy
which is frequent in the diabetic population. natural appearance. They may be preferable
Skin-to-skin inset of fasciocutaneous flaps can be when reoperation is planned, such as a delayed
tight when covering convex contours, unless the orthopedic joint surgery that takes place after
flap is very thin to match the thinness of the foot successful skin coverage and resolution of
skin. This can create a compressive environment infection. Fasciocutaneous flaps such as the
beneath the flap. When postoperative swelling TDAP, parascapular, gluteal artery perforator,
takes effect, both venous compression and skin and medial plantar flaps also have the ability to
edge necrosis may result. The surgeon must provide thicker, more durable skin for plantar
therefore carefully take into account the thick- surfaces (Fig. 32.12). Theoretically, this is an
ness of the flap and the effect of postoperative advantage for weight bearing areas. Muscle
edema. flaps in comparison will demonstrate atrophy,
Use of thinner skin flaps without deep fat and and purposeful bony contouring such as partial
fascia components obviates some of these prob- calcanectomy should be utilized to prevent
lems. Common examples include the SCIP and ulceration through the flap in weight bearing
suprascarpal ALT or SIEA flaps (Figs. 32.6, 32.7, areas [19]. Muscle flaps can be augmented by
32.8, 32.9, 32.10, 32.18, 32.25 and 32.27). Use of inclusion of fascia or by fat grafting to improve
the suprascarpal plane for skin flap elevation has their suitability for weight bearing. However,
greatly improved the applicability of these flaps in our experience, in the neuropathic diabetic
to diabetic foot reconstruction. Flaps harvested population, thicker skin flaps do not prevent
above the Scarpa’s fascia are thinner and much recurrence of ulceration; the same underlying
more pliable than those harvested with deep fat neuropathy and behavioral inattention that
and fascia, enhancing their ability to conform to encouraged initial wound formation will put
the foot and allow appropriate footwear without any flap at high risk for reulceration
the need for revision surgeries (Fig. 32.9). The (Fig. 32.29). Finally, the advantages of both
prospect of even minor revision surgeries on dia- flap types can be had by including a small mus-
betic foot flaps is a significant consideration, as it cle component to a fasciocutaneous flap, which
creates other opportunities for wound breakdown allows the advantages of fasciocutaneous flaps
or infection, and often means another period of along with the capacity for dead space oblitera-
non-weight bearing which is significant in frail tion (Fig. 32.12).
patients. Multiple methods exist for harvesting With all of the above in mind, the third step
these flaps and have been described by the authors of our algorithm should be considered as
[30, 31]. Generally, as long as the chosen perfora- follows:
tor has a strongly audible venous Doppler signal, Choose the flap based on:
we have found no difference in the reliability of
the skin paddle with suprascarpal flaps versus tra- • The appropriate pedicle length from the cho-
ditional fasciocutaneous flaps and the suprascar- sen recipient vessels to the wound.
pal plane is therefore our preferred plane of Longer is not always better.
elevation in all but the thinnest of patients. • The reconstructive requirements of the wound
Fasciocutaneous flaps have the advantage of (e.g., thick/thin skin, weight bearing or not,
native skin healing and the potential for a more dead space, outflow resistance, etc.).
a b
c d
e f
Fig. 32.29 Both skin and muscle flaps can be equally debridement. Salvage was indicated to avoid bilateral
prone to reulceration if the underlying etiologies or above knee amputations and preserve independence for
behaviors leading to wound formation are not reversed. In transfers in and out of the wheelchair. (b) Antibiotic-
this patient, even a “like with like” reconstruction with impregnated calcium sulfate beads were used to fill the
glabrous skin re-ulcerated due to noncompliance with cavitary defects in the osteomyelitic calcanei. (c, d) After
positioning. (a) A morbidly obese, wheelchair-bound dia- vascular intervention, the right foot was salvaged with a
betic female with end stage renal disease, PVD, bilateral medial plantar flap and the left with a free transverse par-
lower leg lymphedema and bilateral leg venous stasis tial latissimus flap. (e, f) Despite exhortations to use pad-
changes presented with gangrenous decubiti and osteo- ded foot protectors and avoid prolonged pressure on her
myelitis of both heels from inattentive positioning on her wheelchair foot plates, the patient re-presented 6 months
wheelchair foot plates. The wounds are shown after later with erosions through both flaps
Technical Considerations “poke hole” in the recipient vessel used for end-
and Adjuncts to Improve Outcomes to-side anastomosis of a < 1 mm flap vessel.
When using major vessels, formal angiogra-
Key technical considerations and adjuncts for phy is obtained. Although recipient vessel choice
each phase of surgery are considered below. is often limited by the pattern of PVD, generally
speaking, the PT and AT vessels are the most
robust and the best choice, with the peroneal ves-
Wound Preparation sels at the ankle being a distant third choice. If
the peroneal vessels are to be used, it is prefera-
Formal angiography should always be obtained ble to perform the anastomosis proximally
prior to microsurgical reconstruction. The wound behind the fibula in the mid-leg and choose a flap
should be serially debrided to negative post- with a long pedicle (Fig. 32.19). Frequently
debridement cultures before reconstruction. when accessing the peroneal vessels in this fash-
Debridements should be planned as much as pos- ion, there are large muscular branches to the
sible according to the angiosome affected by the soleus that can be used for end-to-end anastomo-
wound [28]. If significant PVD is contributing to sis without disrupting the major vessel, obviat-
wound formation, at times it may be advisable to ing the need for an ETS. The muscular branches
resect the entire affected angiosome, to ensure are also typically less calcified than the main
that the margins of the wound (perfused by adja- peroneal vessel. When the extent of PVD is
cent angiosomes) have adequate perfusion for severe, only a single major vascular system is
healing to the flap. Negative pressure wound available, and the vascular system is remote
therapy with fluid instillation is a very effective from the wound (e.g., dorsal forefoot wound in a
way of staging and preparing a wound between single-vessel leg with only posterior tibial artery,
debridements. Preoperative HBOT with a goal vein grafting from the best-available major ves-
TCP02 of 40 mmHg is an excellent adjunct for sel is safer than attempting minor vessel use).
reconstruction of the ischemic foot, when it is When vein grafting from heavily diseased ves-
logistically feasible within a health system. sels is employed, consideration should be given
to therapeutic anticoagulation during the early
post-op period.
Recipient Vessel Selection
Recipient vessels should always be determined Flap Planning

before flap planning. When PVD is mild or
absent, minor recipient vessels near the wound The flap should be chosen after the recipient ves-
edge are the preferred option for the supermicro- sels are chosen, and the flap should be selected by
surgical approach because this decreases both considering the ideal pedicle size and length to
donor and recipient site morbidity. When minor reach from the wound to the targeted recipient
vessels are used, e.g., in the context of supermi- vessels. Once the pedicle characteristics are
crosurgery, preoperative use of duplex ultraso- decided upon, then the proper flap is chosen by
nography has become an indispensable part of considering the reconstructive requirements of
planning and significantly simplifies the recipient the wound.
vessel selection. This is critical when using flaps As with recipient vessel selection, duplex
with short pedicles, such as the SCIP flap, where ultrasonography has proven highly useful in visu-
it is mandatory to have recipient vessels adjacent alizing and selecting perforators prior to flap har-
to the wound. Intra-operatively, the surgeon must vest. In flaps such as the SCIP, identifying the
evaluate the recipient vessels to ensure that there dominant perforators before dissection reduces
is good pulsatile flow. Supermicrosurgery can the need for exploration and decision-making
still be used with major vessels, with a small during surgery, saving both time and effort.
Incision Planning situation actually increases bleeding and impedes

vessel dissection.
Incisions on the foot should be made along gla-
brous junctions or in watershed areas between the
angiosomes of different arterial systems. An Anastomosis
excellent review of this topic with specific advice
for incision planning can be found in Attinger’s When possible, the supermicrosurgical approach
“Angiosomes of the Foot and Ankle” article [4], with end-to-end (ETE) anastomosis to minor ves-
and this is recommended reading for any surgeon sels within or around the wound is our preferred
planning to approach complex foot and ankle technique. As stated above, this is most appropri-
reconstruction. ate when the surrounding vascular tree is not
When it is necessary to sacrifice intervening severely affected by PVD. A high-quality operat-
tissue between the flap and recipient site, the tis- ing room microscope is needed, and fine super-
sue should be resected in a pattern consistent micro or lymphatic surgery instruments that
with the intervening angiosome of the foot sup- allow dilation and manipulation of vessels <1 mm
plied by the recipient vessels [28]; this is particu- in diameter. Suture size is usually between 9–0
larly true if the anastomosis was performed in an and 11–0 and an average of 6–7 sutures are
end-to-end fashion, which devascularizes the displaced.
tal angiosome. When using workhorse flaps or in the setting
Incision planning should take into account the of severe PVD, we recommend anastomosis to a
expected orientation of the flap pedicle after major vessel of the ankle, using an end-to-side
inset. If there is a long distance between the (ETS) technique. This provides robust and dura-
recipient site and wound, the flap should either ble inflow. The vessels at the ankle are large
cover the pedicle, or a “trough” can be made enough that 8–0 nylon can be used, which is
between the recipient vessels and wound, which much easier to work with than 9–0 or smaller
should follow the watershed between angiosomes sutures, particularly with calcified vessels where
(often the glabrous junction) (Figs. 32.11, 32.12, decreased vessel pliability leads to more resis-
32.13 and 32.14). tance to knot tightening, which may rupture
weaker sutures. Highly calcified vessels, such as
those seen in end stage renal disease (ESRD)
Use of the Tourniquet patients, may need to be sutured using 7–0
prolene on cardiac CC needles to penetrate the
The surgeon should take into account before the dense calcific plaque.
case whether it will be possible to use the tourni- ETS technique should be exclusively with the
quet. It is highly desirable to use the tourniquet “slit arteriotomy” method in the diabetic foot
for recipient vessel dissection, as many patients [32]. This is in contradistinction to cutting out a
will have woody, fibrotic tissues, with dense patch of the artery. The reason for this is that the
adhesions of vessels to surrounding tissue that recipient vessels often contain calcified plaque
impede dissection and create a risk for inadver- that will fracture in an irregular fashion when
tent rupture of deep venae comitantes. They may cutting out a patch of the vessel, leading to unsta-
also be anticoagulated. However, there are fre- ble intimal edges with a tendency to dislodge.
quent contraindications to the use of a tourniquet Making a straight, clean arteriotomy does not
in patients with diabetes and PVD. These include disrupt the plaque and provides clean edges to
a recent angioplasty, stenting, or bypass. sew to. The arteriotomy should be made using an
Frequently, even when no strict contraindications anterior chamber ophthalmic knife to create a slit
exist, attempted use of tourniquet in patients with equal in length to the diameter of the flap artery,
PVD will also create a venous tourniquet due to or slightly smaller. The surgeon and the assistant
calcifications of the arteries of the thigh. This should each grab and lift up the adventitia of the
recipient vessel on either side of the planned arte- flow through anastomosis to reconstruct an
riotomy to prevent the tip of the ophthalmic knife injured major artery has demonstrated a positive
from injuring the intima on the deep surface of effect in combating infected wounds, such as in
the vessel. In extremely calcified vessels, such as cases of chronic osteomyelitis or diffuse gan-
those seen in ESRD, a micro Potts scissor may be grenous infection [35]. Thus, if a gap of an axial
required to complete the arteriotomy. The flap artery is noted, flow through anastomosis or
artery should be cut at an angle so that it branches bypass for the artery defect should be consid-
from the source vessel with a distal orientation, ered to have the best possible reconstruction
for a favorable lie. When suturing the anastomo- [36, 37]. Consideration should be given to use
sis, the surgeon must be very careful to puncture of a flow through anastomosis whenever end-to-
the calcified plaque from inside to outside in such end anastomosis of a major vessel is planned.
a way as to “tack” the intima to the vessel wall An additional use of the T-shaped anastomosis
and avoid pulling it away from the wall and into is to overcome positioning limitations that
the lumen. The intimal plaque is very easily dis- sometimes occur when performing end-to-side
lodged in such cases, and it is critical to respect anastomosis in an unfavorable exposure/ana-
this fact to avoid technical failure with anastomo- tomical constraint. In this setting, converting the
sis. We find it useful to take relatively uneven plan from end-to-side anastomosis to T-shaped
bites of the flap vessel and recipient vessel. The anastomosis can facilitate the technical ease of
flap vessel can be sutured in the traditional fash- the microsurgery without sacrificing important
ion, taking small bites at the edge. Bites of the blood flow.
recipient vessel should be taken from deep within
the lumen, much further from the vessel edge, to
avoid disrupting plaque at the edge of the arteri- ony Contouring and Biomechanical
B
otomy. Although counterintuitive, this discrep- Correction
ancy in the size of the bites does not cause an
issue and is safe. Bony contouring should always be given consid-
When end-to-end anastomosis is necessary, eration when reconstructing the weight bearing
the surgeon must ensure that the dorsal and plan- surface. Often, biomechanical deformities are the
tar systems of the foot adequately perfuse one initial cause of ulceration and infection. Flap cov-
another (e.g., “complete arch”); otherwise, sacri- erage over a displaced metatarsal head will result
fice of one of these systems may lead to severe in immediate recurrence of the ulcer after healing,
vascular embarrassment of the foot. When end- unless the bony displacement is addressed.
to-end anastomosis is chosen, the flap may need Whenever the plantar heel is covered, the calca-
to replace the angiosome of the disrupted recipi- neal tuberosity should be resected to prevent focal
ent vessel. When sensible to do so, the anastomo- pressure ulceration through the flap [19].
sis should be performed at the level of terminal When reconstructing the plantar forefoot or
patent branches of the arterial system. This is reconstructing a partial foot amputation, a percuta-
most often utilized when the wound encompasses neous Achilles tendon lengthening should be per-
the majority of the distal angiosome of the recipi- formed to treat or prevent equinovarus contracture
ent vessels (Figs. 32.9 and 32.15). (Achilles tendon contracture) that is either the
cause of the initial ulcer or will contribute to reul-
ceration after reconstruction (Fig. 32.13).
se of Flow-Through Flaps or
U When multiple toes are involved in the wound,
“T-Shaped Anastomoses” a transmetatarsal amputation should be consid-
ered. When metatarsals are resected, they must
T-shaped or flow through anastomosis also plays be beveled inferiorly to avoid sharp edges, and
an important role to preserve or to reconstruct the normal parabola should be recreated in terms
distal flow [33, 34]. In our experience, use of a of bony length.
se of Antibiotic Cements and Bone

U this means using skin graft or a temporary bio-
Void Fillers logic matrix dressing (e.g., Integra Bilayered
Matrix, Integra Lifesciences, Plainsboro, New
Dead space management in the setting of osteo- Jersey, USA) over the pedicle or anastomosis,
myelitis is a critical element of successful treat- this point is non-negotiable. The surgeon must
ment and may prompt consideration for also account for the effects of postoperative
antibiotic-impregnated cement or bone void fill- edema on the flap pedicle. Diabetic patients are
ers. The choice of bone void filler is up to the frequently anticoagulated in the post-op period
individual surgeon, and multiple different sub- and at high risk for hematoma formation beneath
strates are effective (Fig. 32.29). the flap. Even a small hematoma will invariably
produce flap failure or partial necrosis and may
be initially difficult to distinguish from expected
Drains postoperative edema. At times (in the setting of
anticoagulation) it is advisable to loosely inset
Drains should be routinely utilized beneath flaps the flap, placing but not tying sutures, and to tie
in diabetic foot reconstruction, as essentially all the sutures down 3–5 days after surgery when
diabetic foot wounds are infected. As well, even edema and risk for hematoma have begun to sub-
very small fluid collections can mean flap death in side (alternatively, the flap can be tacked in
the tight soft tissue envelope of the foot (Fig. 32.9). placed and then the patient returned to the operat-
Either small (e.g., 10 French or smaller) closed ing room 5–7 days postoperatively for definitive
suction drains or penrose type drains are accept- inset (Fig. 32.7)). This seems to be particularly
able. For very small flaps such as a small SCIP, a true for superthin skin flaps, which are very sus-
vessel loop can be used as a small drain. Closed ceptible to skin edge necrosis with any amount of
suction drains should be placed with attention to tension and which have delayed adherence to the
avoid creating suction near anastomoses or deli- underlying wound bed, making fluid collections
cate perforator vessels. Drains are kept for more likely. Mattress sutures are recommended
2–5 days when using muscle flaps, when the out- for flap inset, particularly when sewing to gla-
put is very low, when there is minimal dead space, brous skin, which is prone to rapidly epithelialize
or when there is very low suspicion for residual suture lines with any amount of inversion, delay-
infection after debridement. When the risk of ing wound healing. Vertical mattress sutures cre-
infection beneath the flap is felt to be high, or ate less local ischemia than horizontal mattresses
when less adherent tissues such as fascia or fat are and so are our suture of choice.
used over poorly adherent recipient surfaces (such
as bone or tendon), drains may be kept in place for
longer. Frequently, diabetic patients are anticoag- Anticoagulation
ulated in the perioperative period; in this case,
penrose drains and loose suturing allow better For anastomoses involving healthy vessels, we
egress of potential blood. Any fluid collection or typically give aspirin, or no anticoagulants at all.
hematoma noted beneath the flap in the early For cases of severe PVD, with completely calci-
post-op period should be dealt with by prompt fied vessels and no normal tunica intima, we rec-
return to the OR for drainage. ommend anticoagulation with a heparin drip
(goal PTT 50–60), along with aspirin, and some-
times clopidogrel as well depending on the
Flap Inset difficulty of the anastomosis. When a vein graft is
used in the setting of severely diseased vessels,
The primary consideration during flap inset therapeutic anticoagulation should also be
should be achieving a totally straight lie of the administered. When therapeutic anticoagulation
veins, without any venous compression. Even if is planned, we recommend only loosely insetting
the flap at the time of index surgery in order to as underlying Doppler signals from the wound
allow bleeding to occur without creating a hema- bed will easily transmit through the very thin
toma (Fig. 32.7). Delayed inset can be performed flap. For these flaps, monitoring is performed by
at 5–7 days post-op once the flap has demon- making a partial thickness scratch into the dermis
strated viability and the risk of hematoma forma- to cause a small area of bleeding. The bleeding
tion has passed. should be bright red. The flap is checked by irri-
gating the scratch with heparinized saline at bed-
side, and mechanically agitating it with either
Postoperative Monitoring wet gauze or a blunt tipped needle (Fig. 32.25).
Duplex ultrasonography can also be employed at
For traditional workhorse flaps with anastomosis bedside if desired.
to major vessels, use of the Cook implantable Patients are kept in the hospital for up to
Doppler (Doppler Blood Flow Monitor, Cook 10 days to detect and prevent subacute complica-
Medical LLC, Bloomington, Indiana, USA) is tions that may result in delayed (non-anastomotic)
recommended when possible, particularly when flap failure.
using muscle flaps. The silicone cuff and doppler The white blood cell count (WBC) and
crystal should be placed on the recipient vein, just C-reactive protein (CRP) should be checked
proximal to the venous anastomosis. The utility of daily, as unrecognized postoperative infection
the Cook Doppler has to do with continuous can lead to delayed flap failure.
venous monitoring that gives immediate feedback If an angioplasty was required to provide suf-
on vein compression during inset of the flap and ficient blood flow for reconstruction, then post-
closure. At times, a single suture placed during operative monitoring must be frequent until the
closure (particularly over the anastomosis) can wound has fully healed. This is because unex-
produce acute venous compression or occlusion, pected reocclusion of the post-angioplasty seg-
and the implantable venous Doppler is the best ment may lead to delayed flap failure. Emergency
way to detect this (Fig. 32.26). Reconstruction of return to the OR for repeat angioplasty may be
the foot uniquely involves a tight tissue envelope indicated for flap salvage.
and accommodation of sometimes complex con-
tours, with minimal native tissue available for
coverage of the anastomosis. A straight inset of Positioning
the pedicle may be challenging, depending on flap
choice and the specific situation. There is also The surgeon must maintain careful control over
usually significant intraoperative and postopera- postoperative positioning. Patients are kept on
tive swelling that may contribute to venous com- bedrest for 5 days following surgery. The foot
pression. Venous occlusion is by far the most must be constantly elevated above the level of the
common cause of flap failure and can be quickly heart. Any amount of pressure with dependency
detected with the Cook system. Muscle flaps in can lead to either venous occlusion (particularly
particular may not have a detectable venous signal when the PT vessels are used, or vein grafting is
in the substance of the flap using pencil doppler. needed) or neuropathic decubitus ulceration. A
The flap is usually covered with skin graft, which splinted dressing that is very well padded with
makes color assessment difficult. Muscle flaps Jones cotton is most often used to protect the flap.
may continue to have an arterial signal even days The heel must be carefully padded to prevent
following venous thrombosis. Skin flaps can be decubitus ulceration. The surgeon should clearly
more reliably monitored with traditional assess- mark areas vulnerable to pressure on the dressing
ment, although the Cook is still very useful for the with tape and a marker. Alternatively, an Ilizarov
reasons listed above [38]. frame is the surest method to avoid flap compli-
For supermicrosurgical flaps such as the SCIP cations related to postoperative positioning, but
and PIA, pencil Doppler exam can be misleading, comes with significant potential downsides.
Compression 7–14 days if tolerable. If there was skeletal insta-

bility, initiation of ambulation must be adjusted
The use of early compression therapy over lower accordingly. For weight bearing flaps, compres-
extremity free flaps has been a major recent sion is applied on day 5 along with short leg
advance that hastens healing and reduces compli- splints and partial-weight bearing begun with the
cations associated with edema. It also reduces aid of walkers, gradually reaching full weight
reliance on arcane and unsubstantiated “dangling bearing at 3–6 weeks when the splints are
protocols.” In our institutions, we routinely apply removed. Usually the patient is discharged at day
an early compression protocol (from postopera- 7–10, educated with the protocol, and visits the
tive day 3–5) to all flaps when applicable. Flaps outpatient clinic every week for follow-up.
that are used for resurfacing can be candidates for The weaning of the compression garment usu-
compression with the exception of flaps that are ally ensues after several months. If the flap does
used for ischemic limbs, where arterial supply not swell without applying the garment after a
may be very sensitive to any degree of external full day of activity, then the patient can stop using
compression (especially in the setting of concur- compression. As for weight bearing flaps, the
rent vascular bypass). compression is recommended whenever the
In health systems where custom compression patient ambulates for more than a short distance,
garments are available, these can be fabricated to minimize any shearing of the tissue related to
prior to the reconstruction and are designed based weight bearing [39].
on the mirror measurements of the contralateral
limb with the aim of generating a compression
pressure of 30–40 mmHg. When a mirror image External Fixation
is not possible, the compression garment is tai-
lored after manual measurement then fitted The use of Ilizarov-type external fixation for
accordingly to reach the target pressure. As the offloading, flap protection, and tissue immobili-
flap swelling is reduced and molded into contour, zation is a powerful tool [40]. It can also control
the garment can be adjusted accordingly. The biomechanical deformities, such as the equin-
area covered by the compression garment ovarus contracture of the Achilles tendon that
includes the micro-anastomosis site and the flap may occur during the prolonged period of heal-
pedicle. ing. The frame can be fitted with a foot plate to
In institutions where compression garments allow some weight bearing for transfers.
are not available, we have found that a multilayer However, complications such as pin tract infec-
compression wrap functions adequately as the tions with osteomyelitis are known to occur.
“poor man’s compression garment.” The wrap is Additionally, the Ilizarov frame makes edema
made of readily available supplies and includes a control difficult, as contiguous wrapping of the
cotton gauze wrap from the toes to the knee, fol- extremity cannot be performed. The presence of
lowed by an ACE bandage, followed by 3 in. the protective foot plate that allows weight bear-
Coban elastic bandage. A total contact cast can ing may wrongly encourage the patient to allow
then be applied atop the compression wrap prolonged dependent positioning of the operated
(Fig. 32.30). foot.
Compression helps to stabilize the soft tissues Total contact casting is an alternative option
against shearing and allows for earlier ambula- for flap protection. Total contact casting in the
tion with less risk of dehiscence. For lower acute postoperative setting carries a risk of sec-
extremity reconstruction in non-weightbearing ondary pressure injuries from the cast, as well as
areas, the patients are allowed to ambulate at day being laborious for the clinic staff. However, it is
5 under compression. For non-weightbearing highly effective in protecting the reconstruction
flaps, full weight bearing is commenced at and allowing earlier ambulation. Commercially
a b
c d
Fig. 32.30 Use of compression wrapping and total con- the flap. The total contact cast is advantageous versus an
tact casting. Compression wrapping eliminates the need Ilizarov frame because compression wrapping can be used
for “dangling” and provides a significant reduction in beneath the cast. It is difficult or impossible to apply a
early and late flap edema. It also seems to expediate heal- compression wrap when an Ilizarov frame is in place. This
ing. Custom compression garments can be fabricated or fact, along with the weight of the frame creating a ten-
effective compression wrapping can be performed with dency to keep the foot dependent, can lead to significant
readily available materials. (a) A layer of soft cotton or and prolonged edema. If the flap is in a weight bearing
rolled gauze is first applied from the metatarsal heads to area, the cast is not initially fitted with a cast shoe, and the
the knee. (b) This is then over-wrapped with an ACE ban- patient remains non-weightbearing. Once the sutures have
dage, with very gentle pressure. (c) The wrap is completed been removed, ambulation in a cast shoe is allowed. The
with an elastic crepe bandage. The multiple layers provide cast is no longer needed once the incisions are felt to have
gentle but effective compression. (d) Finally, if desired, a regained full tensile strength (6–12 weeks)
total contact cast can be applied to immobilize and protect
available casting systems can be applied in min- Hyperbaric Oxygen Therapy (HBOT)
utes and fitted with a cast shoe to allow for weight
bearing without direct pressure on the surgical It is very useful to have access to HBOT services
site. Additionally, a compression wrap can be when attempting reconstruction of the diabetic
applied beneath the total contact cast. This com- foot. HBOT can support flap viability but, more
bination seems to do an excellent job of control- commonly, is used to improve the surrounding
ling edema, facilitating healing, and protecting tissue bed and optimize healing to the flap.
the flap from injury. Ideally, in very high risk cases (such as with
severe concomitant PVD and osteomyelitis), 3. Armstrong DG, Boulton AJ, Bus SA. Diabetic
foot ulcers and their recurrence. N Engl J Med.
HBOT should be started before reconstruction 2017;376(24):2367–75.
and continued after reconstruction. 30 dives 4. Attinger CE, Evans KK, Bulan E, Blume P, Cooper
before surgery and 30 after are ideal. Preoperative P. Angiosomes of the foot and ankle and clinical
transcutaneous oxygen measurements (TCOMs) implications for limb salvage: reconstruction, inci-
sions, and revascularization. Plast Reconstr Surg.
should be taken of the surrounding skin to deter- 2006;117(7S):261S–93S. https://doi.org/10.1097/01.
mine whether HBOT will be of benefit. TCOM prs.0000222582.84385.54.
values should be 40 mmHg or greater to support 5. Janhofer DE, Lakhiani C, Kim PJ, et al. The utility of
healing. preoperative venous testing for lower extremity flap
planning in patients with lower extremity wounds.
Plast Reconstr Surg. 2020;145(1):164e–71e. https://
doi.org/10.1097/prs.0000000000006384.
Conclusions 6. Cho MJ, Kwon J, Pak C, Suh H, Hong J. The role
of duplex ultrasound in microsurgical reconstruc-
tion: review and technical considerations. J Reconstr
The advent of supermicrosurgery and the other Microsurg. 2020;36(07):514–21. https://doi.
advanced techniques described herein have org/10.1055/s-0040-1709479.
expanded the possibilities for reconstruction and 7. Neville RF, Attinger CE, Bulan EJ, Ducic I,
decreased the morbidity associated with tradi- Thomassen M, Sidawy AN. Revascularization of a
specific angiosome for limb salvage: does the target
tional flap surgery. These tools have allowed us to artery matter? Ann Vasc Surg. 2009;23(3):367–73.
shift our goals from “obtaining coverage” to cre- https://doi.org/10.1016/j.avsg.2008.08.022.
ating individualized and elegant reconstructions 8. Hong JP, Oh TS. An algorithm for limb salvage for
that seek to provide the best functional outcomes diabetic foot ulcers. Clin Plast Surg. 2012;39(3):341–
52. https://doi.org/10.1016/j.cps.2012.05.004.
for the patient. However, reconstruction of the 9. Attinger CE, Ducic I, Cooper P, Zelen CM. The
diabetic foot remains challenging. It requires role of intrinsic muscle flaps of the foot for bone
considerable knowledge of underlying patho- coverage in foot and ankle defects in diabetic
physiology, disease progression, and functional and nondiabetic patients. Plast Reconstr Surg.
2002;110(4):1047–54. https://journals.lww.com/
consequences of salvage versus amputation. It is plasreconsurg/Fulltext/2002/09150/The_Role_of_
at times highly technically demanding, and there Intrinsic_Muscle_Flaps_of_the_Foot_for.7.aspx.
is no room for error in any of the variables. 10. Attinger CE, Ducic I, Zelen C. The use of local mus-
Successful outcomes can only be obtained in a cle flaps in foot and ankle reconstruction. Clin Podiatr
Med Surg. 2000;17(4):681–711.
multidisciplinary setting, and by careful planning 11. Suh HS, Oh TS, Hong JP. Innovations in diabetic foot
in concert with flawless technical execution. It is reconstruction using supermicrosurgery. Diabetes
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12. Yoon CS, Noh HJ, Malzone G, Suh HS, Choi DH,
surgeon and patient must also be prepared to Hong JP. Posterior interosseous artery perforator-free
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13. Chen L, Greisberg J. Achilles lengthening proce-
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reconstruction of diabetic foot wounds using the
Partial Foot Amputations:
Technique and Outcomes
33
Jayson N. Atves, Ali Rahnama, and Tiffany K. Hoh
Introduction multidisciplinary approach to lower extremity

amputations. The collaborative efforts of multi-
Partial foot amputations are frequently performed ple specialties, including but not limited to, podi-
procedures where the most common impetus are atric surgery, plastic surgery, vascular surgery,
trauma, infection, and ischemia [1, 2]. Less com- infectious disease, and orthotics and prosthetics
monly seen indications include thermal injury, have transformed and invigorated the paradigm
malignancy, deformity, and intractable pain. of partial foot amputations. In this chapter we
Centuries of historical review cite many exam- review the guiding tenets of partial foot amputa-
ples of limb amputation as a means of ameliorat- tions and offer an assortment of strategies and
ing inciting infection, traumatic injury, or techniques aimed at their appropriate selection,
concerns for “deadening” of tissues. Instances of successful performance, and ultimately contin-
wartime use of extremity amputation illustrate ued endurance.
the quite literal life-saving benefits of lower
extremity amputations. Despite its storied his-
tory, surgeons continue to develop and refine sur- Indications
gical techniques in lower extremity amputations
and partial amputations of the foot are no excep- General
tion to this tact. Recent innovations in vascular
intervention and wound management techniques The overarching purpose of any amputation is to
and considerations have improved patient out- excise the tissues which would otherwise impart
comes and in turn have allowed for partial foot patient harm if not removed. In many cases the
amputations to gain increased popularity and overwhelming indication for partial foot amputa-
success. However, perhaps the greatest advance- tion is either ischemia and/or infection, although
ments have been born out of the emphasis on the others exist.
Weledji and Fokam noted in the limb which
presents with pure ischemia, vascular optimiza-
J. N. Atves (*) · A. Rahnama · T. K. Hoh tion and prevention of superimposed infection
Department of Plastic Surgery, Georgetown may result in favorable outcomes [3]. The degree
University School of Medicine and MedStar
Georgetown University Hospital, Washington, of tissue loss, however, is highly dependent on
DC, USA the time of discovery and time to vascular inter-
e-mail: [email protected]; vention. The anatomic location, distribution, and
[email protected]; degree of the vascular involvement are important
[email protected]

522 J. N. Atves et al.
parameters which can influence the precise level which increase the risks for amputation [7] and
of amputation. challenge limb salvage efforts. Hobizal and
Any patient with an open skin lesion is predis- Wukich illustrated that several host factors such
posed to lower extremity infection, particularly as medical comorbidities, nutritional status, gly-
in the comorbid population, especially the immu- cemic control, nonadherence to medical regi-
nocompromised and diabetic populations for mens, and socioeconomic status clearly play a
example. Infections can be either acute or chronic role in these patient outcomes [8].
and include soft tissue and/or bone infections. As Without question, the compromised patient
shown by Altemeier and Fullen, fulminant infec- host presents clinical and socioeconomic com-
tions such as necrotizing infections, gas gan- plexity to the discussion of amputation. Partial
grene, and infections that cause hemodynamic foot amputations must be understood as a single
instability all require urgent surgical intervention component of a larger process within the contin-
[4]. In such cases, the postoperative soft tissue uum of a patient’s diseased state. Many patients
deficit, bone loss, and the predicted functional have a subset of known and unknown medical
outcome often dictate the level of final amputa- conditions each of which may not be well con-
tion. Price demonstrated that chronic infections trolled, have associated risks, and have particular
have a dramatic impact on patient quality of life, and even predictable patterns of evolution.
increase the risk of osteomyelitis, and have major Though each patient presents with unique and
implications in overall amputation risk [5]. distinct challenges, the overall sequence of events
Another major factor that may contribute to can be somewhat predictable if these parameters
ultimate partial foot amputation is deformity. are properly identified, stratified, and mitigated
While deformity alone is not typically a primary in a timely, continuous, and conscientious
indication for amputation, in patients with failed manner.
osseous reconstructions or those who are at high Yazdanpanah et al. demonstrated how optimi-
risk for complex surgical correction of lower zation of disease-modifiable factors such as gly-
extremity deformities, such as those seen in cemic control, blood pressure, and vascular
Charcot neuroarthropathy, amputation may be insufficiency may allow patients to have more
considered the treatment of choice primarily, favorable long-term health outcomes [9].
especially if functional status and quality of life However, once ulceration, deformity, neuropathy,
cannot be predictably improved with reconstruc- or infection occurs, the risk for amputation
tive surgery. More common, acquired skeletal remains undeniably high. Every effort must be
deformities predispose the neuropathic patient taken to slow the rate of progression and prevent
population to ulcer development and increased the onset of disease-related complications.
fall risk. Raspovic et al. demonstrated that when Fernandez et al. reported how healthcare dispari-
ulcers develop secondary to biomechanical aber- ties, food insecurity, and cultural, ethnic, and lan-
ration, healing the ulcer without addressing the guage barriers all carry socioeconomic
underlying osseous structural alignment and/or implications which impact the overall quality of
stability will inevitably lead to recurrent ulcer- care in the
ation, increased amputation risk, and a decrease at-risk population [10]. Ultimately, partial
in quality of life [6]. foot amputations are largely cumulatively based
All too often patients have a combination of on patient-specific risk factors and may be simply
the aforementioned cardinal pathologies. They unavoidable.
present with a biomechanically induced ulcer, The surgical indications for amputations must
have peripheral neuropathy, have some degree of not be made in isolation of the patient’s ambula-
ischemia, and are typically infected or at mini- tory status and must include a realistic assess-
mum chronically harbored with bacteria. ment of the patient’s overall capacity to ambulate
Beaulieu et al. reported that these patients often following amputation. The level of amputation
have multiple conditions and comorbidities must be carefully taken into account during sur-
33 Partial Foot Amputations: Technique and Outcomes 523
gical planning and must align with the patient’s gery, and infectious disease, is paramount to any
wishes. Regardless of the exact level of amputa- limb salvage and vital to the performance and
tion, disease progression, advancing age, and endurance of any partial foot amputation.
worsening vascular pathology almost guarantee
the need for revisional surgery and perhaps more
proximal amputation. Furthermore, Glaser et al. Infection
elucidated how the contralateral extremity
becomes a high-risk limb due to the increased Foot infections are among the most common rea-
load subsequent to an amputation and peripheral sons for hospital admission for the diabetic
arterial disease [11]. In truth, bilateral foot patient [13] (Fig. 33.1). While there are many
pathologies leading to amputations are factors that must be considered to achieve suc-
commonplace. cessful outcomes in any partial foot amputation,
there are four major factors which can greatly
help predict the likelihood of success. Those fac-
Wound tors are the presence and extent of infection or
bacterial bioburden, the vascular supply to the
Wounds about the foot most commonly occur involved anatomy, ability to provide appropriate
due to underlying vascular or biomechanical pro- soft tissue coverage, and biomechanical function-
cesses which must be addressed in order to both ality of the considered amputation. Infection can
heal the wound itself and to avoid further pro- play an important part in determining the level of
gression or complication. In some instances this successful amputation. Both soft tissue and bony
may be a matter of offloading management, (osteomyelitis) infections can play roles in choos-
obtaining appropriate shoe gear and having the ing the level of amputation. It is important to note
patient perform daily foot checks in addition to that there may be scenarios where there is soft
glycemic control to prevent recurrence. tissue infection that does not involve the osseous
Unfortunately, in many instances the prevention anatomy, those where there is acute or chronic
of recurrence or further complication such as osteomyelitis but the overlying soft tissues are
chronic osteomyelitis may require surgical inter- largely viable and can be used for a salvage
vention. Therefore, determining the etiology of attempt and finally those where there is involve-
the wound is an imperative first step to prevent ment of both the soft tissue envelope and under-
further complications. Once the etiology is/are lying osseous structures. Each of these scenarios,
identified and addressed, the hard work of metic- while unique, has similarity in their requirement
ulous wound care can begin to help achieve to eradicate the infection, regardless of the level
wound healing. The key goal of wound care is of localization, in order to insure the best chance
debridement of nonviable tissues within the for a successful outcome and decrease the need
wound bed and periphery to the level of healthy for subsequent surgical intervention [14]. While
bleeding and noninfected tissue margins. This much is yet to be determined, such as the ideal
not only decreases the bacterial burden of the number of debridements to achieve adequate
wound when performed in the appropriate set- eradication of infection, there is consensus in try-
ting, but also helps create an environment within ing to achieve an environment in which the
the wound that is conducive to healing [12]. That wound is clean and as close to culture-negative as
is, one where foreign, nonviable, necrotic tissue possible prior to the performance of definitive
is removed from the wound and what remains is closure [15]. A close relationship between the
healthy, vascularized tissue that can allow the surgical and infectious disease teams is para-
body to heal. Although outside the scope of this mount in determining which organisms to tailor
chapter, a dedicated wound care team, ideally a antibiotic coverage to and how to manage antibi-
multidisciplinary collection of specialists in otic coverage postoperatively. At our institution,
podiatric surgery, plastic surgery, vascular sur- we routinely obtain pre-debridement tissue cul-
a b c
d e f
Fig. 33.1 Clinical images multiple views: (a, b, c, d, e, number of ways and may range from the subtle to the
and f) Infection of the foot and ankle is appreciated at frankly obvious. Many times, patients with infection pres-
varying levels of involvement. Infection may present in a ent with concomitant relative ischemia (f)
tures and post-debridement tissue cultures taking obtaining tissue cultures can lead to false posi-
care to separate our clean instruments from the tives and unnecessary or incorrect antibiotics and
dirty instruments via two separate surgical tables every precaution must be taken to avoid such a
and strictly avoiding cross contamination scenario. Additionally, a false positive culture
between the two. While surgical debridement may result in unnecessary further trips to the
cases are often not technically challenging to per- operating room in order to achieve a clean envi-
form, any cross contamination, especially in ronment in the wound prior to closure.
a b c
d e f
Fig. 33.2 Clinical images multiple views: (a, b, c, d, e, and f) Ischemia of the foot and ankle secondary to insufficient
arterial perfusion is appreciated at varying levels of involvement
Ischemia indicated at the most distal level that has adequate

arterial perfusion. Furthermore, when consider-
Arterial perfusion to the foot, the degree of isch- ing revascularization, direct revascularization of
emia, and the potential to restore adequate blood the ischemic angiosome should be the goal in
flow all play arguably the largest role in deter- order to achieve the greatest likelihood of healing
mining the healing potential of any level of and avoidance of major amputation [16]. Luckily,
amputation (Fig. 33.2). Indeed, if there is signifi- great advances in both open and especially endo-
cantly decreased blood flow to the foot and the vascular evaluation and interventional techniques
patient lacks adequate intervention candidacy or have paved the way for greater success in limb
revascularization options, major amputation is salvage.
Deformity Deformity of the foot and ankle may present in a

variety of manner from the subtle to the obvious.
While every effort should be made to achieve limb More specifically, deformity of the foot and ankle
salvage, it should be emphasized that limb salvage may be seen at varying levels (toes, forefoot, mid-
must also be functional. Indeed, there is little ben- foot, rearfoot, ankle, and/or leg), planes (sagittal,
efit to the patient if their limb does not allow for coronal, and/or transverse), severities (mild, mod-
the demands placed upon it (i.e. weight-bearing erate, severe), flexibilities (flexible, partially flexi-
and ambulation). While this may be intuitive in ble, rigid), and tissue types (soft tissue and/or
theory, there is still much to be learned about the bone). Again, although outside of the scope of this
mechanics of the foot and ankle and what truly chapter, consideration for the presence or predis-
constitutes a functional limb in any one patient. position for foot and ankle deformity is paramount
Indeed, there are many scenarios, too numerous to and the onus of its recognition and the formulation
discuss in this chapter alone, which exist that may of an appropriate intervention(s) and/or referrals is
precipitate or complicate a partial foot amputation ultimately placed upon the treating surgeon. The
(Fig. 33.3). However, there are general principles acquisition of proper alignment and/or stability for
to adhere to when it comes to amputation manage- safe and efficient ambulation are the overarching
ment of the foot and ankle with concomitant defor- goals of lower extremity deformity correction.
mity. The identification of deformity or When addressing a pressure induced wound,
predisposition for its development is largely based local wound care alone and offloading may tem-
on irregularity of alignment and/or stability. porarily aid in healing the wound, only for the
a b c d e
f g h i j
Fig. 33.3 Clinical and radiographic images multiple deformity in the foot and ankle and ultimately poses
views. Deformity of the foot and ankle is appreciated at increased risk of aberrant force distribution and wound
varying levels of involvement. (a and b) Digital deformi- formation. (g, h, i, and j) Multi-plane and multi-level
ties in the form of hammertoes, crossover toes, and hallux deformity, specifically in the at-risk patient population,
malleus are appreciated. (c) Heterotopic ossification of can pose exponentially added risk for the bearing of
bone status post-transmetatarsal level amputation is adverse forces within the foot and ankle and create sce-
fraught with the potential for uneven force distribution narios of wound formation and stagnation, the possibility
from bony prominence. (d, e and f) Charcot’s neuroar- of infection and necessitate deformity correction or
thropathy commonly leads to significant multiplanar accommodation
wound to recur when ambulatory function is plement healing wounds or pre-ulcerative lesions.
resumed. Thus, the musculoskeletal abnormality A common example of this is the equinus or
or deformity must be corrected via soft tissue bal- varus deformity that occurs after a midfoot ampu-
ancing and/or exostectomy, osteotomy, or fusion. tation. A tendo-achilles lengthening at the time of
If a corrective osteotomy is planned, bone biopsy the midfoot amputation of shortly thereafter may
and culture should first be performed to confirm help to relieve plantar forefoot pressure that
or refute the presence of infection involving the would otherwise lead to aberrant pressure distri-
bone as deep chronic infection can not only con- bution and ultimately new ulceration [17].
tribute to nonhealing wounds but may also spread Additionally, when encountering the varus stump
infection directly to other parts of the extremity, after midfoot amputation either tibialis anterior
especially when internal or external fixation is tendon or posterior tibial tendon transfer can be
used. used to assist in correction of the flexible varus
In cases of flexible biomechanical deformi- deformity and avoiding further plantar wound
ties, tendon transfer and/or lengthening may be development (Fig. 33.4) [18, 19]. In such cases
used for correcting the deformity and may sup- where the biomechanical deformity continues to
a b
Fig. 33.4 Clinical images axial foot views: of the residual forefoot varus with resolution of the aber-
Transmetatarsal amputation before (a) and after (b) tibia- rant biomechanics is appreciated
lis anterior tendon transfer. Significant clinical correction
be a major risk for re-ulceration, a major amputa- retard overall healing. In general, a majority of
tion may be considered for a permanent solution partial foot amputations will ascribe to a more
that allows for the patient to return to normal simplistic manner of closure via primary closure
activities of daily life with a greatly reduced risk or delayed primary closure. A minority of ampu-
for recurrence. tations will require definitive closure via tissue
flap reconstruction and in these cases it is only
when necessary to cover vital structures like
Partial Foot Amputations bone, tendon, or capsule. It is dependent upon the
surgeon to discern when and where to implement
General or supplement with each of these methods of
reconstruction in order to provide the most expe-
The surgeon must consider the following basic dient and durable result for the patient.
factors when performing a partial foot amputa- Maximizing lower extremity function is a
tion: definitive level of amputation, anticipated significant consideration for every patient.
means of soft tissue closure, and the resultant Regardless of confounding factors associated
biomechanical function of the foot and limb. with the successful closure or reconstruction of
Additionally, perioperative management, reha- an amputation site, the ability to maximize a
bilitation management including appropriate patient’s ambulatory function is of the utmost
orthoses and/or prostheses, and the patient’s importance. Poor consideration for a patient’s
baseline and anticipated ambulatory status are functional demands and limitations can perpetu-
helpful factors. The guiding principle in any ate a cascade of events that ultimately result in
lower extremity amputation, inclusive of partial failure, recurrence, and the need for more proxi-
foot amputation, is to maintain or improve the mal amputation. Although outside the scope of
patient’s ambulatory function and thus quality of this chapter, supplementary procedures to afford
life [20]. Clinicians should not sacrifice biome- a preservation or even increase in functional
chanical alignment or stability, however promis- limb capacity may include soft tissue proce-
ing or well-intentioned, in order to merely dures like tendon lengthening or transfer, or
maximize foot length. It is of utmost importance bony procedures such as exostectomy, osteot-
that the surgeon properly conveys this message to omy, joint arthroplasty, or joint fusion. Notably,
the patient and their social support structure, as a considerations for functional limb preservation
failure to identify the most appropriate level of can afford patients a more expedited recovery,
amputation can result in dire consequences. greater likelihood for avoidance of recurrence,
Following the eradication of infection and the and ultimately a superior quality of life. For
optimization of local and systemic healing fac- these reasons patient and limb functional abili-
tors, an assortment of options exist on the plastic ties and demands should always be a consider-
and reconstructive ladder for definitive amputa- ation prior to definitive procedure performance.
tion closure including primary closure and
delayed primary closure, secondary closure, skin
grafting, intrinsic tissue flaps, extrinsic tissue Tissue Handling
flaps, and free tissue transfers [21]. It is incum-
bent upon the surgeon to choose the most appro- Regardless of the precise level of amputation or
priate method(s) of closure based on the method of closure, proper tissue handling is para-
availability of resources, logistical feasibility for mount and may quite literally “make or break” an
both the patient and surgeon, wound characteris- attempted amputation closure, especially in the
tics including location, size, topography, and comorbid population. Bunnell [22] first coined
concomitant factors which may either advance or the term “atraumatic technique” to describe how
soft tissues should be handled during surgery. An The toe amputation procedure begins with a
atraumatic technique should be implemented at fish-mouth incision at the level of the interpha-
all times in order to preserve vascularity to the langeal joint creating dorsal and plantar skin
existing tissues and maximize the potential for flaps. Free the soft tissues of the head of the
healing. This technique is especially paramount more proximal phalanx bone and use a sagittal
for the immunocompromised or diabetic patient saw to resect the head of the phalanx bone. The
population. Regardless of the exact location or wound is irrigated with saline. Hemostasis is
presentation of amputation, one should minimize obtained and the wound is inspected to ensure
excessive traction and manipulation of the tis- that the extensor and flexor tendons are not visu-
sues. This is best accomplished with strictly alized in the wound. The dorsal and plantar skin
intent motions and manipulations and blunt flaps are closed full-thickness with monofila-
retraction only when necessary for appropriate ment suture. Alternatively, a clam-shell verti-
visualization or performance of a surgical task. cally oriented incision may be utilized with
Proper instrumentation selection is key to pre- medial and lateral tissue flaps (Fig. 33.6). Still
serving an atraumatic technique. A thorough more, a full tissue flap from plantar, medial, lat-
understanding and knowledge of the available eral, or dorsal may be utilized if tissue availabil-
instrumentation and more importantly how well a ity and vascularity are restrictive (Fig. 33.7).
particular surgical task can be accomplished in Tissue availability and surgeon preference will
one’s hands is crucial. For example, the authors ultimately determine the most appropriate mode
often prefer to forgo the use of forceps for tissue of closure (Fig. 33.8).
handling unless absolutely necessary, especially Alternatively, a racquet type incision can be
during suturing as this may cause repeated trauma performed dorsal to a central digit, medial to the
to the microvasculature of the remaining tissues. great toe, or lateral to the fifth toe. This incision
Rather, the use of strategically positioned and curves circumferentially around the interphalan-
oriented sutures is best utilized for transposition, geal joint to disarticulate the distal portion of the
rotation, and overall manipulation of tissues dur- toe. The soft tissues are freed from the head of
ing a definitive amputation closure. Ideally, when the next phalanx bone and a sagittal saw is used
utilizing suture material one should use a nonab- to resect the head of the phalanx bone. The wound
sorbable monofilament. The authors prefer a ver- is irrigated with saline. Hemostasis is obtained
tical mattress technique when reapproximating and the wound is inspected to ensure that the
skin layers directly and absorbable monofilament extensor and flexor tendons are not visualized in
when affixing grafts and supplementing with sta- the wound. The skin is closed full-thickness with
ples where warranted. monofilament suture.
The dissection and technique are the same for
the toe amputation that is done at the interphalan-
Toe Amputation geal joint or metatarsophalangeal joint. However,
if the toe amputation is done at the level of the
Toe amputations are extremely common proce- metatarsophalangeal joint, the cartilage should
dures performed as disarticulations at the level of be removed from the metatarsal head with a
the interphalangeal joint, metatarsophalangeal curette or curved osteotome. The soft tissues
joint, or as transection amputation through the adhere better to subchondral bone, minimize risk
phalanx. It is preferred to preserve the base of the of infection from retaining avascular cartilage,
toe for central digits to lessen the likelihood of and decrease risk of seroma forming from joint
digital crossover deformities with adjacent toes, fluid.
which may lead to aberrant pressure distribution It is preferred to allow the extensor and flexor
and subsequent ulceration (Fig. 33.5). tendons to retract proximally so they are not visu-
a b
c d
Fig. 33.5 Clinical images axial foot views (a and c) and post partial third toe amputation secondary to the forma-
radiographs dorsal-plantar foot view (b and d): tion of osteomyelitis from an open wound
Preoperative (a and b) and postoperative (c & d) status
alized in the wound prior to closure. This allows Partial Ray Amputation
the tendons to scar in an appropriate position to
maintain extension and flexion of the remaining A partial ray amputation involves the removal of
base of the toe. The authors do not recommend the entire toe and a portion of the distal metatar-
tenodesing the extensor and flexor tendons over sal. An indication for this procedure would be
the residual phalanx bone as this can result in osteomyelitis of the metatarsophalangeal joint
unwanted contracture of the base of the toe result- involving both the head of the metatarsal and
ing in deformity and ulceration. base of the proximal phalanx such as a diabetic
foot ulcer with osteomyelitis located at the medial medial glabrous junction extending distally cir-
first metatarsophalangeal joint due to bunion cumferentially around the base of the hallux
deformity. The exact technique and means of clo- (Fig. 33.9). This incision can include excision of
sure of partial ray amputations are quite variable the medial diabetic foot ulcer. Using atraumatic
but are often dictated by the location (first ray, technique, the skin and soft tissues are freed from
fifth ray, or central rays) and the extent of soft the first metatarsophalangeal joint and the hallux
tissue loss, presumably secondary to infection, is disarticulated at the joint. Full-thickness dis-
ischemia, deformity, or combined pathologies. section of the soft tissues off the bone is extended
Traditionally, a partial first ray amputation proximally to expose the head of the first meta-
begins with a long racquet incision from the tarsal. A sagittal saw is used to cut across the first
metatarsal neck angled 45 degrees from the coro-
nal plane, creating a resected surface that is
slightly shorter medially and parallel to the
weight-bearing surface. The sesamoids are visu-
alized and removed using curved Mayo scissors.
The wound is irrigated with saline and hemosta-
sis is achieved. The full-thickness skin flaps are
reapproximated with vertical mattress stitches.
The same technique can be applied for a par-
tial fifth ray amputation with the racquet incision
along the lateral glabrous junction circumferen-
tially around the fifth toe proximal phalanx
(Fig. 33.10). It is preferred to preserve the base of
the fifth metatarsal bone with the peroneal brevis
tendon attachment to prevent varus deformity of
the foot. If the entire fifth ray is amputated, one
should expect staged reconstruction and further
surgery to correct varus deformity.
For a central ray amputation, the preferred
incision is linear at the dorsal foot over the meta-
tarsal extending distally circumferentially around
Fig. 33.6 Clinical images axial foot view: Clamshell ori- the base of the proximal phalanx (Fig. 33.11).
ented closure of a right second toe amputation at the level
of the metatarsophalangeal joint is appreciated
The toe is disarticulated at the metatarsophalan-
a b c d
Fig. 33.7 Clinical images (a, b, d) and radiographs (c) is appreciated. (a) Initial presentation, (b) definitive clo-
dorsal foot view: Sequential performance of a plantar- sure, (c) immediate postoperative, (d) three weeks status
based flap closure of a Left partial hallux amputation site post-definitive closure
a b
Fig. 33.8 Clinical images axial foot view: Sequential a fish-mouth horizontally oriented type closure. The
performance of three individual partial toe amputations of fourth toe utilized a clam-shell vertically oriented type
the left foot is appreciated, immediate postoperatively (a) closure. Specific definitive closure technique is driven pri-
and four-weeks postoperatively (b). The second toe uti- marily by the amount and pliability of the remaining tis-
lized a medially based flap closure. The third toe utilized sues utilized for closure
a b c
Fig. 33.9 Clinical images medial foot view: Sequential performance of a partial first ray amputation is appreciated (a–c)
geal joint. Retractors are placed on either side of tar to the metatarsal excising the ulceration
the metatarsal neck to protect the soft tissues and extending distally circumferentially around the
a power saw is used to cut the metatarsal neck to toe proximal interphalangeal joint. The toe is dis-
remove the head of the metatarsal. The wound is articulated at the proximal interphalangeal joint.
irrigated and hemostasis is achieved. The skin is The soft tissues are dissected off the proximal
closed full-thickness. This technique is useful for phalanx bone which is disarticulated at the
ulcerations of the dorsal toe interphalangeal joint metatarsophalangeal joint preserving a small dor-
or infection of the metatarsophalangeal joint. sal skin flap from the toe. Retractors are used to
However, a more common indication is an ulcer- protect the soft tissues at the metatarsal neck and
ation plantar to the metatarsal head due to neu- a saw is used to cut the metatarsal at the anatomic
ropathy and bony deformity. The alternative neck to remove the metatarsal. The wound is irri-
incision for a central ray amputation begins plan- gated and hemostasis is achieved. The skin is
a b c
Fig. 33.10 Clinical images lateral foot view: Sequential performance of a fifth ray amputation is appreciated (a–c)
closed plantarly and the dorsal toe flap is used to

obtain closure distally between the toes.
If more than two partial ray amputations are
performed, regardless of location or distribution,
progression to transmetatarsal amputation is pre-
ferred (Fig. 33.12). This provides for a more even
distribution of ground reaction forces on the
plantar foot and a lessened potential for aberrant
accommodation in the form of deleterious toe,
foot, and/or ankle contracture (Fig. 33.13).
Transmetatarsal Amputation
A transmetatarsal amputation involves removing

the forefoot including the toes and the distal
aspect of the metatarsals. Traditionally, a curved
incision is made across the dorsal foot over the
metatarsal heads just distal to the metatarsopha-
langeal joints and continued plantarly across the
sulcus of the foot. Starting medially, all toes are
disarticulated at the metatarsophalangeal joints.
The incision can be extended medially and later-
Fig. 33.11 Clinical image dorsal-plantar foot view: ally along the glabrous junction and Bovie dis-
Open partial second ray amputation is appreciated. section is performed to raise a full-thickness
Central ray amputations often present many unique chal- dorsal tissue flap to expose the metatarsal heads.
lenges for management, especially in the comorbid patient
population
Sharp dissection is used to free the capsule and
Fig. 33.12 Clinical

image dorsal-plantar
foot view: Open
concomitant partial first
and fifth ray amputations
are appreciated. Severely
altered biomechanics of
the foot and the
precipitation of
complication is so
common that multiple
partial ray amputations
are preferably converted
to the transmetatarsal
amputation level in
order to more adequately
balance the altered
mechanics of the foot
a b
Fig. 33.13 Clinical image dorsal-plantar foot view: The tated abnormal force distribution with a resultant
altered biomechanics following partial first ray and partial mechanical plantar wound (a and b). Multiple ray ampu-
second ray amputations have perpetuated severe multi- tations place the patients at exponentially increasing risk
plantar contractures of the remaining digits and precipi- for further complication
ligamentous structures from the metatarsal head used to remove the plantar plates of the metatar-
and neck. A periosteal elevator is used to free the sals from the plantar skin flap. A hemostat is used
periosteum at the level of the metatarsal shaft. to bluntly dissect and isolate the flexor tendons
Hohmann retractors are used to protect the inter- from the plantar skin flap which are tensioned
metatarsal soft tissues at each individual metatar- and resected as proximal as possible to allow
sal where an osteotomy is made. A sagittal saw is retraction back into the anatomy. The wound is
used to cut all metatarsals across the metatarsal copiously irrigated with sterile saline. The dorsal
diaphysis, angled 15 degrees from the coronal and plantar skin flaps are reapproximated and the
plane following a normal metatarsal parabola wound is closed via vertical mattress sutures
when viewed in the transverse plane (Fig. 33.14). under minimal tension. A longer plantar skin flap
A small bone clamp or towel clamp may be used typically covers the metatarsals allowing closure
to hold the metatarsal head and neck to remove to be more dorsal and to provide better surface
from the plantar flap. Curved Mayo scissors are area for ambulation (Fig. 33.15).
closure process. While this maneuver is quite

useful for deficits at the transmetatarsal level, it
may be utilized for closure purposes at any level.
We find the hallux to be the most useful for such
tissue deficits and the lesser toes to be of decreas-
ingly usefulness due to lessening amounts of tis-
sue surface area and pliability. Regardless, the
fillet of toe flap should be considered a useful and
viable mode of tissue closure in the surgeon’s
armamentarium.
Lisfranc’s Amputation
The Lisfranc amputation is a relatively lesser per-

formed level of partial foot amputation which
involves disarticulation of the tissues distal to the
level of the tarsometatarsal joints, or Lisfranc
joints (Fig. 33.17). Often this level of amputation
is predicated by soft tissue or osseous infection or
relative ischemia just distal to this level or where
a transmetatarsal level amputation does not have
sufficient soft tissue envelope for primary
closure.
Most pertinent to the alignment and stability
in this level of amputation is the fact that in addi-
tion to the loss of the long extensor tendon inser-
tions, as is seen in the transmetatarsal level
amputation, the insertion of the peroneus brevis
Fig. 33.14 Radiograph dorsal-plantar foot view:
Transmetatarsal level partial foot amputation. A normal is lost. This creates a scenario where the ankle
metatarsal parabola without osseous prominence but with and foot are placed into a predisposed position of
a preservation of length which is suitable for soft tissue plantarflexion and inversion, respectively. In this
closure is the primary goal
instance it is perhaps more important to prophy-
lactically address the potential for positional mis-
When soft tissue coverage is in short supply alignment and instability with a combination of
from the remaining available tissues, often sec- tendon procedures which address the sagittal
ondary to either infection and/or ischemia, a fil- plane predisposition for plantarflexion and the
leted toe flap may be utilized in order to provide coronal plane predisposition for inversion
for additional coverage for soft tissue closure (Fig. 33.18). This includes but is not limited to a
(Fig. 33.16). The phalanges of the toe of choice, posterior group lengthening in the form of a
most often the hallux as it possesses the most tendo-achilles lengthening, Achilles tenotomy/
amount of shear soft tissue surface area for tenectomy or gastrocnemius soleus recession,
coverage, are skeletonized from the remaining long extensor tendon to long flexor tendon teno-
soft tissues with meticulous sharp dissection. desis, tibialis anterior tendon transfer (split or
This provides for additional tissue which may be whole), and tibialis posterior tendon transfer
utilized to cover atypical soft tissue defects in the (Fig. 33.19).
a b c
Fig. 33.15 Clinical images axial foot: (a) Plantar-dorsal prophylactic gastrocnemius recession posterior group
foot (b) and medial-lateral foot (c)—Right foot well- lengthening at the time of final amputation site closure
healed and well-aligned transmetatarsal level amputation with an excellent clinical result
is appreciated. In this specific case, the patient received a
Chopart’s Amputation
A Chopart’s amputation is an even less com-

monly performed amputation which removes the
forefoot and midfoot at the level of the talona-
vicular joint and calcaneocuboid joint, or
Chopart’s joint, preserving only the talus and cal-
caneus. This level of amputation tends to be more
unstable as all the supporting tendons acting
across the ankle and subtalar joint lose their
insertions in the foot and no longer function. The
only remaining tendinous attachment is the
Achilles tendon insertion on the calcaneus which
provides for powerful plantarflexion.
Special consideration for the patient’s func-
tional demands and age must be taken prior to
considering a Chopart’s amputation as the dura-
bility of the residual limb is considered to be
Fig. 33.16 Clinical images multiple views: Left foot questionable [23]. The authors consider this type
well-healed and well-aligned transmetatarsal level ampu- of amputation for patients who are home ambula-
tation with utilization of a Fillet of Hallux toe flap for soft tors, who merely require a full length limb for
tissue envelope closure. In this specific case, the soft tis- transfers or short periods of ambulating, or those
sue of the hallux was rotated to the most lateral and proxi-
mal portion of the amputation site to provide definitive who would otherwise do more poorly with a
closure with an excellent clinical result more proximal amputation. The Chopart’s ampu-
a b c
Fig. 33.17 Clinical images dorsal-plantar and medial foot of the Peroneus Brevis tendon which predisposes the for-
views (a and b) and radiograph dorsal-plantar foot view mation of an equinovarus contracture of the foot and ankle.
(c)—Right foot well-healed and well-aligned Lisfranc’s Prophylactic performance of a posterior tibial tendon or
level amputation is appreciated. The acquisition of a well- anterior tibial tendon transfer with posterior group length-
balanced foot and ankle is of the utmost importance at the ening in the form of a tendo-Achilles lengthening or gas-
Lisfranc level amputation secondary to loss of the insertion trocnemius-soleus recession is commonplace
tation is not typically considered for younger

patients with higher ambulatory demands as this
level of amputation leaves a residual stump that is
difficult to brace or shoe for moderate or high-
demand ambulation [24]. An ankle equinus con-
tracture deformity is a major complication of the
Chopart’s amputation due to increased pull of the
Achilles tendon on the posterior calcaneus. This
can result in distal plantar stump ulceration and
shift of heel pad posteriorly requiring further sur-
gical intervention or proximal amputation. An
Achilles tenectomy is the preferred prophylactic
treatment at the time of amputation in order to
reduce the possibility of developing this equinus
contracture deformity.
Again, incision placement can vary consider-
ably depending on any prior surgery and tissue
loss secondary to infection, ischemia, deformity,
Fig. 33.18 Radiograph lateral ankle view: Right foot or combined pathologies. Incisions at the medial
Lisfranc’s level amputation without appropriate soft tissue
and lateral glabrous junction allow the surgeon to
balancing resulted in significant equinovarus contractures
with subsequent plantar foot wound and positive probe to create dorsal and plantar skin flaps for bone expo-
cuboid bone sure. A longer plantar skin flap is preferred as this
a b
Fig. 33.19 Clinical images axial foot view: Lisfranc’s level partial foot amputation before (a) and after (b) soft tissue
balancing procedures in the form of posterior tibial tendon transfer and gastrocnemius recession
skin is sturdier for weight-bearing purposes; how- talus to help reduce equinus contracture; how-
ever, this may vary depending on the availability ever, the authors do not routinely perform these
of viable soft tissue structures for closure when performing Chopart’s amputation. These
(Fig. 33.20). The extensor tendons, flexor ten- tendon transfers are not significantly strong
dons, anterior tibial tendon, posterior tibial ten- enough to counter the equinus deformity pro-
don, and peroneal tendons are all detached from duced by an intact Achilles tendon or by the
their insertions. The forefoot and midfoot bones cumulative ground reaction forces which may
are removed preserving only the talus and calca- perpetuate an equinus position. Additionally, the
neus bones. The wound is irrigated and hemosta- Chopart’s level amputation is commonly per-
sis is achieved. Skin flaps are closed meticulously formed in the acute setting of infection and every
to provide for direct dermal contact with minimal attempt should be made to avoid the implantation
tension on the soft tissues (Fig. 33.21). of foreign material such as anchors and non-
The Chopart’s amputation has been described dissolvable sutures to reduce the risk of postop-
with tendon transfers such as anterior tibial ten- erative wound complication or recurrent
don and posterior tibial tendon transfer into the infection, especially in the comorbid population.
ertical Contour Calcanectomy

V
Amputation
The partial calcanectomy amputation is consid-

ered a relatively common type of partial foot
amputation where a significant portion of the cal-
caneus is resected necessitated by soft tissue and/
or calcaneal bone infection or wound formation.
There is significant distinction between plantar
and posterior heel ulcer locations where posterior
heel wounds are generally caused secondary to
pressure and ischemia in non-ambulatory
patients, whereas plantar heel wounds are gener-
ally the result of biomechanical abnormality dur-
ing the gait of ambulatory patients, namely
calcaneal gait. Regardless, the necessity for par-
tial calcanectomy amputation is most often due
to the presence of soft tissue and/or bone infec-
tion at the site of the calcaneus, most commonly
via wound formation. Historically, the conven-
tional partial calcanectomy amputation in the
form of a flattened or non-contoured bone resec-
Fig. 33.20 Clinical image anterior–posterior ankle view:
Open left foot Chopart’s level amputation is appreciated. tion has several pitfalls related to its lack of
The long plantar flap is preferred secondary to its gener- reproducibility and a high risk of recurrence
ally stout arterial perfusion and for the generally thicker owing to residual calcaneal bony prominence,
soft tissues of the plantar foot
a b c
Fig. 33.21 Clinical images axial foot and medial foot views (a and b) and radiograph dorsal-plantar foot view (c)—
Right foot well-healed and well-aligned Chopart’s level amputation is appreciated
edges to prevent loss of elasticity in the soft tis-

sue between operative debridements. Once oper-
ative cultures confirm eradication of infection a
completion VCC can be performed. Alternatively,
a single-stage approach may be used in patients
with overtly noninfected heel wounds following
revascularization and in those high-risk surgical
candidates.
Placing the patient in the prone position pro-
vides optimal visualization and accessibility to
the surgical site. Alternatively, the lateral decubi-
tus position can be used. A supine position can be
Fig. 33.22 Plain film radiograph lateral ankle view: challenging but is an option when aided with sup-
Pathologic fracture of the calcaneus bone with significant port triangles and leg holders. The soft tissue
displacement is appreciated at the site of a previously per- deficit generally dictates the extent of the inci-
formed traditional non-contoured calcanectomy. The tra-
ditional partial calcanectomy can place significant sional approach required to perform the VCC. A
aberrant force distribution through the remaining calca- linear midline Gaenslen split heel incision is used
neus which significantly increases the risk of pathological to create full-thickness medial and lateral flaps,
fracture exposing the plantar and posterior calcaneus.
Once the medial and lateral flaps are created, the
lack of robust soft tissue coverage, and the for- Achilles tendon is then fully detached from its
mation of aberrant force distribution through the insertion and the plantar fascia is detached from
calcaneus which may ultimately result in patho- its origin. A properly sized incision aids in visu-
logic fracture (Fig. 33.22). alization and dissection. Complete detachment of
The vertical contour calcanectomy (VCC) is a these structures enables removal of the calcaneus
novel modification to the conventional partial bone fragments. The full-thickness medial and
calcanectomy amputation [25]. The VCC is an lateral soft tissue flaps are protected to avoid
aggressive partial resection of the os calcis injury to the neurovascular structures isolated
designed to ensure primary soft tissue closure within.
and mitigate the risk of reoperation while respect- Using a sagittal bone saw the first osteotomy
ing the basic tenets of surgical closure, wound is made from the posterior aspect of the calca-
healing, and force distribution upon the remain- neus and directed distally parallel to the long axis
ing calcaneus bone. The procedure promotes of the foot. The starting point of the osteotomy on
early wound closure without the need for com- the posterior calcaneus should be placed in the
plex soft tissue reconstruction and the osteotomy lower half of the bone. The blade should remain
approach can be modified based on a patient’s inferior to the sustentaculum tali, which is easily
unique presentation in order to achieve similar palpated. The osteotomy includes the medial and
results. lateral tubercles of the plantar calcaneus. The
As in other amputation levels, a staged second osteotomy is made parallel to the long
approach is recommended, as this strategy per- axis of the leg and perpendicular to the first oste-
mits for tissue and bone culture and histopathol- otomy. The osteotomy is initiated from the plan-
ogy results to guide the exact timing of closure. tar aspect of the foot and aimed proximally. The
The initial surgical intervention is directed at the blade should exit on the superior aspect of the
removal of infected and nonviable soft tissue and calcaneus and should be within the posterior half
bone to the level of healthy margins. Retention of the superior cortex. If imaging is available, this
sutures may be used to approximate the wound point corresponds with the lateral process of the
talus. Alternatively, the osteotomy can be made In preparation for closure, the surgical site is
from superior to plantar. The final osteotomy is copiously lavaged with normal saline. The calca-
made tangential to the first and second bone cuts neus is a highly vascularized mainly cancellous
at 45 degrees. On lateral projection imaging, the bone and may require extra attention to achieve
cut is generally made roughly parallel to the full hemostasis. To prevent hematoma formation,
posterior facet of the subtalar joint. Generally, the use of a surgical negative pressure non-DME
these osteotomies can be made without intraop- drain is encouraged, especially in those patients
erative imaging; however, intraoperative fluoros- receiving anticoagulation. After the osteotomies,
copy may be of assistance (Fig. 33.23). The final soft tissue closure may be achieved without sig-
step of the osseous component of the VCC is cal- nificant soft tissue tension. Reattachment of the
caneal contouring. Contouring is aimed at creat- Achilles tendon is strictly not performed. Most
ing a rounded final surface with smooth cortical cases require revision of the incisional flaps cre-
borders (Fig. 33.24). This goal can be accom- ated after completion of the osteotomies as there
plished with the use of manual or power rasps to may be redundant soft tissues. Interrupted verti-
ensure there are no sharp corners or projections cal mattress technique using a nonabsorbable 0
and to produce a truly contoured posterior and or #2 monofilament suture is recommended. A
plantar calcaneus. posterior splint is applied in neutral to gravity
equinus to decrease tension on the surgical inci-
sion, with robust padding and offloading of the
heel. Alternatively, an external fixator may be
applied to suspend the foot for offloading of
pressure.
The postoperative course requires strict
offloading and the patient must remain non-
weight-bearing if they are normally ambulatory.
Patients who are non-ambulatory should be pro-
vided with a means to maintain the surgical site
suspended during the healing process. Once
healed, they will require an offloading device to
protect against recurrent ulceration in the form of
Fig. 33.23 Plain film radiograph lateral ankle view: a Charcot Restraint Orthotic Walker (CROW)
Location, orientation, and order of the three osteotomies boot or solid ankle foot orthosis (AFO).
of the vertical contour calcanectomy
Continued offloading is required several weeks
after suture removal to ensure incision healing.
Generally, after six months of ambulation in
CROW boot, progression into a custom solid
AFO should be considered.
Conclusion
The fundamental tenets in the management of

partial foot amputations are the eradication of
infection, optimization of tissue healing factors,
appropriate procedure selection, and adequate
Fig. 33.24 Plain film radiograph lateral ankle view:
musculoskeletal alignment and stability with
Final vertical contour calcanectomy with closed soft tis-
sue envelope is appreciated major consideration for residual functional abil-
ity and demands. In particular, the comorbid Acknowledgements No acknowledgements are made.
patient population requires adherence to a multi-
factorial algorithm which affords the greatest
healing potential while mitigating costs and References
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17. Armstrong DG, Stacpoole-Shea S, Nguyen H, with successful Chopart’s amputation in patients
Harkless LB. Lengthening of the Achilles tendon in with diabetes: a systematic review. Foot Ankle Spec.
diabetic patients who are at high risk for ulceration 2010;3(5):278–84.
of the foot. J Bone Joint Surg Am. 1999;81(4):535–8. 24. Brodell JD, Ayers BC, Baumhauer JF, DiGiovanni
18. Kim PJ, Steinberg JS, Kikuchi M, Attinger BF, Flemister AS, Ketz JP, Oh I. Chopart amputation:
CE. Tibialis anterior tendon lengthening: adjunc- questioning the clinical efficacy of long-standing sur-
tive treatment of plantar lateral column diabetic foot gical option for diabetic foot infection. J Am Acad
ulcers. J Foot Ankle Surg. 2015;54(4):686–91. Orthop Surg. 2020;28(16):284–91.
19. Turan I. Tarsometatarsal amputation and tibialis ante- 25. Elmarsafi T, Pierre AJ, Wang K, Evans KK, Attinger
rior tendon transposition to cuneiform I. J Foot Surg. CE, Kim PK, Steinberg JS. The vertical contour
1985;24(2):113–5. Calcanectomy: an alternative surgical technique to the
20. Attinger CE, Brown BJ. Amputation and ambulation conventional partial Calcanectomy. J Foot and Ankle
in diabetic patients: function is the goal. Diabetes Surg. 2019;58:381–6.
Metab Rev. 2012;28(Suppl 1):93–6.
Below Knee Amputation:
Techniques to Improve
34
Rehabilitation, Pain Management,
and Function
Tanvee Singh, Kevin G. Kim, Grant M. Kleiber,

Introduction above-knee amputation counterparts [3]. This

can be attributed largely to the mechanical advan-
Although the rate of lower extremity amputations tage of preserving the knee joint and resulting
has been declining in the USA, there are still greater functional baseline status postoperatively.
approximately 185,000 amputations performed Although there are functional and ambulatory
annually with nearly two million living amputees benefits attributable to BKA, it is not without
[1, 2]. A transtibial or below knee amputation risks. For example, non-ambulatory patients may
(BKA) is the most common level of major ampu- experience flexion contracture of the knee and
tation and involves surgically removing the foot, subsequent pressure ulcers on the distal residual
ankle, and distal tibia and fibula, along with limb from prolonged immobility [3–5].
related soft tissue structures. The vast majority of Furthermore, chronic pain syndromes of the
patients undergoing a BKA have greater func- resulting stump are not uncommon. BKAs are
tional outcomes and a higher likelihood of ambu- associated with various limitations on activities
lating with a prosthesis compared to their of daily living (ADLs), and adjusting to these
changes poses additional physical and psycho-
logical morbidities for patients [1].
T. Singh Indications for BKA vary widely and may
Columbia University Irving Medical Center, include traumatic injuries, oncologic treatment
New York, NY, USA
e-mail: [email protected] requirements, vascular disease and critical limb
ischemia, diabetic complications such as chronic
K. G. Kim
Department of Plastic Surgery, MedStar Georgetown nonhealing ulcers, congenital deformities, necro-
University Hospital, Washington, DC, USA tizing infections, and other vasculopathies. BKAs
e-mail: [email protected] are performed in both acute and non-urgent set-
G. M. Kleiber tings for a wide range of patients and are able to
Department of Plastic and Reconstructive Surgery, restore and improve patient function in addition to
MedStar Georgetown University Hospital, provide lifesaving and definitive treatment.
Washington, DC, USA
e-mail: [email protected] Diabetic patients, for example, with nonhealing
foot ulcers may improve ambulation and regain
C. E. Attinger (*)
Department of Plastic Surgery, Georgetown function with prosthesis after the removal of an
University School of Medicine and MedStar affected limb [6]. Complicated diabetic foot
Georgetown University Hospital, infections may require major drainage amputation
Washington, DC, USA to limit progression of infection and maximize the

546 T. Singh et al.
optimal subsequent prosthesis fitting and ambula- the tibialis anterior, extensor hallucis longus,
tion. Further, patients with chronic pain after trau- extensor digitorum longus, the deep peroneal
matic injuries may elect to undergo BKA for nerve, and the anterior tibial artery and vein. The
palliative improvement of pain and functional anterior tibial artery is the main blood supply to
outcomes. BKAs may also be performed when the anterior compartment of the leg with reinforce-
limb salvage has failed to preserve a mangled ment by the perforating branch of the peroneal
extremity or in cases of full-thickness burns, seri- artery. The lateral compartment lies lateral and
ous neurovascular compromise, recalcitrant infec- posterior to the anterior compartment and lateral to
tion, and irreplaceable soft tissue defects [6–9]. the fibula and contains the peroneus longus and
Lastly, elective BKAs are appropriate in patients brevis and the superficial branch of the peroneal
with lack of distal foot or ankle function with nerve for much of its course. Its arterial supply
refractory pain, venous stasis ulceration, or mul- derives from the anterior tibal artery proximally
tiple distal to mid-foot amputations with persis- and pedicles from the peroneal artery distally. The
tent infection or vascular insufficiency [6–9]. posterior leg holds both the superficial and deep
Several contraindications to BKA also exist. compartments. The superficial compartment con-
Patients with flexion contracture of the knee tains the soleus, gastrocnemius, and plantaris mus-
greater than 20 degrees, stroke, or neurologic cles. The muscular deep compartment contains the
deficits resulting in spasticity or rigidity on the tibialis posterior, the Flexor Hallucis Longus and
side of amputation, and infections that have Flexor Digitorum Longus. The peroneal and pos-
spread to the skin within 4 to 5 cm of the tibial terior tibial arteries as well as the posterior tibial
tuberosity leaving too short a tibia for a prosthe- nerve also lie within the deep compartment.
sis should not undergo a BKA. Vascular occlu- Advances in surgical technique have contrib-
sion of the superifical femoral artery and popliteal uted to improved outcomes following
artery also poses challenges to wound and stump BKA. Considerable clinical evidence continues to
healing secondary to severe ischemic conditions. support the use of a long posterior musculocutane-
The purpose of this chapter is to discuss various flap comprised of the gastrocnemius and
ous multidisciplinary techniques to improve soleus muscles for stump coverage [10]. The sural
rehabilitation, pain control, and functional out- arteries, which originate proximal to the knee
comes in patients undergoing BKA. First, we joint, are often the major blood supply for this type
give an overview of the etiologies, anatomy and of flap. Many of our patients, especially those with
discuss surgical considerations to optimize pain diabetes, have preserved blood flow through the
after BKA. Next, we highlight morbidities asso- sural arteries despite having restricted blood flow
ciated with BKA, with a focus on pain, and the through the popliteal artery and its major branches.
various treatment options that can be used to Long posterior musculocutaneous flaps with no
address it. Lastly, we discuss surgical interven- anterior flaps can prevent wound necrosis and
tions to treat neuromas and other multidisci- rehabilitation failure [10]. Care should be taken to
plinary options such as nutritional support, ensure the distal end of the fibula is shorter than
physical therapy, and prosthesis. the tibia (1–2 cm.), that it is smooth and that it has
ample musculocutaneous padding to avoid poten-
tial pressure points within the socket of the pros-
Anatomy and Surgical thesis. Bony protrusions can impede
Considerations weight-bearing on the residual limb and compli-
cate prosthetic fittings (Fig. 34.1). Subsequent
Musculocutaneous flaps for BKAs are planned myodesis of the anterior tibial, peroneal and super-
according to the anatomy and blood supply of the ficial distal muscles to the distal tibia restores their
lower leg compartments. There are four fascial insertion so that they can still contract and avoid
compartments of the leg, with each containing loosing their bulk. This helps pad the tibia and
muscle and neurovascular structures. The anterior fibula in the distal stump over the long term. In
tibial compartment lies anteromedial to the tibia addition, the myodesis of the gastrocnemius mus-
and anterior to the fibula. The fascia encompasses cles to the distal tibia adds power to knee flexion.
34 Below Knee Amputation: Techniques to Improve Rehabilitation, Pain Management, and Function 547
ANTERIOR COMPARTMENT
Deep fibular (peroneal) n. Tibialis anterior m.

Anterior tibial a. and vv. Interosseous membrane
Extensor hallucis longus m.
DEEP POSTERIOR
Extensor digitorum longus m. COMPARTMENT
Anterior intermuscular Tibialis posterior m.
septum
Fibular (peroneal)
LATERAL a. and vv.
COMPARTMENT Flexor hallucis
longus m.
Superficial Flexor digitorum
fibular longus m.
(peroneal) n.
Posterior tibial
Fibularis a. and vv.
(peroneus)
longus m. Tibial n.
Fibularis
(peroneus)
brevis m.
Posterior
intermuscular
septum
Soleus m.
Transverse
intermuscular
septum Gastrocnemius m.
SUPERFICIAL POSTERIOR
COMPARTMENT
Fig. 34.1 Anatomy of muscle compartments of the leg
Understanding the anatomy of the amputation residual limb with functional length. This
site is also critical to placing a successful nerve decreases the shear and torque pressures on the
block for adequate postoperative pain control. amputation stump. The anatomic level of bony
BKAs require sciatic nerve blockade, whereas an transection is an important consideration to
above the knee amputation necessitates blockade ensure proper soft tissue coverage of the residual
of both femoral and sciatic nerves for successful limb. The incision line should be placed distal to
pain control [11]. Tourniquet site placement is the distal anterior tibia bone cut in order to pre-
also paramount when planning a peripheral nerve vent the scar from being at the highest friction
block, to ensure access neurovascular structures and pressure point when wearing a prosthesis.
of interest. Skin closure should be without ten- The ideal length of the residual limb is 12–18 cm
sion to minimize the pressure applied per unit from the tibial tubercle [13]. Optimal prosthetic
skin surface and facilitate wound healing [12]. alignment promotes steady and comfortable
A key underlying principle to improve reha- mobility [14, 15]. We elaborate more on prosthet-
bilitation and function after BKA is to provide a ics in Chap. 28.
548 T. Singh et al.
Morbidities Associated with BKA 24]. Following peripheral nerve transection

injury, the nerve undergoes three biologic pro-
Patients undergoing BKA are susceptible to a cesses: Wallerian degeneration, axonal regenera-
constellation of postoperative morbidities that tion, and muscle reinnervation if end organs are
are medical, psychological, social, and financial present [25]. If the distal end of the proximal
in nature. Beyond acute postoperative deficits in nerve stump is in proximity to the proximal end
function, pain after BKA often has complex of the distal nerve stump, end-to-end neurorrha-
pathophysiological mechanisms and may mani- phy may occur. In this process, proximal axons
fest weeks, months, or years following amputa- regenerate into distal endo-neural tubes and elon-
tion. This pain can be function limiting, a gate until they reinnervate the end organ, achiev-
detriment to quality of life, as well as a negative ing maximal functional recovery [26]. However,
impact to mental health and interpersonal rela- in the context of amputation, these end organ tar-
tionships. It is estimated that 70–80% of ampu- gets are surgically removed. Thus, peripheral
tees in the USA deal with chronic pain of varying nerves in the residual limb may sprout and regen-
etiologies, often necessitating revision surgeries erate in an uncoordinated fashion, forming a neu-
and limiting prosthetic use [16, 17]. roma in the process, leading to symptomatic,
Pain at the amputation site can be classified focal pain. Neuroma pain may be attributable to
into one of the four categories: residual limb pain the neuroma microenvironment, which has dif-
(RLP), phantom limb pain (PLP), phantom limb ferent mechanochemical sensitivity and excit-
sensations, and postoperative pain. Acute postop- ability, as well as the neuroma itself, which has
erative pain is pain at the surgical site due to sur- altered expression of transduction molecules,
gical trauma that most patients experience after sodium channels, potassium channels, and axo-
surgery. This pain is often described as sharp and nal connections [27].
stabbing in nature, due to the involvement of the The pathophysiology of neuroma pain makes
nociceptive afferent nerve innervating the surgi- neuromas particularly difficult to treat using tradi-
cal site. Some patients also experience muscle tional medical interventions, requiring the use of
spasms and tenderness at the amputation site due surgical management for definitive treatment.
to prolonged immobility and use of surgical Techniques for neuroma management are varied
dressings [11, 18, 19]. and can involve nerve grafting, nerve cap place-
RLP, or “stump pain,” is localized, intense ment, use of regenerative peripheral nerve inter-
pain experienced in the residual limb after ampu- face (RPNI), “end-to-side” neurorrhaphy, and
tation. There are several possible etiologies to targeted muscle reinnervation (TMR). These tech-
RLP including soft tissue inflammation, infec- niques are discussed further later in this chapter.
tious processes such as osteomyelitis, heterotopic Perceived pain in the amputated limb was first
ossification, and neuromas. One of the most com- described in 1462 by Dr. Ambrose Pare, a French
mon causes of RLP is neuroma formation. surgeon, and the term “phantom limb” was
Although neuromas may be asymptomatic, one coined in 1871 by Silas Weir Mitchell, a Civil
in four of limb amputees will develop chronic War surgeon [18, 28]. PLP is the perceived pain
localized pain because of symptomatic neuromas in an area of the amputated limb that is no longer
within their residual limb [8, 20–23]. Painful present. The etiology of PLP) is not well under-
symptomatic neuromas are frequently the cause stood but is thought to be caused by functional
of RLP and are known to compromise prosthetic reorganization of the somatosensory cortex and
rehabilitation and diminish the quality of life changes in inhibitory sensory feedback signals
after amputation. sent to the dorsal horn of the spinal cord, result-
Neuromas may form following transection of ing in pain transmission [11, 18, 19]. In compari-
a peripheral nerve, as the nerve attempts to regen- son, phantom sensations are nonpainful
erate in response to intrinsic signals, as well as perceptions of the amputated limb that can be
those from the distal targets they innervate [13, kinetic (perceived movements of the amputated
limb), kinesthetic (perceived shape or position of inflammatory drugs, antidepressants, muscle

the amputated limb), or exteroceptive (perceived relaxants, anticonvulsants, nerve modulators,
touch, pressure, itching, vibration in the phantom local nerve blocks, steroid injections, and lido-
limb) [29, 30]. caine patches. Psychological methods include
It is well understood that effective control of mirror box therapy, antidepressant therapy, and
acute postoperative pain decreases the risk of following up with a pain psychologist [38, 39].
residual and phantom limb pain development Physical methods include transcutaneous electri-
[31]. Thus, preoperative pain optimization is cal nerve stimulation to the limbs, spinal electri-
essential to control acute post-amputation pain cal stimulators, rehabilitation with exercise or
and subsequently decrease the risk of lasting massage, and surgery [23].
chronic and phantom pain. By doing so, amputa-
tion patients may maximize their chances of
post- amputation pain control and successful Targeted Muscle Reinnervation
ambulation with a prosthesis. and Regenerative Peripheral Nerve
Preoperatively, patients undergoing non-Interface Surgery for Neuroma
traumatic BKA should have their medical condi- Prevention and Treatment
tions and nutritional status optimized for maximal
wound healing, undergo narcotic evaluation for Traction neurectomy is a simple surgical option to
opioid tolerance, and be evaluated by physical ther- treat symptomatic neuromas that entails neuroma
apy/occupational therapy to enhance postoperative excision, with high transection of the nerve while
recovery. Patients with underlying depression and on traction [40, 41]. The nerve stump is proximally
high baseline pain scores are more likely to experi- relocated into an area more protected by muscle and
ence physical and psychosocial difficulties [32]; soft tissue, thereby making sure it remains undis-
thus, it also appropriate for psychiatric conditions turbed and asymptomatic [40, 41]. Regenerative
to be evaluated and managed through a psychologi- peripheral nerve interface (RPNI) surgery and tar-
cal or psychiatric consult prior to BKA [33–35]. geted muscle reinnervation (TMR) are innovative
On the day of surgery, a multidisciplinary and surgical techniques to prevent neuroma formation
collaborative approach is essential. and chronic pain, ultimately improving prosthetic
Anesthesiologists and the Acute Pain Service control. Originally designed to provide amputees
team play a vital role in the formulation and exe- better control of upper limb myoelectric and bio-
cution of an optimized perioperative analgesia prostheses [42–47], TMR reestablishes function of
plan. Adopting a patient-tailored approach is the severed nerve through the creation of bio-ampli-
important in perioperative pain management as fiers. This is accomplished using multiple nerve
individual pain perception accounts for variabil- transfers to reroute transected peripheral nerves to
ity and multifactorial etiologies of pain between motor nerves, increasing neuro-excitability and
patients [36, 37]. Perioperative catheter nerve motor function [24]. TMR) is thought to decrease
blocks during the operation and subsequent hos- neuroma formation by exploiting the biology of
pital recovery allow for a 5 day relatively pain regenerating peripheral nerves and minimizing the
free period that helps minimize subsequent pain. number of aimless axons available. It is important to
A preoperative discussion with physical therapy recognize, however, that TMR involves sacrificing
and occupational therapy, when permitted, also donor nerves, which may lead to central sensitiza-
allows for improved pain management and tion and additional neuroma formation, and dener-
expectations. vating muscles that could potentially be useful in
If chronic pain develops following amputa- post-BKA rehabilitation [24].
tion, several modalities are available: pharmaco- Contrarily, RPNI surgeries do not carry the
logical, psychological, and physical [23]. risk of neuroma formation. RPNI surgery is indi-
Pharmacological options include narcotics, cated for the treatment of symptomatic neuromas
peripheral nerve catheters, nonsteroidal anti- and is increasingly performed after major limb
550 T. Singh et al.
amputation. It involves implanting the distal end -Methyl d-Aspartate (NMDA)

N
of a transected peripheral nerve into a free skele- Receptor Blocker
tal muscle graft [24]. RPNI surgery offers a phys-
iologic mechanism of decreasing neuroma pain Ketamine is a noncompetitive blocker of NMDA
by providing peripheral nerve axons targets for receptors and is effective in treating perioperative
reinnervation [24]. Although RPNI surgery is an pain in its intravenous (IV) form [50]. Data from
effective surgical technique that decreases neu- a randomized controlled trial by Hayes et al.
roma pain by providing peripheral nerve axons found that patients receiving IV ketamine periop-
targets for reinnervation, it is not a panacea [24]. eratively developed lower rates of PLP); how-
Patients can experience incomplete pain relief, ever, these results were not statistically significant
thus highlighting the crucial role of multidisci- at 6 months [53]. There is insufficient evidence,
plinary approach to pain management after BKA. however, regarding the use of ketamine for
In a preliminary cohort of BKA patients treated chronic pain management.
with traction neurectomy at our institution, 57%
report RLP and 47% report PLP), with an average
severity of 5.2/10; 24% were taking chronic opi- Gabapentinoids
oids, and 42% on neuroleptic medications with an
average daily dosage of gabapentin. We recently Gabapentin is an anticonvulsant and structural
wrote a case report providing unique insight into a analogue of GABA. According to published lit-
patient we treated with symmetric bilateral ampu- erature, gabapentin and pregabalin are well
tations, with TMR on one side and RPNI on the established options for treating existing PLP [3,
other. While the patient still experiences RLP 54–56]. In a cross-over study, authors found gab-
which she attributes to chronic edema from her apentin to be superior in relieving established
DVTs and pressure from her wheelchair, she does PLP) but had no difference in its effect on mood,
not have a symptomatic neuroma at either stump. sleep, and functionality compared to placebo
Future studies must be conducted to compare the [57].
efficacy and safety of TMR and RPNI. Our recent
experience of 100 consecutive BKAs with TMR
has shown a 6% requirement for narcotics and an Calcitonin
ambulatory rate of 91% at 3 months [48]
Calcitonin is a hormone produced by the parafol-
licular C-cell of the thyroid gland. Its exact
Pharmacological Agents mechanism of action for pain management is
and Regional Analgesia unclear, but it is thought to have opioid like action
on μ receptors and modulate voltage gated Ca2+
Opiate Analgesics channels on nociceptive neurons [58, 59]. One
study showed epidural calcitonin could be used
Parenteral opioids are widely used for the manage- as a preventive strategy for PLP; however, addi-
ment of acute perioperative pain in patients under- tional studies are needed in this regard [60].
going amputation surgeries [49, 50]. Tramadol is a
weak opioid agonist and acts by inhibiting the
reuptake of serotonin and norepinephrine. The use Non-steroidal Anti-inflammatory
of both tramadol and morphine is well established Drugs (NSAIDs)
for managing acute pain in the perioperative period
[51, 52]. However, evidence supporting the use of Non-steroidal anti-inflammatory drugs (NSAIDs)
opioids to reduce PLP is sparce. Additional can be useful in postoperative pain relief and can
research is needed to evaluate the role of periop- be used to treat inflammatory pain, but they do
erative opioids in preventing post-BKA pain. not specifically treat neuropathic pain, which
derives from a largely different physiological that empower patients with coping mechanisms
mechanism [50, 61, 62]. and information about rehabilitation in a support-
ive environment. This is discussed in further
detail in Chap. 38.
Epidural Analgesia
The role of epidural anesthesia in immediate Nutrition

postoperative pain relief for patients undergoing
amputation has been well-documented and is The environment into which amputees must
thought to be attributed to the interference of assimilate has changed considerably since the
nociceptive inputs to the spinal cord [63–68]. passage of the Americans with Disabilities Act
Existing literature has not established epidural (ADA) in 1990. Not only has the ADA increased
analgesia as a preventive strategy of PLP; how- awareness of the biopsychosocial needs of ampu-
ever, a handful of randomized trials have reported tee population, but it also expressly prohibits dis-
promising results demonstrating the role of peri- crimination against people who have suffered
operative epidural anesthesia in combination major limb loss, among other disabilities [78]. It
with adjuvants such as opioid [63], ketamine is not uncommon for patients undergoing BKA to
[67], and calcitonin [60], in preventing PLP). experience a significant increase in metabolic
demands following amputation, attributable to
surgical stress in the postoperative period and
Perineural Catheters increased use of lower extremity muscles unac-
customed to the new biomechanical distribution
Perineural catheters (PNCs) decrease the need [77, 79, 80]. These metabolic changes emphasize
for opioids and play an important role in provid- the importance of postoperative nutritional sup-
ing postoperative pain relief after BKAs [49, 69, port in optimizing recovery and wound healing.
70]. However, evidence is non-concrete on Otherwise, poor outcomes may ensue. For exam-
whether PNCs are effective in preventing PLP ple, patients with poorly controlled diabetes, a
[69–74]. There is no definitive evidence demon- population known to have poor nutritional status,
strating that PNCs can prevent PLP). Nonetheless, face poor long-term survival following BKA due
they are still used widely as they do not have the to high glucose levels [79, 81].
same hemodynamic effect (i.e., usage of pressors Therefore, it becomes paramount to provide
intraoperatively) as epidural blockade [75]. tailored nutritional care and education, keeping
in mind dietary preferences, allergies, and cul-
tural restrictions. Lack of nutritional knowledge,
Psychological Treatment Modalities nutritional counselling, and dialogue with nurses
and Support Groups has previously shown to negatively affect
patients’ experiences [82–84]. Furthermore,
Post-operative wound healing is considerably nutritional counselling may better position
shorter-lived and less complex than the psycho- patients to improve their own health and nutri-
logical healing that follows a BKA [76]. tional status through increased health literacy.
Psychological therapies can be very effective in
helping patients modify their perception of pain.
Modalities such as cognitive behavior therapy, Physical Therapy, Rehabilitation,
mindfulness, brief interpersonal therapy, and bio- and Patient Education
feedback can play important and meaningful
roles in pain management and improved out- Patient-centered education and counseling is
comes [77]. In our institution, we have imple- applicable to many aspects of patient care follow-
mented monthly amputee support group meetings ing amputation. Patients undergoing BKA should
552 T. Singh et al.
be provided with resources to manage stump lowing elements: socket, interface, suspension,
pain, stump care, and prosthesis care and fitting. shank, and foot and ankle. It is important to note
Post-amputation rehabilitation is a multidisci- that prosthetics are not a “one size fits all” modal-
plinary, collaborative effort between physicians, ity. Each patient’s baseline, unique needs, and
nurses, prosthetists, orthotists, physical thera- functional status should be carefully considered.
pists, occupational therapists, and nutritionists, This topic is discussed in more detail in Chap. 28.
among other members of the healthcare team. Functional scoring scales are a valuable tool
Success of rehabilitation depends on a myriad of to collect objective information regarding patient
factors such as patient age, baseline health, cog- quality of life and function in society, which is
nitive status, comorbid diseases, and sequence of inherently a subjective measure. One such scale,
onset of disability. The first step of rehabilitation the amputee mobility predictor (AMP), is a vali-
consists of caring for the wound and managing dated performance-based outcome measure
pain and edema to increase joint and muscle flex- (PBOM) developed for patients with lower
ibility. It is also critical to strengthen the trunk extremity amputations. It measures functional
prior to prosthetic fittings, as patients take time to capabilities and mobility both with (AMPPro)
adjust to the new distribution of weight and are at and without prosthesis (AMPnoPro) or with a
increased risk of falls. Patient education and prosthesis [93]. Research demonstrates the AMP
shared-decision making is a cornerstone of the tool correlates with other measures of functional-
rehabilitation process. ity such as self-reported measured of prosthetic
Physical therapy can have meaningful impacts mobility, Time-up and Go, and walking speed
on functionality and quality of life in patients [93–98]. The utilization, importance, and appli-
after BKA. Patients who receive physical therapy cability of functionals scoring scales are also fur-
post-amputation are more likely to have improved ther detailed in Chap. 28.
walking speed, prosthetic fit and mobility, mus-
culoskeletal endurance, and increased survival Financial Disclosure Statement The authors have no
[85–88]. Despite these benefits, only a fraction of financial disclosures, commercial associations, or any
other conditions posing a conflict of interest to report.
patients undergoing amputation utilize physical
therapy services due to multilevel barriers such
as financial costs, accessibility, and availability
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Distinguishing true change from statistical error.
Complications and Revision
Surgery in Complex Limb Salvage
35
Ali Rahnama, Noman Siddiqui,
and Janet D. Conway
Introduction chapter we will focus on infections, malunion,

and nonunion. General considerations on the
Undoubtedly, surgeons will encounter complica- workup, physical exam, and overall evaluation of
tions and revision cases that need to be managed. the patient will be discussed before moving on to
Patients with surgical complications that require give guidance on specific clinical scenarios in
revision surgery may come from outside of your terms of surgical technique that will help guide
practice, referred to you for further management the best management and outcomes possible.
or may have been your own patients who return Furthermore, while we strive to practice in an
to you for further management of their complica- evidence based manner, we do understand that
tion. Regardless, while a complication may be many of the details that have helped drive suc-
secondary to iatrogenic factors, complications cessful outcomes have been through trial and
and the need for further revision surgery are not error on the parts of the authors and we hope to
necessarily an indication of inadequate or incor- share those “pearls” with you the reader.
rect surgical intervention. While the hope is to
minimize the frequency of these cases through an
evidence based surgical decision-making process Complication Workup
and sound surgical technique, keys to ensuring
these patients will have successful outcomes History
involve factors that extend beyond the operating
room both before and after surgical intervention. Various complications can point to different
While there are many complications that one may underlying issues stemming from the patient’s
encounter in limb surgery, for the purposes of this existing metabolic disease, vascular insuffi-
ciency, or social practices. It is important when
evaluating the patient and working them up to
A. Rahnama (*) have a stepwise approach that evaluates all pos-
Department of Plastic and Reconstructive Surgery, sible avenues for why the patient had their spe-
Georgetown University School of Medicine, MedStar
Georgetown University Hospital, cific complication. Common complications
Washington, DC, USA include surgical wound dehiscence/infection,
e-mail: [email protected] deep wound infection, nonunion, malunion, avas-
N. Siddiqui · J. D. Conway cular necrosis, implant failure, nerve damage or
Rubin Institute for Advanced Orthopedics, Sinai neuroparalysis, limb length discrepancy, new or
Hospital, Baltimore, MD, USA persistent pain after the procedure.

560 A. Rahnama et al.
Situations requiring immediate attention such Indeed smoking is well documented to have
as surgical wound dehiscence and/or infection effects on bone and surgical wound healing both
will often need aggressive and immediate atten- directly via the smoking itself and indirectly via
tion in the form of systemic antibiotics and local- the deleterious effects smoking has on the vascu-
ized debridement (either in the clinic or operating lature with long term use [3, 4]. Coordination
room) before further workup can be done to with the primary care physician can help the
understand the etiology of the issue at hand. patient be placed on nicotine supplementation to
While a simple superficial dehiscence of the sur- help with reducing or ceasing tobacco use com-
gical wound can be treated with relatively minor pletely. Additionally, excessive alcohol intake
interventions such as a change in the type of and alcoholism is thought to be associated with
dressings used, ignoring or undertreating wound malnutrition as alcoholics are thought to con-
complications early in the postoperative course sume too little carbohydrates, protein, and vita-
can have severe ramifications for the high risk mins in addition to the direct inhibitory effects
patient, particularly those with multiple medical alcohol has on the absorption and digestion of
comorbidities that may further contribute to the these nutrients [5]. A better understanding in
issue at hand and prove limb threatening. recent years of the effects of inflammatory mark-
A detailed history is an important first step in ers on albumin and prealbumin levels has caused
assessing the patient for potential barriers to a shift from the reliance on these markers as the
healing. Particularly as it pertains to limb salvage sole metric for nutritional status evaluation.
and reconstruction, diabetes and glucose control/ Nevertheless, checking albumin and prealbumin
management needs to be paid close attention to. levels, in addition to a detailed history and physi-
A HgA1C >8, for example, is grounds for pause cal exam may further help quantify the level to
and further referral to the endocrine specialist to which one is malnourished and therefore help in
help decrease the likelihood of further complica- guiding appropriate avenues for nutrition supple-
tions by better managing the patient’s diabetes mentation prior to any further surgical interven-
when possible [1]. Management of other underly- tion [6]. These social factors and habits can have
ing medical problems such as autoimmune dis- direct effects on proper wound and osseous heal-
ease and the medications needed to appropriately ing and can contribute to the incidence of compli-
manage those disease processes need to be paid cations if not addressed appropriately in the
particular attention to. Indeed it may be neces- perioperative period.
sary to discuss and coordinate with the rheuma- Complications such as malunion/nonunion,
tologist a schedule to discontinue and alter the nerve damage and neuroparalysis as well as an
dosage and schedule of any steroids or disease unintended limb length discrepancy can often
modifying anti-rheumatic drugs (DMARDS) point to improper technique (i.e. over aggressive
prior to any surgery [2]. bony resection, periosteal stripping, poor soft tis-
In cases of nonunion, when the fixation con- sue handling leading to nerve, muscle and tendon
struct selected in the initial surgical procedure is damage). Unfortunately, due to the anatomic
not thought to be a contributing factor, metabolic constraints present in limb surgery such as a lim-
causes need to be evaluated. Vitamin D levels ited soft tissue envelope between the skin and
should be checked and supplemented when underlying osseous and tendon/nerve structures,
appropriate. If there is any doubt that the low the management of these complications often
vitamin D is secondary to any other contributing requires a high degree of skill in procedures that
endocrine disorder, evaluation with an endocrine are not often performed in the community setting
specialist is recommended. and referral to a revision surgeon in the tertiary
Social factors such as smoking or excessive care setting may be necessary for a chance at
alcohol use should also be addressed and man- limb salvage. Complex constructs involving both
aged prior to any revision surgery to help decrease internal and external fixation and advanced tech-
the likelihood of any further complications. niques such as bone transport, vascularized bone
35 Complications and Revision Surgery in Complex Limb Salvage 561
grafting, nerve transfers, and others may be indi- closure and soft tissue mobilization in any subse-
cated in these difficult cases. Additionally, a cen- quent procedure. Additionally, the quality of the
ter where a multidisciplinary approach to care soft tissue envelope is an important factor in
involving vascular, plastic, podiatric, and ortho- whether the patient is a candidate for further revi-
pedic surgeons all offering their unique skill sets sion surgery at all. Unfortunately, chronic pro-
to the patients’ care may help increase the cesses such as venous stasis disease and chronic
likelihood of achieving an adequate outcome to lymphatic insufficiency often make options for
not only save the limb but also allow for it to further surgery limited.
remain functional [7]. Finally, the neurologic examination may be
consistent with absent sensation or neuropathy
which may be in accord with chronic disease pro-
Physical Examination cesses such as diabetes that have been shown to
be associated with higher rates of complications
After a detailed history, the physical exam is an and therefore an indication for a varying approach
important part of the workup that must not be in construct or procedure selection in any further
brushed past with haste. The patient’s vascular surgical procedure [1]. Additionally, new neuro-
exam, for example, may demonstrate diminished paralysis may signify nerve damage from the
pulses and can potentially predict or point to why index procedure and may need to be factored into
a patient is having difficulty healing a wound (i.e. any other procedure in the revision setting or
dehiscence). Vascular workup and potential inter- require the nerve damage to be evaluated for
vention with a vascular surgeon may be indicated potential repair before any further procedures are
to help overcome the barriers of arterial and performed or considered.
venous disease in the healing process.
Furthermore, in areas where there is any concern
for vascular compromise, even in the setting of Imaging
adequate peripheral pulses, noninvasive vascular
studies such as ankle brachial index/toe brachial Imaging plays an important part in evaluating
index with pulse volume recordings as well as and managing the limb salvage patient from a
diagnostic angiography may be indicated to musculoskeletal perspective. Radiographs should
assess blood flow to specific angiosomes [8]. be a routine part of the postoperative visit to eval-
The orthopedic exam may help to uncover uate the patient after any procedure involving the
signs of complications from the primary proce- skeletal anatomy. Radiographs help assess the
dure. Mobility and motion or swelling and persis- integrity of any implants used, help to evaluate
tent pain at joints where arthrodesis was the patients healing, and can identify any compli-
previously attempted may point towards non- cations such as periprosthetic fracture, hardware
union and warrant X-ray or other advanced imag- loosening, or signs of malunion or nonunion.
ing such as CT or MRI. Muscle tone and strength Furthermore, radiographic evaluation and subse-
may help predict how the patient may do in any quent identification will determine the need for
subsequent procedure, particularly if a tendon more advanced imaging (i.e. MRI, CT scan, or
transfer is being considered. Flexibility vs rigid- ultrasound).
ity of a deformity also helps in the surgical MRI can aid in the evaluation of the soft tis-
workup and helps to make decisions in regard to sues and assess any nerve, tendon, chondral, vas-
further procedure selection. cular damage, or injury from previous procedures
The dermatologic examination may demon- as well as in the assessment of avascular necrosis
strate scar tissue and adhesions of the soft tissue and help to better formulate a surgical plan going
envelope to the muscle and tendons below and forward based on the findings present. CT scan-
may be reason to encourage consultation with ning can aid in the assessment of skeletal defor-
plastic surgery in anticipation of issues related to mity and also for the evaluation of any malunion
or nonunion if there is any concern for these com- ity and specificity for IL-6 were found to be 0.97
plications after the index procedure. and 0.9, 0.88 and 0.74 for CRP, and 0.75 and 0.70
Ultrasound is also another imaging modality for ESR, respectively. Furthermore, the absence
that can aid in the assessment of nerve, tendon, of an elevated ESR and CRP is a good predictor
vascular injuries as well as in the evaluation of of an absence of prosthetic joint infection [11].
scar tissue and any fluid collection. While Procalcitonin level monitoring has also gained
ultrasound can be done quickly and is usually favor over the last decade because it is thought to
more cost-effective than in comparison to imag- have several advantages over ESR and CRP,
ing modalities such as MRI, its interpretation mainly that it typically is unelevated in noninfec-
requires a high degree of skill, is user dependent, tious cases and also tends to be detectable and
and relies on a well-trained radiologist for their peaks sooner than those other inflammatory
interpretation as most surgeons are less likely to markers [12].
routinely evaluate their own ultrasound images in In cases of nonunion, obtaining a vitamin D
comparison to MRI or CT and this lack of com- level is an appropriate first step for evaluation of
fort may explain why it is less often used in prac- the etiology of the nonunion. While the construct
tice [9]. selected in the index procedure may have played
Other advanced imaging modalities that may a role, metabolic etiologies should be ruled out
help distinguish between complications such as before surgical revision is attempted. Indeed it is
infection, nonunion, Charcot neuroarthropathy, thought that as many as 25–50% of patients can
or other more subtle problems of the skeletal be vitamin D deficient. Large pulse dosing should
anatomy that may be causing problems for the be considered to help achieve the appropriate lev-
patient include labeled white blood cell bone els before any further surgery when appropriate
scanning or single-photon emission computed [13]. At our institution we typically will “load”
tomography (SPECT). Both of these imaging severely deficient (<10 ng/mL) patients with
modalities may be valuable tools to help the sur- 50,000 IU weekly for 12 weeks with an end goal
geon make the appropriate diagnosis but are lim- of 300,000 IU before initiating a maintenance
ited in their availability at all institutions and dose of 2000 IU daily. When to initiate surgical
there is a general lack of widespread use in most intervention once treatment has been initiated for
clinical practices [10]. the severely vitamin D deficient patient is depen-
dent on the surgeon and the amount of time the
clinical scenario allows for optimization before
Laboratory Studies further intervention is absolutely necessary to
address the nonunion. Generally, if the clinical
Laboratory values have immense value in helping scenario is not considered urgent, this author will
to determine what the underlying cause of a consider surgical intervention at 4–6 weeks after
potential complication is, help to determine the initiation of treatment and continue treatment
best course of action in the near and long term, throughout the perioperative period before transi-
and also to help track progress. tioning to a maintenance dose.
In infection, erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) when ele-
vated can be signs of underlying infection and Complications
can be trended to monitor for progress and reso-
lution of the inflammatory process associated Lower Extremity Nonunion
with infection after antibiotics have been initi-
ated. In a meta-analysis of more than 30 studies, Tibial nonunions as well as ankle/hindfoot
it was found that the diagnostic accuracy for arthrodesis nonunions are very common.
prosthetic joint infections was best for CRP and Traumatic injuries resulting in nonunion can
ESR only second to IL-6 levels. Pooled sensitiv- often be secondary to the initial fracture with dis-
ruption of the blood supply to the bone and soft rotation of the femurs with the patient prone as
tissue, especially when the initial fracture is well as comparing the thigh foot axis on each
open. As it pertains to the ankle joint in the lower side. Since the patient will be receiving an opera-
extremity, special considerations with ankle tive procedure to address the nonunion, the
arthrodesis nonunions are whether the fibula was malalignment should be corrected at the same
resected at the time of initial arthrodesis resulting setting. Any varus malalignment or malrotation,
in less bone stock, an anterior approach that for example, can also contribute to nonunion by
resulted in disruption of the anterior tibial artery causing gait disturbances and uneven force distri-
and the lack of good anterior soft tissue bution across the arthrodesis or fracture which
coverage. may further lend to complications such as further
As previously discussed, there are many host nonunion if not addressed at the time or
factors that can contribute to a nonunion includ- revision.
ing smoking, diabetes, patient noncompliance, Plain radiographs and CT scan are the most
vitamin D deficiency, malnutrition, steroid use, useful imaging modalities to document a failed
peripheral vascular disease, and peripheral neu- arthrodesis/nonunion. Underlying osteoporosis
ropathy. Efforts made for the correction of these and osteopenia can be assessed with these tools
host factors preoperatively can optimize a suc- as well [17]. MRIs and bone scans are not useful
cessful outcome. Other host factors that compli- in these settings since there is typically hardware
cate healing include renal and liver failure, present and would therefore potentially obscure
anticoagulant use, and deep vein thrombosis with appropriate evaluation for nonunion. Osteoporosis
venous stasis of the leg. These patients with dif- and osteopenia can be addressed with the non-
ficult underlying medical comorbidities must be union treatment by starting bisphosphonate ther-
counseled about prolonged nonweightbearing, apy after the initial remodeling phase and
chronic CROW boot protection, elevation and choosing a surgical treatment plan that does not
compression stockings for at least a year postop- delay weight bearing unnecessarily [18].
eratively [14, 15]. A full set of preoperative labs is necessary.
Important points from the history include Nutrition markers are assessed with total pro-
whether the injury was open or closed and the tein, albumin, and prealbumin levels. CRP and
degree of contamination. Previous culture results ESR are used to determine if the nonunion is
are helpful especially if the patient presents infected. Metabolic contributions to the cause of
already on oral antibiotics. A thorough under- the nonunion are assessed with vitamin D levels
standing of the previous procedures performed is and PTH. Any abnormal nutrition and metabolic
critical as it may not always be obvious that a flap parameters must be addressed as soon as possi-
procedure has been performed. Furthermore, all ble preoperatively via the surgeon or with the
previous autologous bone graft donor site loca- assistance of an endocrine specialist [19]. In the
tions need to be documented so that further har- case of an infected nonunion, additional immu-
vesting from a prior site can be avoided. A notable nology labs are sent to further assess the host
exception to this is in the cases of a previously immune system. Often there are abnormal values
harvested intramedullary canal via the RIA that contribute to the hosts inability to fight the
(Reamer, Irrigator, Aspirator autologous bone infection. These values such as low IGG can be
harvesting system). It has documented that the corrected preoperatively with IGG infusions to
intramedullary canal can be sequentially har- improve the patient’s ability to clear the
vested as early as 3–6 months from the previous infection.
harvest without issue [16]. Bone biopsy as a separate procedure prior to
Sensation, joint range of motion, and palpable definitive surgical intervention in nonunion sur-
pulses as well as any preexisting scars must be gery is typically avoidable. In the majority of
documented. Any rotational malalignment is nonunion cases, the question of infection is
assessed by comparing the internal and external resolved preoperatively. We typically do bone
biopsy and cultures of every nonunion at the time Atrophic Nonunion

of the definitive operation via fresh frozen sec-
tion and stat gram staining. When planning an Atrophic nonunions are usually a result of inad-
operative procedure for nonunion, infection is equate blood supply. The bone ends are avascu-
always a possibility and it is imperative to always lar and treatment will almost always involve
enter the operating room with multiple plans resection of the distal ends of the nonunion down
based on the potential scenarios encountered. to bleeding and healthy appearing bone. As pre-
The amount of bone that is required to be resected viously mentioned, the amount of bone resected
down to healthy, bleeding bone often dictates the will dictate one of the several treatment options
stabilization and fixation construct selection that include acute shortening, tib/fib synostosis
needed and the best method to determine live when working in the leg, or bone transport to
bone ends at the site of nonunion is still intraop- deliver new, healthy bone to the site where the
erative evaluation via the naked eye. bone defect is. The distal tibia and ankle are not
ideal places for acute shortening because of the
difficulty with shoe wear as ankle circumference
Hypertrophic Nonunion increases with shortening. It is important to note
that acute shortening is not recommended for
Hypertrophic nonunions are typically secondary defects larger than 4 cm because of the potential
to a problem with stability of the initial construct for vascular compromise associated with kink-
selected for fixation. The bone ends are viable but ing of the vessels. In these cases, gradual short-
do not have enough stability to heal and often ening using an external fixator with or without
appear wider than the normal diameter of the internal fixation is necessary and defects greater
bone involved. Treatment for this always includes than 4 cm mandate bone transport [20].
increasing the stability of the bone with addi- Furthermore, our preference is to maintain
tional instrumentation. This type of nonunion is length if there is more than a 2 cm defect via the
also amenable to distraction with an external fix- use of bone graft, bone transport, or tib/fib
ator because the external fixator provides the synostosis.
increased stability and the hypertrophic nonunion
can be distracted/compressed at a rate of 0.5 mm/ xample of Atrophic Nonunion
E
day to get the bone to consolidate. No additional Here is a case where we demonstrate how Tib-fib
bone graft is typically needed for these cases. synostosis is ideal for a distal tibial nonunion
where there is a poor soft tissue envelope anteri-
xample of Hypertrophic Nonunion
E orly. From a lateral approach, the interval poste-
Here is a case of a patient with a hypertrophic rior to the fibula and the posterior tibia can be
nonunion after a distal tibia/fibula fracture that exposed where there is excellent soft tissue cov-
was treated conservatively (Fig. 35.1a–d). The erage and blood flow available from the poste-
patient was initially distracted and the deformity rior compartment musculature. The surface area
corrected via hexapod external fixator. We elected of the tibia and fibula is large and can be pre-
to use this construct as it allows for gradual cor- pared with a burr. Furthermore, the interosseous
rection of the deformity and minimal insult to membrane and the posterior soft tissue envelope
both the osseous anatomy and soft tissues. Once are used to maintain bone graft that is harvested
the deformity was corrected and the signs of from the patient or sourced as allograft and
radiographic consolidation were noted, the fix- placed into the wound between the tibia and fib-
ator was removed. Final clinical pictures of the ula. The postoperative radiographs show the
patient showing the leg in anatomic position with patient at 6 months from revision surgery
the patient able to bear weight to the operative (Fig. 35.2a–c).
extremity.
Fig. 35.1 (a) Preoperative and immediate postoperative lateral radiographs of the right leg. (c) AP and lateral
clinical photos of the right lower extremity status post dis- radiographs demonstrating final corrected position of the
tal tibial and fibular hypertrophic nonunion with malposi- tibia and fibula with resolution of the nonunion. (d) Final
tion surgical reconstruction via hexapod external fixator clinical photos demonstrating the right lower extremity in
for gradual deformity correction. (b) Preoperative AP and anatomical position with the patient weight bearing

a b c
Fig. 35.2 (a) Atrophic nonunion of a tibial shaft fracture. (c) Patient at 6 months demonstrating continued consoli-
(b) Patient 6 weeks status post tibial nonunion revision dation and synostosis formation in accord with healing
with preparation of the tibial and fibula and bone grafting and resolution of the nonunion
of with signs of consolidation and synostosis formation.
Infected Nonunion biotic coated rods or external fixation [21]. These

cases are also among the most common cases to
This category of nonunion is the most complex as require additional blood supply to the nonunited
it usually involves a combination of a poor soft area in the form of either local or free tissue/mus-
tissue envelope and infected bone. Much like cle flaps, as the soft tissue envelope and local
cases of atrophic nonunion, the infected bone blood flow are typically compromised. Plastic
must be resected down to a healthy appearing, surgery consultation and a multidisciplinary
bleeding bone. The surgeon should anticipate and approach should be utilized for a chance at the
plan for the worst case scenario in terms of bone successful outcomes. The distal one-third of the
resection but again, the actual amount of bone tibia is amenable to a soleus muscle flap or a
resection is determined intraoperatively using reverse sural flap. Often, the infected nonunion
visual inspection of the bone for bleeding when can be prepared, stabilized, and flapped in one
debrided with the high speed burr. Several options session depending on the quality of the surround-
for stability after the bone resection include anti- ing soft tissues (see Figs. 35.3 and 35.4). If the
Fig. 35.3 (a) Clinical photo of an infected nonunion in a solidation at the nonunion segment in accord with healing
patient with a midshaft tibial fracture with an open wound at 5 months from the date of revision surgery. (d) Immediate
and exposed hardware. (b) Preoperative AP and lateral postoperative clinical photo status post local tissue transfer
radiograph of the tibia and fibula with nonunion noted at the via gastrocnemius flap and split thickness skin grafting and
midshaft of the tibia. (c) Post-revision AP and lateral radio- at 5 months from the date of revision surgery demonstrating
graphs of the tibial and fibula demonstrating signs of con- no open wound healed flap and skin graft
bone is too small to accommodate an antibiotic xample of Infected Ankle Arthrodesis

E
coated intramedullary rod, calcium sulfate paste Nonunion
containing antibiotics can be injected into the Nonunited ankle arthrodesis and distal tibial non-
canal for local antibiotic delivery [22]. unions can be challenging. The key to success is
optimizing the patient prior to surgery and devel-
xample of Injected Nonunion
E oping a surgical plan that is best suited for post-
Here is a patient who presented after initial ORIF op patient compliance. The surgeon should have
of a tibial shaft fracture via intramedullary nailing multiple plans in case the bone resection is larger
and plating of the anterior tibial fracture at an out- than initially estimated. All options should be
side facility. The initial injury was reported as discussed with the patient so that everything can
open. The patient subsequently went on to dehis- be done in one surgical setting in terms of render-
cence and necrosis of the anterior tibial wound ing the bone clean, bleeding, healthy appearing,
with exposed hardware and nonunion of the tibial and the anatomy stabilized. Surgeons need to be
fracture. The patient’s biopsy and cultures were comfortable with bone transport and bone length-
found to be positive and a decision was made for ening technologies as tools to create and lengthen
revision surgery. The patient’s existing hardware bone. Furthermore, rotational flap skills are help-
was explanted, bone was debrided with high speed ful when there are compromised soft tissues or
burr, and a new antibiotic cement coated nail was otherwise require the assistance of a trained plas-
placed with simultaneous gastrocnemius local flap tic surgeon for a multidisciplinary approach.
and split thickness skin grafting. The patient went These challenging cases require surgeon patience
on to heal without incident (Fig. 35.3a–d). and close patient follow-up to ensure success.
Fig. 35.4 (a) Radiographs of a patient with infected medullary hindfoot nailing, and proximal tibial osteotomy
ankle arthrodesis nonunion in accord with post-traumatic with bone transport of the tibia. (d) Radiographs at
arthritis of the ankle. X-rays are shown after hardware 9 months from frame removal and hindfoot arthrodesis via
removal and radiographic nonunion is visible. (b) Clinical posterior plating demonstrating bony consolidation in
photographs of the open wound and local free tissue trans- accord with fusion. (e) Clinical photo demonstrating ade-
fer to achieve closure as part of the revision procedure. (c) quate clinical positioning and closed medial ankle wound
Radiographs after resection of the infected distal tibial after surgical revision
segment with antibiotic cement bead placement, intra-
c d

Here we present a case involving infected Malunion

ankle arthrodesis nonunion with an open ankle
wound that presented for a second opinion. What In cases involving malunion, host biology is not
makes these cases particularly challenging is in question as can be the case with nonunion as
that since the foot is a long lever arm and the the patient has demonstrated their ability to heal,
entire body weight force is concentrated on dor- albeit in a poor and nonfunctional position.
siflexing the ankle with ambulation, the forces at Nevertheless, a great deal of consideration needs
the ankle extending from the leg and upper body to be given to these deformities prior to any surgi-
down to the foot must be taken into consider- cal intervention or revision procedure. This is
ation. Furthermore, post-traumatic arthritis particularly the case in a high risk patient popula-
involving talar AVN can prove difficult for fusion tion. A diabetic with peripheral vascular disease
secondary to the tenuous blood supply to the may not have a soft tissue envelope that is ame-
talus. For these reasons, we prefer intramedul- nable to multiple revision procedures and a
lary fixation and the use of a long calcaneocu- patient who previously healed uneventfully may
boid screw to neutralize the foot. This patient not be guaranteed to heal without complication in
underwent a two stage approach where in stage the revision setting. Hence, care should be taken
one, the infected area of bone was resected to to avoid the need for excess surgery and meticu-
bleeding bone, antibiotic cement beads placed lous planning should be done to allow for correc-
and local tissue rearrangement for coverage and tion of any deformity in one stage when possible
closure of the wound. Additionally, we utilized and with as little insult to the soft tissue envelope
placement of an antibiotic cement coated nail as possible when dealing with the skeletal
and bone transport was done via proximal tibial anatomy.
osteotomy. With exceptionally complex cases, a Revision cases can be particularly challeng-
“belt and suspenders” approach is helpful where ing for the surgeon and a familiarity and com-
a hindfoot fusion intramedullary rod is supple- fort with a wide array of techniques and fixation
mented with a posterior plate through a posterior constructs (i.e. internal vs external fixation)
trans-Achilles approach as shown below which need to be had in order to achieve the best pos-
was part of the second stage of the procedure sible outcomes in each particular malunion
where the external fixator was also removed. The case. The following case will demonstrate an
approach for the posterior hindfoot plate is usu- example of a malunion that required revision
ally through a virgin soft tissue envelope and surgery.
there is a large bony surface area along the pos-
terior calcaneus and posterior tibia for bone
grafting. xample of Tibial Malunion
E
We prefer autologous bone grafting for ankle in the Setting of Ankle Arthritis
arthrodesis nonunion cases and typically there
are several options for autograft. In cases where As it pertains to the lower extremity and the ankle
the operative procedure is performed prone, the joint in particular, it is essential to assess the
posterior iliac crest or the RIA reamer retrograde overall limb alignment when considering an
from the femur can be a good option. In cases of ankle fusion. In certain cases, there is no subtalar
hindfoot fusion via an intramedullary rod used joint or supple ankle to compensate for any
for ankle and subtalar arthrodesis, the RIA reamer amount of deformity proximally. Often when
can be used to harvest bone graft from the proxi- there are alignment problems secondary to a
mal tibial canal and create a channel for the hind- proximal deformity, the corrections are both done
foot fusion rod simultaneously as was done here at the same surgical setting to prevent persistent
(Fig. 35.4a–e). deformity and subsequent pain.
a b
Fig. 35.5 (a) Long leg radiographs of the left lower radiographs status post clamshell osteotomy of the tibia
extremity demonstrating varus and recurvatum deformity with hindfoot ankle and subtalar joint arthrodesis via
with malunion of the tibia in addition to equinus defor- hindfoot intramedullary nailing
mity of the ankle joint. (b) Postoperative AP and lateral
Here is a case where an ankle arthrodesis is Advanced Surgical Techniques

necessary but there is a total knee arthroplasty and Troubleshooting in the Revision
above and a distal tibial oblique plane deformity Setting
with varus and recurvatum secondary to a pre-
cious shaft fracture of the tibia with malunion. There are a variety of challenging components to
This is also complicated by the ankle equinus. An tackle when faced with a complication in limb
isolated ankle arthrodesis with screws, without salvage. Furthermore, different challenges can
addressing the deformity, would leave the varus present during various phases. The goal of this
and recurvatum with subsequent stress being section is to provide clinical examples that will
placed on the total knee arthroplasty or promot- provide guidance and strategies, along with a
ing uneven weight distribution across the fusion systematic thought process when encountering
and foot. In this case, the ankle equinus and distal surgical challenges during the care of a limb sal-
tibial recurvatum with varus were addressed at a vage patient in the lower extremity. Indeed, for
single surgical setting with a hindfoot fusion rod the highest chance at achieving a successful out-
transfixing the ankle arthrodesis and clamshell come, particularly in the revision setting and in a
osteotomy of the tibia (Fig. 35.5a, b). high risk patient population, it is important for
the surgeon to have familiarity and comfort with as in the proximal leg, among other factors [23].
a number of fixation constructs (i.e. internal ver- Furthermore, pin site infections can be divided
sus external fixation) and surgical techniques. into three grades with grade 1 being inflamma-
Paley subclassified challenges that are encoun- tion, grade 2 is soft tissue infection, and grade 3
tered during limb lengthening in an easier method involving an infection down to bone [24]. To pre-
by describing them as problems, obstacles, and vent pin site irritation and infection from occur-
complications. This classification differentiates ring, the surgeon can utilize a number of local
challenges during care into the following method: methods to prevent these issues such as placing
foam sponges or rubber stoppers on the wire or
–– Problems are difficulties that do not require wrapping betadine soaked gauze around each
operative treatment for resolution. wire to prevent pistoning of the soft tissue due to
–– Obstacles require operative intervention, but swelling therefore, decreasing the likelihood of
do not impact final outcome. pin tract infection. If wires have lost tension, re-
–– Complications are those issues that do not tensioning in the clinic with the tensiometer or
resolve by the end of treatment. manual tensioning via the “Russian” method can
resolve the issue. If a pin tract infection does
We have utilized this simple classification to develop, however, it is important to start a short
guide common to complex limb salvage compli- course of broad-spectrum antibiotics, typically
cations. This decreases the stress associated with an oral first-generation cephalosporin in our
the different challenges and allows one to man- practice, for one week. If the pin infection does
age any complication appropriately in a system- not respond to oral antibiotic therapy, intrave-
atic fashion. Furthermore, this can be applied to a nous antibiotics may be indicated and cultures
number of possible scenarios that can occur when from around the pin site or any drainage may
treating the patient undergoing limb salvage sur- help direct the best antibiotic regimen.
gery. The following sections will demonstrate the Furthermore, removal of the wire in the clinic
application of this classification with case exam- may be necessary in addition to the antibiotic
ples and how it can be applied to achieve success- therapy. For this reason, we will often advocate
ful outcomes. placing one or two additional wires to prevent
loss of stability of the fixation segment in the
event of an infected wire that necessitates
Problems removal.
External fixation is a common modality of stabi-

lization when performing limb salvage proce- Obstacles
dures. One of the more common problems is pin
site infections. In this scenario, treatment can As previously stated, obstacles are challenges
often be rendered that requires no operative inter- that present during limb salvage that require a
vention, therefore, classified as a problem. return to the operating room, however, they do
External fixation pin site infections are often not impact the final outcome. Hardware related
a result of bacterial contamination presenting infections can pose a significant challenge for
from the external environment along the path of management and often result in operative inter-
the wire. A wire infection will present with local- vention for either removal/exchange. If a con-
ized redness, pain, and even purulent drainage. comitant deep infection is present with
This may have started as local irritation or osteomyelitis it can further complicate the man-
inflammation when wires are inadequately ten- agement and salvage of such cases. The follow-
sioned, lose tension, or secondary to excessive ing case demonstrates this challenge and the
edema in the extremity as well as secondary to stepwise approach taken to manage the
pistoning of the soft tissue against the wire such infection.
xample of a Case Involving

E protein and a normal white blood count. Given
a Midfoot Obstacle the radiographic findings, constitutional symp-
toms, and clinical appearance of the foot a deci-
A 60-year-old male with chronic ulceration and sion to go to the operating room was made. The
Charcot neuroarthropathy of the midfoot pre- medial and lateral column fixation was removed
sented for surgical consultation. The patient had a through percutaneous incisions and any drainage
non-healing ulceration for greater than one year was swabbed for cultures. The long-cannulated
and was treated with offloading and total contact screw tracts were further reamed with cannulated
casting with no improvement. Patients initial pre- ACL reamers one to two millimeters larger than
operative diagnostic workup included standard the size of the screws (6.5 mm–8 mm in diame-
weight bearing radiographs that demonstrated ter) until medullary bleeding was witnessed, fol-
peri-navicular collapse and fragmentation of the lowed by medullary irrigation. The hardware
midfoot joints. No acute bony signs of infection along with the reaming’s was cultured and sent
were noted and a preoperative nuclear medicine for gram stain evaluation and pathologic exami-
Indium-111 scan demonstrated negative uptake nation. The medullary defect was then filled with
for bone infection. Notable in the medical his- poly-methyl methacrylate cement impregnated
tory, the patient has hypertension, anemia of with vancomycin and tobramycin. The cement
chronic disease, and stage one chronic kidney was coated on 1.8 mm Ilizarov wires until the
disease. The patient was taken for an initial cement hardened and the diameter of the coated
wound debridement and bone biopsy given the pins was between 7 and 10 mm. The pins were
long-standing history of ulceration. In these press-fitted into the reamed canals and 1–1.5 cm
cases, it is imperative to be certain that there is no of the coated pin was left exposed to allow for
deep bone infection or contamination. The bone easy retrieval at a later time. Coagulase Negative
biopsy and cultures were both negative for osteo- Staphylococcus species was determined to be the
myelitis; therefore, a decision to proceed with offending pathogen and six weeks of intravenous
formal arthrodesis with internal and external fix- antibiotics was initiated with weekly laboratory
ation was performed. There is much debate in studies to monitor CBC, ESR, and CRP. During
regard to internal versus external versus a com- this time, serial radiographs were obtained to
bined construct approach and each option can monitor signs of infection resolution and it was
offer its own benefits and disadvantages. The noted that the talus had started to demonstrate
patient underwent medial and lateral column signs of avascular necrosis. After six weeks of
arthrodesis with intramedullary foot fixation and intravenous antibiotics and serial radiographs,
application of external fixation [25, 26]. The the patient returned to normal ESR and CRP in
patient had an uneventful postoperative course accord with a resolution of the infection.
and after 12 weeks had his external fixator However, talar avascular necrosis required stabi-
removed. Serial radiographs had demonstrated lization and arthrodesis of the tibio-calcaneal
medial and lateral column arthrodesis, while clin- component to maintain stability of the midfoot
ically the patient had no open wounds and had and hindfoot which was done via application of a
returned to normal shoe gear. At two months new frame to stabilize both the hindfoot as well
from frame removal and five months from initial as also offer compression and stability to the foot
surgery, the patient presented to the emergency and allow for healing. This went on to heal with-
department with a red, hot, swollen foot with out any further complicating factors and the
subjective complaints of a fever and malaise. patient was able to ultimately transition back into
Radiographic signs of bony fragmentation around diabetic shoes at about one year from the final
the hardware and lucency along the fixation were revision surgery. In this case we elected to pro-
noted in both the medial and lateral columns. ceed with internal and external fixation as the
Laboratory findings demonstrated an elevated dual construct allows for a more robust fixation
erythrocyte sedimentation rate and c-reactive construct that allows for the patient to also
weightbear immediately with the aid of a walker. with concomitant distal tibial lengthening to
The downfall of this being that it is possible the address the limb length discrepancy that would
pintracts introduced bacteria to the internal fixa- otherwise result from talar loss. Additionally, the
tion that was present deep within the osseous patient was notified that he would likely have a
anatomy. This case demonstrated multiple obsta- limb length discrepancy greater than 3 cm due to
cles while managing an initial complaint. The the loss of talar height and in the process of
key features of this case demonstrate that hard- obtaining arthrodesis if the tibial lengthening was
ware related deep infection and osteomyelitis not performed and was counseled on gradual dis-
spanning from the metatarsals to the talus does traction osteogenesis to restore limb height to
not have to result in limb loss. The key to manag- within 1 cm of the contralateral limb. The goal of
ing the infection is predicated on having adequate height restoration is to improve and maintain
perfusion, managing the bony and soft tissue near normal gait and minimize complications at
infection, and providing stability through arthrod- proximal joints that could potentially accompany
esis. Other technical aspects of this case have a limb length discrepancy. Furthermore, while no
been borrowed from management of infected literature has been published on this topic to our
nonunions and segmental defects of long bones. knowledge, we hypothesize that the tibial length-
In their study, Thonse et al. demonstrated suc- ening encourages a more robust arthrodesis at our
cessful outcomes with management of infected distal fusion site secondary to the proximal turn-
nonunions and segmental defects treated with over of bone and regenerate formation that occurs
antibiotic coated nails. In this cohort, ninety-five as part of the lengthening process.
percent were able to achieve infection control Intraoperative findings demonstrated signifi-
and eighty-five percent were able to achieve bony cant fragmentation and dissolution of the talus
union. This method has been shown to be effec- and superior aspect of the calcaneus. The healthy
tive when managing medial and lateral column remnants of the talar medullary contents were
fixation that spans from the metatarsals to the morselized and incorporated into the fusion mass
ankle and can successfully be utilized when man- of the distal tibia and calcaneus. We then pro-
aging these complex infections (Fig. 35.6a–g). ceeded with a distal tibial osteotomy which was
made to facilitate distraction osteogenesis of the
tibia and arthrodesis of the hindfoot. A hexapod
xample of a Case Involving an Ankle
E external fixator was designed to include a tibial
Obstacle block with six hexapod struts that would gradu-
ally lengthen the osteotomy and a foot block was
Here is a case of a 55-year-old male with ankle fixated to the distal tibial block with threaded
and subtalar joint neuropathic collapse. The rods that were acutely compressed between the
patient was initially managed at another location tibial and calcaneal segment to allow for com-
and due to increased pain, instability in bracing, pression and promote arthrodesis. A prescription
and an inability to continue working as a heating for gradual correction with distraction of
and ventilation technician he presented to our 0.75 mm/day was given to the patient and the
office for surgical evaluation. His only significant patient was able to complete the distraction of
past medical history included hypertension and 20 mm per the prescription. This distraction
type 2 diabetes with a recent HgA1c of 7.8%. amount is based on the average height of the
Preoperative medical clearance was obtained via talus. Unfortunately, the patient started having
the primary care physician and a decision to pro- difficulty with maintaining the frame and due to
ceed with surgical intervention was made for recurrent pin site irritation and pain, a decision
arthrodesis of the hindfoot and ankle complex was made for removal of the external fixator at
a b c
d e
f g
Fig. 35.6 (a) AP radiograph of the right foot demonstrat- removal demonstrating signs of lucency and fragmenta-
ing Charcot breakdown at the hindfoot tarsal bones. (b) tion around the hardware. (e) Lateral foot radiograph
Lateral lower extremity radiograph immediately follow- demonstrating the patient status post hardware removal
ing midfoot beaming and application of circular external and antibiotic cement beaming with operative debride-
fixator. (c) Lateral radiograph of the foot demonstrating ment. (f) Patient at final follow-up after infection manage-
adequate positioning and intact hardware at 12 weeks ment and subsequent hindfoot arthrodesis with
from frame application and internal beaming fixation of radiographic signs of consolidation and healing through-
the foot. Picture shown is just following frame removal at out the midfoot and hindfoot. (g) Final clinical result
12 weeks. (d) AP radiograph at 8 weeks from frame
10 weeks. Due to a lack of consolidation of strated radiographic signs of union and

regenerate at the distraction gap, an antibiotic consolidation and has maintained an infection
coated medullary nail was placed to provide sta- free limb at greater than one year from the last
bility to the regenerate and the arthrodesis site procedure performed and subsequently returned
[27]. One month after medullary nailing, the to regular shoe gear and work as a heating and
patient presented to the emergency department ventilation technician (Fig. 35.7a–h).
with fever, malaise, and a red, hot, swollen ankle The above cases demonstrate the required
and extremity. Duplex studies were negative for steps for managing complex infections that
deep vein thrombosis. Radiographs demonstrated require revision and can further be summarized
signs of bone infection, hardware lucency and a below:
CT scan revealed an abscess within the anterior
distal tibia. Elevated levels of ESR and CRP all 1. Step 1 involves management of the infection
but confirmed a likely active infection. The both medically and surgically. This typically
patient was taken to the operating room for involves a staged approach that requires
removal of the infected hardware, aggressive removal and aggressive debridement of
medullary debridement, and multiple bone and infected hardware, bone, and soft tissue.
soft tissue cultures. Cultures and sensitivities Leaving any infected tissue allows for prolif-
were sent from the hardware and bone. The med- eration of biofilm and negates the benefits of
ullary canal of the tibia and surrounding calca- systemic antibiotic delivery, therefore,
neus was aggressively debrided with a reamer decreasing the effectiveness of this staged
until bleeding bone was noted. A temporary anti- approach to revision [28].
biotic rod was inserted to provide local delivery 2. Bone and soft tissue cultures obtained during
while the patient was placed on IV antibiotics for the debridement can determine the medical
six weeks of antibiotic management by the infec- treatment with systemic antibiotics. A multi-
tious disease service. Cultures were positive for disciplinary approach with an infectious dis-
coagulase negative staphylococcus. Once the ease specialist will facilitate the identification
patients ESR and CRP started to trend towards of the most effective antibiotic regimen.
normal and subsequent radiographs demon- 3. Once infection markers and radiographic
strated signs of bone remodeling, the patient was parameters improve, a revision can be per-
subsequently taken to the operating room for formed with antibiotic coated stable fixation
revisional arthrodesis via antibiotic coated intra- to achieve union and stability for limb
medullary nail. The patient subsequently demon- salvage.
a b
Fig. 35.7 (a) Lateral ankle radiographs demonstrating strating hardware lucency adjacent to the medullary nail.
ankle and subtalar neuropathic collapse with fragmenta- (e) CT scan of the lower extremity demonstrating non-
tion of the talus and calcaneus. (b) Radiographs demon- union and bone abscess formation to the distal tibia and
strating primary hindfoot arthrodesis with distal hindfoot. (f) Radiograph shown status post removal of
metaphyseal-diaphyseal tibial osteotomy and application infected hardware, intramedullary reaming and placement
of hexapod circular external fixator ready for tibial length- of an antibiotic cement rod. (g) AP and lateral radiographs
ening. (c) AP and lateral radiographs status post removal demonstrating signs of consolidation and healing of the
of external fixator following primary hindfoot arthrodesis hindfoot arthrodesis and lengthening segments with anti-
and distal tibial lengthening demonstrating anatomic biotic coated nail placement. (h) Clinical photo at final
alignment and signs of regenerate formation at the length- follow-up demonstrating anatomic alignment of the foot
ening segment. (d) Radiograph of the extremity demon- and ankle with no open wounds present
d e f
g h

Complications ready for a stable brace [29]. In this case a

wedge of midfoot tarsal bones was removed to
As described earlier, true complications are oper- allow for acute decompression and primary
ative injuries or problems that do not resolve by excision and closure of the plantar ulceration.
the end of treatment. A below knee amputation in The ankle was also fused in the neutral position
limb salvage would be considered a complica- to provide stability and to negate the effects of
tion. The goal of any attempt at limb salvage is to varus and valgus stress from the extrinsic mus-
prevent complications in a high risk patient popu- culature. The patient was placed in an external
lation. Important to note, however, that some fixator after the acute correction. Within 2 weeks
cases can have complications that can be revised of the correction the patient started to demon-
with a dedicated team of surgeons committed to strate progressive ischemic changes to the digits
functional limb salvage. which went on to fully demarcate to gangrene of
the forefoot with a concomitant soft tissue infec-
tion of the excised plantar ulcer. Vascular con-
xample of a Complication Based
E sultation and angiography revealed the patient
on the Paley Classification had distal occlusions at the level of the ankle of
the posterior tibial and anterior tibial arteries
The following case is of a 60-year-old male with with poor collateralization. A joint decision
a chronic non-healing midfoot ulcer secondary with the vascular team and the patient was made
to Charcot neuroarthropathy. Prior to surgical to proceed with removal of the gangrenous fore-
intervention, the patient went through preopera- foot along with peripheral bypass beyond the
tive medical and vascular surgery clearance. He occlusion and proximal to the infected wound.
had previously obtained a right sided below The goal was to increase flow to the proximal
knee amputation secondary to complications transmetatarsal amputation and, therefore,
associated with a diabetic foot infection and was improve the likelihood of healing and prevent a
eager to prevent another amputation to the con- below knee amputation. A successful peripheral
tralateral extremity. At the vascular evaluation bypass was performed after removal of the
he demonstrated triphasic flow to his extremi- external fixator. The final procedure involved a
ties and has no other medical comorbidities transmetatarsal amputation after restoration of
other than type II diabetes with a HgA1C of blood flow to the foot and hindfoot medullary
7.5% in addition to hypertension. The patient rod placement for stabilization of the hindfoot.
had developed a chronic midfoot ulcer due to The patient was followed closely and he went
neuropathic collapse through the tarsal joints on to heal without difficulty (Fig. 35.8a–g).
and a decision was made to correct his defor- This case demonstrates a complication that
mity acutely with an ankle and subtalar arthrod- still led to limb salvage by following sound surgi-
esis and a modified midfoot internal pedal cal principles and a multidisciplinary approach to
amputation to allow for a single stage correction salvage. Furthermore, it demonstrates that even
and closure of the midfoot ulceration. Koller in some of the most complex clinical cases, sal-
described an internal pedal amputation in which vage can be achieved via sound surgical princi-
a majority of the tarsal bones are removed to ples and a multidisciplinary approach to patient
allow for soft tissue closure and make the foot management.
b c
Fig. 35.8 (a) AP and lateral foot radiographs demon- changes initially and after demarcation following the
strating midfoot collapse and rocker bottom deformity in index procedure. (e) Clinical photo demonstrating the
accord with Charcot neuroarthropathy. (b) Preoperative patient status post transmetatarsal amputation of the foot.
clinical photo demonstrating plantar midfoot ulceration. (f) Lateral radiograph demonstrating hindfoot nailing of
(c) Clinical photograph immediately post midfoot recon- the left lower extremity. (g) Clinical photo at final follow-
struction with application of external fixator and primary up demonstrating a healed midfoot amputation in ana-
excision and closure of the plantar wound. (d) Gangrenous tomic alignment
e f

Postoperative Management intervention in a high risk patient population and

in particular the patient undergoing revision sur-
When managing the patient who has recently gery. It should be noted, however, that there is a
undergone revision surgery, the details in regard lack of strong scientific evidence to support a
to the postoperative course are not to be over- definitive postoperative protocol and more work
looked. Indeed, many patients leave the operating needs to be done to make definitive recommenda-
room with radiographic and clinically successful tions. Furthermore, it is important to have long
outcomes that can be significantly altered if not term follow-up with these patients to assess their
managed appropriately. This is especially true in progress and look for signs of new problems or
a high risk patient population such as those with further late manifesting complications such as
diabetes and other similarly immunocompro- new bony collapse or new skin and soft tissue
mised patient populations where we know there breakdown.
is an increase in complications as compared to a
nonimmunocompromised patient population
[30]. Decisions such as when to advance weight Conclusion
bearing, etc. need to be tempered with the known
fact that many of these patients will have delayed While complications and the need for revision
bone healing because of their underlying comor- surgery will undoubtedly arise for any surgeon, a
bidities [31]. For this reason many surgeons, number of factors will have a direct effect on the
including the authors of this chapter, advocate for likelihood of success. Understanding and identi-
delayed return to weight bearing after surgical fying the factors associated with the need for
revision surgery in the first place is an important can help you, the surgeon, help your patients with
first step at the time of index surgery and will these complex clinical cases.
optimize the care that the patient receives via
appropriate workup, consultation with other spe-
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for the treatment of infected nonunions and segmental A, Wee A. Ankle fractures in diabetic patients.
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4):163–74. org/10.1302/2058-5241.5.200025.
22. Ferguson JY, Dudareva M, Riley ND, Stubbs D,
Atkins BL, McNally M. The use of a biodegradable
Establishing and Running
an Amputee Support Group
36
to Empower Your Patients
Firras Garada and Holly Shan
Introduction strongly believe amputee support groups are a

key component in the acceptance of the trauma
In the USA, there are approximately two million associated with losing a limb. Accepting this
people living with limb loss currently, with an trauma will ultimately lead to more favorable
estimated 180,000 new amputees added annu- metal health outcomes.
ally [1]. Of those amputees, approximately 30%
are currently suffering from anxiety, depression,
or a combination of the two disorders [1]. In I mportance of Support After
fact, some of the most common reactions toward Amputation
amputations are feelings of isolation, denial,
and loneliness. These feelings can continue long Injuries resulting in amputation is a major health
after an amputation, even if an amputee’s loved burden on medical services and families of ampu-
ones are offering emotional support [2]. Anxiety tees. Some amputees view their limb loss as body
and depression have been linked to numerous distortion which leads to decreased self-esteem
health problems, including headaches, heart dis- and believe that they are an incomplete human
ease, high blood pressure, stroke, sleep prob- [4]. Limb loss also leads to lifestyle changes that
lems, weight gain/loss, memory impairment, often leave individuals unable to care for them-
and suicide [3]. As behavioral medicine contin- selves which may prompt further psychiatric dis-
ues to evolve, we now understand a combination orders in addition to physical adjustments.
of pharmaceutical and cognitive therapy works Psychiatric comorbidities include depression
best to treat anxiety and depression. in up to 30–70% of amputees, suicidality in 30%,
Understanding this, the authors of this chapter and posttraumatic stress disorder (PTSD) in up to
20% in some studies [5].
Thus, it is imperative that we create a com-
munity where amputees can confide their feel-
F. Garada ings to others experiencing similar struggles.
Georgetown Medstar University Hospital, Support groups can provide resources, connect
Washington, DC, USA amputees, and be a stable source of information
e-mail: [email protected] for amputees.
H. Shan (*)
Georgetown University School of Medicine,
Washington, DC, USA

588 F. Garada and H. Shan
The Amputee Coalition cess [9]. Since 1935, Alcoholics Anonymous has
demonstrated the power and importance of peer
In 1986, the Amputee Coalition was founded support to help with the recovery process. Peer
when “a small amount of amputee support group support can come in the form of a support group,
leaders recognized the need for an organization or a visit from a trained individual. Immediately
dedicated to the needs of people with limb loss, before or after amputation, peer support is essen-
their families and healthcare providers” [6]. They tial. Hearing stories from fellow amputees has
are the leading Amputee Coalition in the USA the potential to reach an individual on a level that
that works to create guidelines and give structure no friend, family, or professional can while jump
to amputee support groups around the country. starting their transition into their new life.
The Amputee Coalition has three key tenets that Support groups are a form of peer support that
they believe should be incorporated into any allow individuals to find “others like me.” Any
amputee support group. These tenets are as fol- time a group of individuals come together around
lows [7]: a shared life experience, there is already a “com-
mon ground” connection noted between them.
1. Limb loss is not uncommon and becoming This understanding and connection allow for the
less uncommon every day. opportunity to reestablish a sense of belonging to
2. No amputee alone. a community. Being able to mirror other ampu-
3. Living well with limb loss. tees allows for another opportunity to come to
terms with the limb loss and helps with the accep-
Understanding and teaching these tenets to tance of losing a limb.
amputees should be a keystone in therapy.
Since 1986 the Amputee Coalition has made
significant strides in supporting amputees. In stablishing Your Own Amputee
E
2010, the Amputee Coalition convened the first Support Group
Limb Loss Task Force Summit with the goal of
improving amputee care and reducing limb loss In the twenty-first century, there are a multitude
in America [8]. In 2012, the Amputee Coalition of ways to go about forming a group of like-
was able to get a letter from the President of the minded individuals for support. Most commonly
United States recognizing April as National Limb are through social media sites, such as Facebook,
Loss Awareness Month. The Amputee Coalition Discord, YouTube, Zoom and Teams. Also,
has also fought to have revisions to state and fed- groups can be created in person—the more com-
eral insurance laws to help cover prosthetic mon places are within libraries or churches, as
devices, having been successful in 20 states. both have been strong bulwarks of community.
Advertising a group in a wound center where
patients seeing the same physicians can gather
The Power of Peer Support can provide a great way for amputees to have
common topics to discuss. The draw of online
Healing from an amputation takes time. However, groups is that they can be far-reaching and need
time alone is not enough [9]. There are amputees not be limited to only a singular geographic loca-
that recover from their amputations physically, tion. Zheng et al. presented strong evidence that
but emotionally are not able to get back to who online support groups are very popular. It was
they were. This is where the power of peer sup- shown that almost 67% of US citizens alone used
port can come in. the popular social media site Facebook, and 1 in
It is well documented that support from peers 7.7 people worldwide have an active Facebook
in the wake of a life-altering event, like an ampu- account. It was also shown that having a group
tation, is an invaluable part of the recovery pro- composed of like-minded individuals in which
36 Establishing and Running an Amputee Support Group to Empower Your Patients 589
Fig. 36.1 Useful

National Suicide Prevention Hotline 1-800-273-8255
resources for group
members
Substance Abuse and Mental Health Services National 1-800-662-4357
Hotline
Nacional de Prevencion del Suicidio 1-888-628-9454
Crisis Text Line Text“Home” to

741741
people can share their innermost thoughts, fears, assist them. Creating an atmosphere where mem-
and concerns about their medical health led to bers are encouraged to share feelings freely and
overall better physical and mental health out- confide in each other about their feelings is essen-
comes [10]. tial for the group’s success (Fig. 36.1).
After deciding whether you want to create a
virtual or physical support group, one should sur-
vey their members to determine what interests References
they have. Some popular interests that are dis-
cussed in meetings include prosthetic issues, 1. “15 limb loss statistics that may surprise you.” Access
Prosthetics, 1 Mar 2019. https://accessprosthetics.
medical issues, daily living issues, sports and rec- com/15-limb-loss-statistics-may-surprise/
reational issues, emotional issues, and legal 2. A.B.L.E.: Benefits of Joining an Amputee Support
issues [11]. It is also recommended to make sure Group. https://www.hortonsoandp.com/a-b-l-e-
to set aside time to discuss more positive and benefits-of-joining-an-amputee-support-group/
3. Mofatteh M. Risk factors associated with stress, anxi-
“fun” topics like humorous experiences of the ety, and depression among university undergradu-
attendees, pets, jobs, hobbies, and vacations. ate students. AIMS Public Health. 2020;8(1):36–65.
As a support group leader there are important . Published 2020 Dec 25. https://doi.org/10.3934/
components to therapy that you should be able to publichealth.2021004.
4. Mall CP, Trivedi JK, Mishra US, et al. Psychiatric
provide for your group. These include [9]: sequelae of amputation. I: Immediate effects. Indian
J Psychiatry. 1997;39:313–7.
1. Providing a safe environment for your group. 5. Sahu A, Gupta R, Sagar S, Kumar M, Sagar R. A
2. Assisting group members with goals and study of psychiatric comorbidity after traumatic
limb amputation: a neglected entity. Ind Psychiatry
objectives. J. 2017;26(2):228–32. https://doi.org/10.4103/ipj.
3. Providing educational information and ipj_80_16.
referrals. 6. Nathan EP, Winkler SL. Amputees’ attitudes toward
4. Avoiding giving advice on how to solve prob- participation in amputee support groups and the
role of virtual Technology in Supporting Amputees:
lems and instead facilitate the discussion and survey study. JMIR Rehabil Assist Technol.
resolution of problems. 2019;6(2):14887. . Published 2019 Aug 29. https://
doi.org/10.2196/14887.
As a leader, you should recognize when your 7. “Mission & Goals.” Amputee Coalition, 10 Jan
2019, https://www.amputee-coalition.org/about-us/
members’ emotional states appear different than mission-goals/
normal. Dealing with feelings of limb loss can 8. “Mission & Goals.” Amputee Coalition, 10 Jan. 2019,
affect everyone differently. A leader’s job is not to https://www.amputee-coalition.org/about-us/impact/
diagnose psychiatric disorders, but to recognize 9. Support Group Manual—Amputee Coalition of
America. https://www.amputee-coalition.org/
signs of anxiety, depression, and suicidal ideation wp-c ontent/uploads/2015/01/lsp_support-g roup-
to ensure group members get proper referrals to manual_090115-065319.pdf
590 F. Garada and H. Shan
10. Zhang Y, He D, Sang Y. Facebook as a platform for 11. “U-CAN amputee support group: physical
health information and communication: a case study medicine and rehabilitation: Michigan medi-
of a diabetes group. J Med Syst. 2013;37(3):9942. cine.” Physical Medicine and Rehabilitation,
https://doi.org/10.1007/s10916-013-9942-7. Epub 12 Jan 2022, https://medicine.umich.edu/dept/
2013 Apr 16 pmr/patient-c are/therapeutic-o ther-s ervices/
orthotics-prosthetics/u-can-amputee-support-group
Analyzing the Population
Dynamics of Limb Salvage
37
Kevin G. Kim, Paige K. Dekker, and Kenneth L. Fan
Introduction Based on emergency department discharge

data from the Agency for Healthcare Research
An estimated 1–2% of the USA population will and Quality (AHRQ), over 54 million cases pre-
suffer from a chronic wound within their lifetime senting to emergency departments between 2006
[1]. This may include pressure ulcers, diabetic and 2010 involved a diagnosis of diabetes, repre-
ulcers, venous stasis ulcers, and arterial insuffi- senting 8.7% of all emergency department cases
ciency ulcers [1]. Considering that successful [7]. 1.2 million cases were due to complicated
wound healing is negatively correlated with age, DFUs, with 81.2% of these cases requiring sub-
this number is expected to increase as the sequent admission for inpatient care [7]. This
American population continues to age [1, 2]. represents a stark increase compared to the period
In 2017, nearly 25 million people in the USA between 1997 and 2007, in which 20.2 million
were diagnosed with diabetes, representing 9.7% cases involved diabetes, or just 1.7% of total
of the population [3]. In 2020, this number has emergency department cases [8]. This increase is
increased to 34.2 million people, or just over 1 in likely related to the growing prevalence of diabe-
10 Americans [4]. Diabetic foot ulcers are esti- tes in the USA: by 2050, the number of people in
mated to affect 15–25% of diabetic patients, with the USA with diabetes is expected to exceed 48.3
50% of these cases requiring hospitalization for million [7, 9].
serious infections [5, 6]. On risk analysis, an Conservative estimates reveal that annual
infected DFU increases risk of hospitalization by Medicare spending on wounds exceeds $28 bil-
55.7 times and amputation by 154.5 times, com- lion and that management of diabetic foot ulcers
pared to non-infected DFUs [5]. (DFU) accounts for over 20% of this spending
[10]. DFUs not only have significant financial
implications, but also carry serious morbidity and
mortality. Patients with DFUs have decreased
K. G. Kim · P. K. Dekker quality of life, increased psychosocial burden,
Department of Plastic Surgery, MedStar Georgetown and require an increased number of healthcare
University Hospital, Washington, DC, USA
e-mail: [email protected]; interactions [11]. Following amputation, mortal-
[email protected] ity is estimated at over 33%, 53%, 64%, and 80%
K. L. Fan (*) at 1, 3, 5, and 10 years, respectively [12].
Department of Plastic and Reconstructive Surgery, While some surveys seem to suggest that rates
MedStar Georgetown University Hospital, of diabetes-related complications are trending
Washington, DC, USA downwards, these findings must be considered in

592 K. G. Kim et al.
the context of broader population trends. One disparities may lead to delay in care, loss to fol-
survey with data collected from 1990 to 2010 low-
up, and ultimately increased rates of
found that rates for diabetes-related complica- amputation.
tions, such as lower extremity amputation, end-
stage renal disease, myocardial infection, stroke,
and death, were on the decline. Importantly, the Geographical Location
same period saw two- and three-fold increases in
the incidence and prevalence of diabetes, respec- A large study found that the majority of compli-
tively [13–15]. Lower complication rates applied cated diabetic foot cases presenting to emergency
to populations with higher prevalence of diabetes departments occurred in the Southern region
can lead to an overall decreased complication (36.3%) of the USA, compared to the Northeast
burden, and this has been the case with several (22.9%), Midwest (22.1%), and West (18.6%).
diabetes-related complications. Annual rates of Using the Northeast as a point of reference, the
lower extremity amputations in diabetics, for relative risk (RR) of major amputation was sig-
example, decreased by 50% between 1990 and nificantly higher in the South (RR = 1.210) and
2010; however, the same period witnessed an the West (RR = 1.384) (Fig. 37.1) [7, 18].
increase of more than 20,000 diabetic persons Data suggests that patients treated in rural
requiring amputation per year [13]. areas may be at increased risk of negative out-
Data from the National Inpatient Sample comes compared to their urban counterparts.
(NIS) estimates that non-traumatic lower extrem- Residing in a rural area is associated with a sig-
ity amputation rates in diabetic patients declined nificantly increased risk of major amputation
by 43% between 2000 and 2009 but further data (RR = 1.513), minor amputation (RR = 1.149),
analysis demonstrated that the amputation rate and death during hospital admission (RR = 1.414)
changed course between 2009 and 2015. During [7]. Diabetic black patients who are treated in
this time, the non-traumatic lower extremity rural areas may have amputation rates 9 times
amputation rate increased by 50% to 4.62 per higher than those treated in urban areas [19]. This
1000 adults, with rates most pronounced in young mirrors our institution’s findings, where access to
and middle-aged adults [16]. This was largely urban teaching hospitals was predictive of access
driven by a significant increase in minor amputa- to advance limb salvage modalities and decreased
tions, which increased by 62% in this time period, loss to follow-up [20, 21].
but it is of note that major amputations also
increased in this period [16]. We should expect
amputation rates to continue to rise in this popu- Access to Care
lation: in the USA, an estimated 1.6 million peo-
ple underwent amputation in 2005 and this Differences in access to adequate care have a
number is projected to more than double to 3.6 significant effect on health outcomes in the dia-
million by 2050 [17]. betic foot population. In a study encompassing
over 155,000 admissions utilizing National
Inpatient Survey (NIS) data, it was determined
isparities Faced by the Diabetic
D that access to urban teaching hospitals was the
Foot Population strongest protective factor against amputation,
decreasing risk by 9% (p < 0.01) [21].
The development of diabetic foot complications Furthermore, patients were significantly more
is complex and multi-factorial, often with devas- likely to undergo limb salvage, whether with or
tating consequences despite timely recognition without free flap reconstruction, when treated in
and treatment. Unfortunately, the prevalence and an urban teaching hospital [21]. Physical prox-
distribution of DFUs and its complications are imity to any limb salvage center is important for
inequitable among its patient population. These longitudinal care; increased driving distance sig-
37 Analyzing the Population Dynamics of Limb Salvage 593
Fig. 37.1 Geographical portrayal of leg amputations per and race. (Reproduced with permission from Goodney
1000 Medicare beneficiaries with diabetes and peripheral et al. [18])
arterial disease (2007–2011). Rates adjusted for age, sex,
nificantly increases odds of loss to follow-up in pandemic, in which access to care via telemedi-
the limb salvage population (distance >20 miles; cine was dramatically increased in a relatively
Odds Ratio = 2.95, p = 0.045), demonstrating the minute amount of time. In an institutional study,
need for decentralized specialty care models we determined that the increase in telemedicine,
[20]. Such models were proposed by Ibrahim as a result of the COVID-19 pandemic, had a
et al. whereby patients requiring expertise within dramatic effect on the type of patients lost to
a given specialty can obtain expert care at follow-up at our wound center. Before the pan-
smaller, regional facilities as opposed to having demic, Social Vulnerability Index (SVI), which
to travel to flagship, centralized institutions [22]. incorporates factors such as transportation,
Through specialty care decentralization, health- housing, and socioeconomic status, was predic-
care networks can standardize evidence-based tive of loss to follow-up [23, 24]. After telemedi-
specialty care, increase healthcare access to cine was incorporated, SVI was no longer
patients, and streamline the patient care process. predictive of loss to follow-up. Although its
This can be accomplished through establishing infrastructure and care pathways may be under-
treatment pathways, investing in regional facility developed, telemedicine and remote technolo-
infrastructure, and optimizing care coordination gies may offer solutions to disparities in access
via health navigators and telehealth [22]. This is to care, especially for the diabetic foot popula-
perhaps exemplified by the recent COVID-19 tion [23].
Race and Ethnicity Socioeconomic Status
Diabetes disproportionately affects minority pop- In patients with DFUs, the risk of major amputa-
ulations, with a prevalence that is significantly tion significantly increases as income level
higher in Hispanic (22.1%), non-Hispanic black decreases. Compared to the highest income quar-
(20.4%), and Asian adults (19.1%) compared to tile, the relative risk of major amputation for the
non-Hispanic white adults (12.1%) (p < 0.001) third, second, and first quartiles is 1.152, 1.317,
[25]. These minority populations are also signifi- and 1.385, respectively [7]. Regardless of
cantly more likely to have undiagnosed diabetes whether the patient has Medicare, Medicare, pri-
(Hispanic, 7.5%; Asian, 7.5%; non-Hispanic vate insurance, or is uninsured, odds of amputa-
black, 5.2%; non-Hispanic white, 3.9%; tion decreases from lowest quartile of median
p < 0.001) [25]. These disparities continue to be household income to the highest quartile [28].
reflected in the number of diabetes-related emer- Furthermore, beneficiaries of Medicaid and
gency department visits. Both black race patients without insurance are significantly more
(OR = 1.8) and Hispanic ethnicity (OR = 1.6) likely to undergo major amputation [7, 26, 28].
carry significantly higher odds of having a Inpatient mortality appears to be less influenced
diabetes-related visit [8]. by socioeconomic status [7, 28]. The reasons for
These racial disparities persist with respect to these discrepancies in amputation rates across
risk of amputation. Both black (Hazards Ratio income levels remain unclear but may be due to
(HR) = 1.9) and Native American (HR = 1.8) selection bias secondary to insurance type, more
patients have significantly increased risk of major severe disease, or delayed presentation [28].
amputation for DFUs or infection [26]. Black When accounting for geographic factors using
(OR = 2.9) and Native American (OR = 2.4) the area deprivation index (ADI), a study by
patients with peripheral arterial disease (PAD) Zhang et al. determined that geographic socio-
also have significantly increased rates of major economic disadvantage is associated with both
amputation compared to white patients [19]. short-term and long-term outcomes following
Black patients who have undergone amputation minor amputation in Maryland [29]. For exam-
are also less likely to have undergone revascular- ple, patients considered the most deprived (ADI4)
ization, wound debridement, or hospital admis- have 1.40 greater odds of reamputation compared
sion prior to amputation when compared to white to patients who are considered the least deprived
patients who have undergone amputation [19]. (ADI1) [29].
Although race and ethnicity have been utilized Level of education also appears to play a role
as proxies for socioeconomic status, analysis of in lower extremity amputation rates and out-
patients with PAD demonstrates that minority comes. A small, single-center study involving
populations face significantly higher amputation patients with major amputation(s) determined
rates, regardless of socioeconomic stratum [27]. that over 50% of the studied cohort had a high
Healthcare disparities facing minority populations school level education or less [30]. Furthermore,
is certainly multi-factorial, stemming from socio- survival at five years is significantly higher for
economic gaps, comorbidity burden, and physical patients who have completed high school versus
access to healthcare facilities. Nonetheless, this those who have not (OR 0.377) [31]. Lack of
increased risk of major amputation for DFUs in advanced education may result in decreased
minority populations has been maintained on sta- health literacy, which increases susceptibility to
tistical analysis adjusting for sociodemographic chronic disease, poor self-reported outcomes,
and comorbidity confounders [26]. and mortality [31].
Comorbidities Single-center studies began reporting

improved outcomes and cost savings achieved
Patients with diabetes or previous foot ulcer- using a multidisciplinary approach to chronic
ations are susceptible to the development of new wounds [32, 34]. Joret et al. reported a 25% total
or recurrent ulcers [3]. Among patients who pres- cost savings per wound care episode with the
ent to an emergency department with a DFU, cer- implementation of a multidisciplinary team to
tain underlying comorbidities are associated with treat diabetic foot patients [35]. Subsequent stud-
significantly increased risk of major amputation. ies have further supported the improved patient
These include peripheral vascular disease outcomes made possible by utilizing a multidis-
(RR = 3.016), renal disease (RR = 1.281), and ciplinary approach. A systematic review by
sepsis (RR = 3.875) [7]. It is estimated that Musuuza et al., for example, demonstrated that
roughly 50% of patients with DFUs have con- 94% of studies involving a multidisciplinary
comitant peripheral vascular disease [19]. Of the approach to care reported decreased amputation
nearly 100,000 major lower extremity amputa- rates in patients with DFUs [33]. Although team
tions performed in the USA annually, over half composition greatly varied between studies, the
are attributable to diabetes and peripheral arterial authors cited efficient care algorithms and clear
disease [19]. rereferral pathways as a unifying theme underly-
ing success [33].
The multidisciplinary approach to the man-
he Multidisciplinary Limb
T agement of DFUs has revolutionized diabetic
Salvage Team foot care and is now the gold standard. Expertise
spanning across a variety of disciplines has
Achieving success in management of chronic resulted in reduced rates of amputation, improved
wounds and amputation reduction is complex wound healing, decreased lengths of stay, and
and multi-dimensional. The holistic approach less frequent recurrence of lesions [3]. As the lit-
required for successful chronic wound care has erature continues to report the objective benefits
evolved into today’s multidisciplinary limb sal- of a multidisciplinary team, this approach has
vage team. Although there is lack of consensus witnessed increased standardization and wide-
on team composition, wound care teams are often spread use. For example, a practice guideline for
led by a core group of plastic surgeons, vascular the management of diabetic foot co-sponsored by
surgeons, and podiatric/orthopedic surgeons the Society for Vascular Surgery, the American
[32]. Surrounding this group are other essential Podiatric Medical Association, and the Society
specialists, such as family medicine, endocrinol- for Vascular Medicine centers on an evidence-
ogy, hyperbaric medicine, and nurse practitioners based multidisciplinary team approach [36].
[32]. In a study examining 27 multidisciplinary These guidelines have evolved to include biome-
diabetic foot teams, 36 different disciplines were chanical offloading, various wound therapies,
identified, with an average of five physician dis- and surgical management requiring involvement
ciplines per team [33]. The most common surgi- of specialists across a multitude of specialties to
cal specialties were vascular surgery (74%), adequately prevent and treat DFUs [36].
orthopedic surgery (67%), podiatry (52%), and Studies utilizing large data-sets from the NIS
plastic surgery (44%) [33]. The most common have demonstrated that DFU patients are more
non-surgical specialties were endocrinology likely to avoid amputation and undergo advanced
(82%), infectious disease (37%), general medi- limb salvage therapies when treated at an urban
cine (30%), and physical medicine and rehabili- teaching hospital [21, 37]. A large underlying
tation (22%) [33]. reason for this benefit is likely the access to
advanced surgical modalities available within reform that has resulted in improved population
academic centers, which house the necessary health and superior mortality rates, compared to
infrastructure and technology for a functioning the remainder of the European Union [43].
multidisciplinary limb salvage team [21]. Within Largely reformed in 2006, the Dutch healthcare
these centers, multidisciplinary teams are able to system relies heavily on widely available primary
provide streamlined care, from preoperative care providers, well-developed tertiary care infra-
management to postoperative wound care, that structure, and privatized not-for-profit insurance
has enabled them to achieve remarkable limb sal- coverage for inpatient care [43]. This, in theory,
vage and ambulation rates [21]. When competi- has created an expansive net to catch patients
tion within hospital markets was accounted for, requiring specialized care, leading to reduced
the protective factor for urban academic hospitals loss to follow-up and expedited care. In the man-
was removed, indicating regional competition agement of DFUs, timely and available care is
may spur funding for advanced limb salvage paramount. In fact, the Netherlands has witnessed
capabilities [38]. Considering the complex tech- a reduction in diabetes-related lower extremity
nological and surgical skill associated with vas- amputations over the last several decades,
cular intervention and free flap reconstruction, decreasing from 5.5 per 1000 in 1991 to 0.8 per
these surgical modalities may be limited to urban 1000 diabetic adults in 2011 [44, 45].
academic centers that not only have the infra- Although national legislative change regard-
structure and finances to support this limb sal- ing healthcare is a seemingly immense task,
vage option, but are incentivized to invest in it efforts to create a regional or statewide model
[38]. Further investigation into the role of infra- are perhaps within reach. Many multidisci-
structure and institutional centrality of a multi- plinary limb salvage centers have emerged
disciplinary team would be of value. throughout the USA. However, despite provid-
ing expert care in the management of diabetic
foot ulcers, many of these centers lack efficient
The Future of Multidisciplinary Care and reliable referral pathways to ensure patients
are treated in a timely manner and not lost to
A Global Context follow-up. Additional resources dedicated to
creating regional limb salvage systems and
As previously discussed, the diabetic foot popu- screening centers may serve as a valuable focus
lation in the USA faces a multitude of disparities, for future health policy research.
limiting access to care and manifesting as subop-
timal medical outcomes. A large wage gap and
inequitable distribution of low-quality insurance Care Delivery Optimization
continue to remain a barrier to care for many
patients. The Affordable Care Act largely The treatment of DFUs requires a significant
expanded access to health insurance coverage but amount of medical and financial resources. In
not without its challenges and criticisms [39, 40]. developed countries, the cost of amputation can
On balance, however, the Affordable Care Act range between $35,000 and $45,000, and in gen-
has achieved positive gains in insuring minorities eral, the cost of amputation in the USA is higher
and reducing amputations [41, 42]. Future study than that in European countries [46]. There are
needs to examine interventional approaches to multiple factors affecting total cost per care epi-
disparity and amputation reduction. sode. One of the largest underlying factors deter-
It is perhaps worthwhile to examine the struc- mining cost is the degree of management needed
ture of healthcare systems in other countries to to adequately treat a DFU. One study found a
provide insight for the refinement of our own significant increase in cost of admission correlat-
healthcare system. For example, the Netherlands ing with progression of intervention: ~$4800 for
has become a well-praised case of large-scale primary healing, ~$13,500 for single minor
amputation, ~$31,800 for multiple minor ampu- intensive teams are often organized and deployed
tations, and ~$73,800 for minor amputation without much evidence-based strategy or under-
necessitating major amputation (p < 0.001) [47]. standing [32, 34, 52–54]. The field is in need of
Severity of patient presentation can also signifi- standardized methods by which team organiza-
cantly affect cost of care. Increasing Society for tion and distribution are optimized for increased
Vascular Surgery Wound, Ischemia, and foot referrals and efficient patient care. Other health-
Infection (WIfI) score has been demonstrated to care systems have successfully implemented limb
correlate with increased healing time, more sur- salvage teams with clear organization. In the UK,
gical procedures, and increased cost of care [48]. nearly 90% of primary care physicians have an
Specifically, the total cost per wound care epi- identifiable limb salvage center they are able to
sode for Stage 1 wounds is ~$4000, which refer patients to; 85% of the time, these centers
increases to ~$50,500 for Stage 4 wounds are within 12 miles [55]. As a result, the rate of
(p < 0.001) [48]. More complex procedures and late referrals (>3 months) for DFU patients is less
increased lengths of stay are inherently related to than 10% in the UK [56].
increased costs [49].
The multidisciplinary limb salvage team is in a
unique position to optimize care delivery and Collaborative Initiatives
decrease the financial burden of diabetic foot
management. In the outpatient setting, a well- National patient databases, such as the National
organized multidisciplinary team with good com- Surgical Quality Improvement Program (NSQIP)
munication and clear referral pathways can from the American College of Surgeons (ACS)
expedite the diagnosis of chronic wounds and and the Nationwide Inpatient Sample (NIS) from
provide proper treatment depending on severity. the Healthcare Cost and Utilization Project
An outpatient multidisciplinary diagnosis and (HCUP), have been instrumental in outcomes
management model has already been shown to research, allowing large-scale analysis of out-
decrease hospitalization time, department transfer comes following limb salvage and amputation.
time, delay in undergoing surgery, and hospital However, there are limitations in their applicabil-
length of stay [50]. As a result, total cost per care ity to limb salvage research. For example, both
episode was significantly decreased [50]. NSQIP and NIS do not capture wound character-
Similarly, efficient clinical pathways and multi- istics or specific location of treatment, which are
disciplinary treatment algorithms have decreased details often needed to properly assess clinical
length of stay, amputation rates, and complication outcomes. Furthermore, the two databases are
rates in the inpatient setting [49, 51]. The propor- limited to short-term outcomes data and lack
tion of total costs attributed to inpatient care can itemized cost-of-stays, which limits comprehen-
double when escalating from primary wound care sive analysis [57].
to amputation [49]; thus, a multidisciplinary out- Collaborative quality initiatives are discipline-
patient approach aiming to reduce progression in specific registries that aim to collect carefully
severity of DFUs should be a priority. curated quality measures to improve quality care
Despite the multitude of studies demonstrating [58]. These registries involve collaboration
the clinical and financial superiority of the multi- between multiple institutions, often sharing a geo-
disciplinary limb salvage team, consensus on graphic region, and collect data in a non-
organization and structure is lacking. For exam- judgmental and non-punitive manner (Fig. 37.2)
ple, team composition usually involves vascular [58]. Already, collaborative initiatives have been
surgery, plastic surgery, or podiatry/orthopedic established for other specialties, such as colorec-
surgery; however, it is otherwise highly variable tal surgery, vascular surgery, and obstetrics and
between institutions [32, 33]. Limb salvage teams gynecology, resulting in improved outcomes and
also rely on clear referral pathways and interdisci- significant cost savings [58–61]. Such an endeavor
plinary optimization; in the USA, these resource- within the realm of limb salvage may illuminate
Fig. 37.2 Collaborative

initiatives are built upon
institutions and
providers sharing data,
protocols, and strategies
within an open forum to
build and assess
discipline-specific
quality measures
areas in need of reform and improve both surgical

and patient-centered outcomes for the chronic Conclusion
wound population. The US Wound Registry© is a
Qualified Clinical Data Registry that collects dei- The multidisciplinary limb salvage team has
dentified patient records, specifically for wound revolutionized medical care for the diabetic
care [62, 63]. Through their collective database, foot population. However, the discipline con-
the organization acts in many ways similar to a tinues to face many hurdles that can only be
collaborative initiative. For a fee, providers are overcome with careful systems-level examina-
able to access the database, contribute patient tion, quality reform, and care delivery optimi-
data, compare their benchmarks against those of zation. As the field continues to improve,
other providers, and utilize quality measures spe- chronic wound patients may bear witness to
cific to wound care already approved by the decreased amputation rates, improved postop-
Centers for Medicare and Medicaid Services erative function, and decreased financial
(CMS) [64]. In doing so, providers are able to burden.
avoid penalties imposed by the Merit-based
Incentive Payment System (MIPS) in addition to Financial Disclosure Statement The authors have no
improving quality care in their practice [64]. financial disclosures, commercial associations, or any
other conditions posing a conflict of interest to report.
Collaborative initiatives may represent the next
horizon of quality care in limb salvage.
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patterns between primary care and specialised units.
DLS Innovations: Landmark
Publications and Innovations
38
from Our Team
Samuel S. Huffman, Christopher E. Attinger,

John S. Steinberg, Karen K. Evans,
and Kenneth L. Fan
Evolution of Multidisciplinary Care poor self-care, and physical decline [9, 10].
Substantial evidence exists suggesting the
In the USA, up to 2.4–4.5 million people suffer employment of a multidisciplinary approach is
from chronic lower extremity wounds, costing critical at both preventing and treating chronic
our health system $31.7 billion annually [1, 2]. lower extremity wounds [11–14].
The incidence of lower extremity wounds is ris- Wound care centers are high functioning orga-
ing as a result of the aging population and nizations that at their core provide broad methods
increased risk factors for atherosclerotic disease to treat patients with complex wounds through
such as diabetes, smoking, and obesity. Lower four critical elements including organizational
extremity wounds are a major cause of disability structure, facilities, finances, and a multidisci-
as diabetes mellitus has moved to the second plinary approach, now the standard of care [15,
leading cause of disability-adjusted life years and 16]. Understanding and applying the combina-
years lived with disability [3]. With inadequate tion of these four factors increases the odds of a
treatment, exacerbation occurs leading to a pre- beneficial outcome for the patient while ade-
dictable pathway toward amputation. After a quately utilizing allocated health care funding
below the knee amputation, the 5-year mortality [15, 16]. Due to the intensity of care required to
may be greater than 68%, primarily due to the treat complex wounds, effective management can
deterioration of existing comorbidities and be delivered through multiple specialists as a sin-
increase in cardiovascular events [4–8]. gular provider does not meet the medical, surgi-
Associated emotional impact leads to depression, cal, and nutritional needs of the patient [16]. The
specific composition of multidisciplinary teams
is loosely defined, although no consensus exists
S. S. Huffman (*) · K. K. Evans · K. L. Fan
Department of Plastic and Reconstructive Surgery, regarding the optimal team of specialists. The
MedStar Georgetown University Hospital, Georgetown DLS team believes patients are best
Washington, DC, USA served when the core group consists of plastic
e-mail: [email protected]; Karen.K.Evans@ surgery, vascular surgery, and podiatric/orthope-
medstar.net; [email protected]
dic surgery, even though surgery may not be nec-
C. E. Attinger · J. S. Steinberg essary for all patients (Fig. 38.1) [16–19]. For
University School of Medicine and MedStar non-surgical care, consultation with internal
Georgetown University Hospital, medicine for optimization of glycemic control,
Washington, DC, USA infectious disease for treatment if an infection is
e-mail: [email protected]; present or suspected, and physical therapy,
[email protected]

604 S. S. Huffman et al.
Infectious Disease Medicine Rheumatology
Wound Nurses
Plastic Surgery Vascular Surgery
Hyperbaric
Nurse Practitioners
Medicine
Specialist Podiatric/Orthopedic Surgery Physician Assistants
Physical Therapy General Surgery Orthotist/Prosthetist
Fig. 38.1 Representation of the core and broad multidis- shaded area. (Source Building a Multidisciplinary
ciplinary care team members. The core team is defined by Hospital-Based Wound Care Center: Nuts and Bolts
the central group of team members in the blue shaded box. Plastic and Reconstructive Surgery138(3S):241S–247S,
Other essential team members are located within the September 2016)
among other teams, is crucial [20]. Each of these and medical care in addition to a shared pager
team members supplies a key role in the evi- system, conducive for immediate communication
dence-based approach for treatment and preven- [15, 16]. Ideally, outpatient clinics are structured
tion of foot ulcers proposed by Shaper et al. [20] under the same EMR and should parallel the
Specifically, patients may require offloading of inpatient management as patients’ care extends
pressure placed on wounds by podiatric surgeons beyond the hospital. This structure mutually ben-
due to biomechanical stress of gait. Similarly, efits the patients and hospital system as the sup-
vascular surgeons aid in assessment and, when port and sustainability of wound centers can
required, endovascular intervention to restore tis- generate revenue for the hospital (Fig. 38.2) [22].
sue perfusion. Plastic and podiatric surgeons However, tertiary wound centers are only capable
additionally provide local wound care via routine of providing these services to patients with com-
inspection, application of wound dressings to plex chronic wounds if the community-based
maintain optimal healing conditions, and debride- wound care centers refer patients for more
ment of wounds. All team members can provide advanced treatment modalities [15].
continuous patient education in diabetic foot care Even such, the clear advantages and success
with the goal of achieving long-term prevention of a hospital-based wound care center are reliant
of foot ulcers [20, 21]. Multidisciplinary care on the core value of providing evidence-based
under a singular comprehensive wound care cen- and patient-centered care [12]. Kim et al. describe
ter is critical to the adherence and provision of the ideal hospital-based model as a three tier sys-
these evidence-based principles, although some tem—inpatient service, clinic, and operating
center’s capabilities may be limited by the lack of room—all of which interplay with one another in
these key specialties. their provision of continuous care for a diabetic
Regardless of the combination of involved population who may require multiple hospital
specialists, communication and shared owner- admissions [14–16, 23–25]. Implementation of a
ship between all team members is paramount to multidisciplinary care approach has been demon-
increasing likelihood of successful outcomes. strated as efficacious in reducing the rate of major
Moreover, the hospital-based wound center amputations while simultaneously improving
which employs the same electronic medical clinical outcomes and quality of life for patients
records (EMR) system for all team members pro- [11–14, 17, 25–30]. Similarly, this approach has
vides access to a patient’s entire history of wound the potential to reduce healthcare costs through a
38 DLS Innovations: Landmark Publications and Innovations from Our Team 605
Fig. 38.2 Flow diagram

depicting patient flow Operating room
through a hospital-based
wound care center
model. The larger box
represents the
EMR
employment of the same
EMR system for all
parts of the wound care
center. (EMR: electronic Inpatient care Outpatient clinic
medical record)
more efficient delivery of care, all of which has has helped reduce the primary amputation rate
been accomplished through varied applications in patients with a threatened extremity [33, 34].
of the multidisciplinary model [31, 32]. These Utilizing free tissue transfer, Evans et al. illus-
alternative models of wound care centers exist trated the importance of limb preservation
through private practice offices or outpatient clin- among the diabetic population, even with addi-
ics; however, the hospital-based inpatient and tional comorbidities of peripheral vascular dis-
outpatient model has been described as the most ease and end-stage renal disease, which are
conducive for complex wounds that require known risk factors for increased complication
intensive care [16]. The immediate access to rates during limb salvage (see section on Lower
resources and the wide array of ancillary services Extremity Reconstruction) [35]. In this popula-
and personnel in continuity with outpatient clin- tion, limb salvage rates between 54 and 59%,
ics allow the hospital-based delivery model to with 64% of patients functionally ambulatory at
provide a concerted effort toward amputation 2-year follow-up can be achieved [35]. One rea-
reduction and functional improvement [16]. son for increased amputation rates in a non-
multidisciplinary setting may be the ease of
amputation for a clinic that does not have the
he Effect of Multidisciplinary Care
T multitude of resources as a hospital-based
on Amputations team [16].
When amputation is necessary, Attinger et al.
Among the Georgetown Diabetic Limb Salvage demonstrated that by utilizing a team approach,
(DLS) team, the hospital-based multidisciplinary limb salvage and below-knee amputation can
care approach has been the fundamental driving both achieve a 64% ambulation rate. Additionally,
force to reduce mortality following amputation. it was determined the 2-year survival rate is
Historically, the 5-year mortality rates following higher in below the knee amputation patients
major lower extremity amputations were higher treated with a multidisciplinary approach (80%)
than breast, colon, or prostate cancer [8]. compared to standard care (52%) [36]. These
Furthermore, approximately three out of four findings highlight the need for a focus on func-
patients who receive lower extremity amputation after amputation. Thoughtful preoperative
tions have diabetes [8]. One recent systematic planning in conjunction with pragmatic use of
review and meta-analysis by the Georgetown viable tissue optimizes potential for amputees to
DLS team found that within both the type 1 and be highly functional [37]. Specifically, preopera-
type 2 diabetic patient population, 1- and 5-year tive care should assess LE biomechanics, ambu-
mortality was 27.3% and 63.2%. Moreover, it latory functional status, and patient goals. In
was found that 10-year mortality rates reached particular, preserving limb length and maximum
80% [7]. number of joints is critical to augment function
As amputation rates vary from center to cen- and preserve ambulatory status. Preoperative pre-
ter, our experience in a team-based approach dictive factors aid in stratifying potential postop-
erative functional status. Preoperative popliteal care shift to patient-centered care following the
patency in patients undergoing below-knee approval of the Patient-Centered Outcome
amputation was associated with higher postoper- Research Institute by congress within the
ative ambulation rates when compared to patients Affordable Care Act [49]. These PROs following
without popliteal flow preoperatively and inde- lower extremity reconstruction additionally
pendently increased the likelihood of postopera- include assessment of chronic pain and mental
tive ambulation [38]. This illustrates that status which have been measured through tools
prioritization of functional status should be con- such as the Short Form Survey-36 and the
sidered even in limbs with compromised vascula- Sickness Impact Profile [10, 49, 50]. However,
ture. Furthermore, patients age > 60 years who application of PROs has been inconsistent. One
underwent bilateral amputation and have a his- systematic review of studies assessing PROs fol-
tory of end-stage renal disease have lower likeli- lowing major LE amputation for peripheral arte-
hoods of ambulating [39]. rial disease or diabetes mellitus found that eleven
Aside from the substantial psychological different amputation specific PROs were utilized,
impact of amputation, maximizing limb length ten of which were developed only for prosthesis
reduces the cardiopulmonary energy demand of users [51]. Additionally, there were limited PRO
amputation which has been associated with tools for patients undergoing major LE amputa-
increased mortality and morbidity [4–6]. tion following limb-threatening trauma.
Therefore, limb-preserving amputations distal to Furthermore, the Georgetown DLS team discov-
the ankle joint with evaluations of LE biome- ered that over the last two decades there has been
chanics are performed when possible to avoid a significant research gap between clinical out-
further amputation and maximize functionality comes and PROs. Specifically, patient-reported
[40]. However, due to advances in prosthetic outcomes for psychosocial measures, quality of
technology some patients can attain better quality life, and functional ability were reported in 24%,
of life with a below-knee amputation than a sal- 21%, and 53% of articles, respectively [52]. This
vaged LE [41–44]. Conversely, patients whose highlights the need for further development and
condition is not conducive to wearing a prosthetic increased utilization of PRO measures, which
device may do better with a limited functioning may help improve patient-centered healthcare
leg, as many patients never wear a prosthetic delivery. Notably, ongoing development of
[45]. Predicting which patients will likely not LIMB-Q for both lower extremity and traumatic
wear a prosthetic device can help surgeons coun- amputation patients exemplifies the progression
sel patients to the most beneficial operative tech- in this field [53–55]. Similarly, [43–45] the devel-
nique that maximizes functionality and quality of opment of WOUND-Q by international collabo-
life. Specifically, it was found that preoperative rators and members of the Georgetown DLS
factors independently associated with not wear- team represents an important step in assessment
ing a prosthesis include non-ambulatory status of the patient perspective in an evidenced-based
prior to amputation, above knee amputation, medicine structure, and therefore, creating an
homebound ambulation only, age > 60 years, avenue to improve patient-centered care for those
presence of dementia, end-stage renal disease, with chronic wounds [56, 57].
and coronary artery disease [39]. Recognizing
the determinants at play that may alter postopera-
tive care is critical to the surgeon. I nnovations in Lower Extremity
Research in lower extremity wounds has Reconstruction
shifted from surgeon metrics, such as time to
heal, to patient-based metrics [46–48]. Patient- One way in which the Georgetown DLS team has
reported outcomes (PRO) have become a corner- been able to increase the rates of limb salvage
stone to assess postoperative functionality and and reduce major amputations is through innova-
quality of life, especially considering the health- tions in free flap reconstruction. Early on, local
flaps were established as a primary method of cant advantage of ALT flaps being the reduced
reconstruction due to their versatility, need for skin grafting [69]. Other areas in which
reproducibility, and successful long-term func- the Georgetown DLS team has improved free tis-
tional outcomes for patients undergoing limb sal- sue transfer (FTT) success are through lower
vage [58]. With advancements in microsurgical extremity vasculature. Prereconstructive targeted
reconstruction of the foot and ankle, free flaps endovascular therapy as part of a multidisci-
emerged as a viable adjunct reconstruction plinary approach to functional limb salvage in
modality [59]. Since success rates of microsurgi- patients with advanced arterial disease has been
cal free flaps exceed 95% in tertiary centers, sur- demonstrated to optimize recipient-site hemody-
geons were able to achieve a higher salvage rate namics and promote flap survival in regions of
of limbs in those that were likely amputated prior compromised distal blood flow [70]. Furthermore,
to the option of microsurgical free flap recon- in a later study, it was found that both direct
struction [59, 60]. revascularization and indirect revascularization
In order to achieve a successful reconstruction with collateral flow offer significantly improved
and limb salvage, it is critical to identify risk fac- wound healing rates and major amputation rates
tors for adverse long-term outcomes that may compared with indirect revascularization [71]. In
hinder functionality and quality of life. the setting of unfavorable vascular anatomy, one
Additionally, recognizing that resource alloca- novel approach is the hemirectus/ALT chimeric
tion required for limb salvage is extensive and clap to cover complex defects and preserve donor
understanding precluding elements of poor out- site function [72].
comes increases the odds of efficient healthcare At our tertiary referral center, we often receive
delivery [61]. In the first microsurgical study complex patients that are deemed inoperable for
committed to determining long-term risk factors FTT reconstruction, such as those with severe
of poor outcomes in patients undergoing micro- peripheral vascular disease or recalcitrant foot
surgical free flap reconstruction for limb salvage, ulcers [73]. Through microsurgical advance-
Kotha et al. found that end-stage renal disease, ments and the multidisciplinary model, it was
hindfoot wounds, wound colonization, and ele- demonstrated that flap success and lower extrem-
vated hemoglobin A1c were risk factors for ity limb salvage of patients with diabetic recalci-
amputation [61]. trant wounds can reach 93% and 79%, respectively
The detriment of diabetes for this patient pop- [74]. Additional use of longitudinal slit arteriot-
ulation is significant as has been shown to omy end-to-side anastomosis for patients under-
increase the number of debridements, prolong going FTT) reconstruction of life-threatening
healing times, and decrease long-term survival in limb defects in the high-risk population has
patients undergoing local or free flaps [62]. shown an overall limb salvage rate of 83.5%, and
However, diabetes does not affect limb salvage of those salvaged, 92.7% were ambulating with-
rates, and if successful limb salvage is achieved, out a prosthesis after one year [75].
it was demonstrated to prolong survival of dia- Although no consensus exists regarding the
betic patients [63]. The innovations in free flap ideal preoperative hypercoagulable workup in
tissue reconstruction at the Georgetown DLS high-risk patients undergoing microsurgical
team have expanded treatment modalities for reconstruction, in the Georgetown DLS patient
lower extremity limb salvage. The anterolateral population we perform preoperative screening
thigh (ALT) and vastus lateralis (VL) flap are protocol for inherited or acquired hypercoagula-
known workhorse flaps of lower extremity recon- ble traits which may predispose patients to
struction due to low donor site morbidity [64– thrombosis. Unidentified hypercoagulability can
68]. In the largest comparison study of the two result in detrimental outcomes following FTT)
flaps, it was found that ALT and VL flaps have reconstruction to the LE ultimately leading to
similar complication rates, postoperative ambula- difficult or nonsalvageable flaps [76–79]. Our
tory rate, and flap success, with the most signifi- tertiary limb salvage center implemented a novel,
risk-stratified algorithm for perioperative antico- Table 38.1 Preoperative thrombophilia screening panel
agulation in July 2015 which parallels the CBC, complete blood count
assumed differences in hypercoagulable risk PT/INR, prothrombin time/international normalized
ratio
among our patient population. The decision to
PTT, partial thromboplastin time
administer heparin—intravenous or subcutane-
MTHFR, methylenetetrahydrofolate reductase
ous—was determined by the presence or absence PAI-1, plasminogen activator inhibitor 1
of thrombophilic risk factors for microvascular QST, quantitative sensory testing
thrombosis (Fig. 38.3) [78]. Table 38.1 list the
Intraoperative Anticoagulation Protocol
Heparinized saline as local irrigant (100 U/mL)

Intravenous (IV) heparin bolus (5,000 units) prior to pedicle division
Thrombotic Complications?
Yes No
Non-titrated heparin drip (500 U/hr) started Postoperative Anticoagulation Protocol

intraoperatively and continued for 5 days
5,000 units subculaneous heparin every 8 hours
Salvage? ASA 325 mg daily for 2 weeks starting POD1
No Yes Thrombotic Complications?
Prophylactic Lovenox POD 5 Yes No

Prophylactic
Lovenox for 2 ASA 325 mg daily starting POD 1
weeks after flap loss
* See Postoperative Protocol IV heparin bolus (150 U/kg) Prophylactic Lovenox
Non-titrated heparin drip (500 U/hr) for 2 weeks after
for 5 days discharge
Re-exploration
Salvage?
Yes No
Prophylactic Lovenox POD 5

continued for 2 weeks after discharge
or flap loss
Fig. 38.3 Novel perioperative anticoagulation protocol Thrombophilic Patients: Managing Expectations in the
based on the presence or absence of thrombotic complica- Setting of Microvascular Thrombosis. J Reconstr
tions. (Source. DeFazio MV, Hung RW, Han KD, Bunting Microsurg. 2016;32 (6):431–444. doi: https://doi.
HA, Evans KK. Lower Extremity Flap Salvage in org/10.1055/s-0035-1571249)
factors included in the thrombophilia screening were nearly 80% more likely to achieve limb sal-
protocol. Prior to the anticoagulation protocol, vage [88].
DeFazio et al. found that 61% of patients under- Undoubtedly, patients still progress and ulti-
going FTT to LE for limb salvage had at least one mately receive amputations. However, innova-
of the 52 identified hypercoagulable traits, with tions in targeted muscle reinnervation have led to
the most common traits being the plasminogen improved patient outcomes and enhanced quality
activator inhibitor-1 4G/5G variant and the meth- of life. Through tibial and common peroneal
ylenetetrahydrofolate reductase A1298C and nerve coaptation during the index amputation and
C677T polymorphisms [79]. Risk-stratified collagen nerve wrapping, patients report lower
patients with identified thrombophilia who VAS pain scores, phantom symptoms, and neu-
received a weight-based intravenous heparin roma formation, with higher ambulation rates
were observed to have lower rates of total and after six months when compared with traction
partial flap loss, ultimately leading to a signifi- neurectomy alone [89]. The Georgetown DLS
cant reduction in postoperative thrombotic events team has also demonstrated advancements in tar-
[78]. Conversely, surgeons must weigh this ben- geted muscle reinnervation, which reduces pain
eficial effect to the risk of bleeding complications and improves ambulation in patients undergoing
following therapeutic heparin intervention which below-knee amputation [90]. These surgical
range between 20% and 60% [80–83]. However, techniques have the potential to improve morbid-
recognition of the impact of morbidity following ity and quality of life in the highly comorbid
flap failure is critical to patient-centered care as patient population.
patients face major LE amputation.
The diabetic patient population often presents
with other challenges such as osseous destruction Policy Implications
and/or superimposed infection. In the foot,
absence of soft tissue coverage over the bony Despite advancements in limb salvage, access to
structures increases the risk of developing osteo- wound care modalities to prevent amputation
myelitis, which ultimately compromises skeletal remains an issue for the US health system [10,
integrity resulting in altered biomechanical 50, 51]. However, we have identified multiple
stresses [84]. In this case, Steinberg et al. illus- patient- and hospital-level factors that decrease
trates the longevity and benefit of permanent access to surgical limb salvage and multidisci-
polymethylmethacrylate cement spacers to pre- plinary care. In the UK, primary care providers
vent amputation by reducing the bacterial load on able to recall multidisciplinary wound centers,
local tissue and filling soft tissue voids [85]. leading to amputation reduction upwards of 70%.
However, in patients with chronic calcaneal Unfortunately, multidisciplinary wound care
osteomyelitis, conservative management may no remains poorly organized and inefficient with
longer be considered. Conventional partial calca- amputations rates varying by region [91].
nectomy has been frequently utilized to address In patients admitted for chronic lower extrem-
osteomyelitis of the calcaneus, but balancing cal- ity wounds, the strongest protective factor against
caneus resection with maintenance of adequate amputation was access to urban teaching hospi-
soft tissue-to-bone ratio is challenging to achieve tals, while receiving limb salvage without and
and often leads to closure under tension [86, 87]. with flaps was predictive of amputation [92].
The novel alternative surgical technique of verti- When amputations are indicated, those living in
cal contour calcanectomy from the Georgetown urban areas and those having vascular interven-
DLS team ensures total resection of osteomyeli- tion in the same hospital stay were predictive of
tis, reduces risk of reulceration, and limits ten- limb-preserving amputations, such as a TMA,
sion of the soft tissue during wound closure [86]. while patients living in rural areas who were
Moreover, patients who underwent primary clo- treated in urban centers were more likely to pro-
sure at the time of vertical contour calcanectomy ceed to a below-knee amputation [93]. Among
patients with chronic wounds, it has been shown 6. Attinger C, Ducic I. Foot and ankle reconstruction.
In: Thorne CH, Beasley RW, Aston SJ, Bartlett SP,
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likelihood hospitals will offer more services. In traumatic major lower extremity amputation: a sys-
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Index
A supermicrosurgery, 467, 475, 479, 500, 502, 504,

Abadeer, A.I., 187 507, 511
Abductor hallucis (ABH) muscle flap, 431, 432 technical considerations
Acellular dermal matrix (ADM), 314 anastomosis, 512, 513
Achilles tendon, 74 antibiotic-impregnated cement/bone void fillers,
contracture, 513 514
lengthening, 454 anticoagulation, 514
Acquired immunodeficiency syndrome (AIDS), 60 bony contouring, 513
Active charcot foot, 245 compression therapy, 516
Activities of daily living (ADLs), 545 drains, 514
Acute bacterial skin and soft tissue infections (ABSSI), external fixation, 516, 517
182 flap inset, 514
Acute coronary syndrome (ACS), 147 flap planning, 511
Acute ischaemia, 121 HBOT, 517
Acute kidney injury (AKI), 98 incision planning, 512
Acute pain service (APS), 36, 152 positioning, 515
Acute rehab (AR) placement, 40 postoperative monitoring, 515
Acute reversible neuropathy, 113 recipient vessel selection, 511
Adductor digiti minimi (ADM) muscle tourniquet use, 512
flap, 430, 431 T-shaped/flow through anastomosis, 513
Adjunctive therapy, 394 wound preparation, 511
Admin Pool, 22 wounds
Advanced plastic surgical reconstruction, in lower ankle, 490
extremity forefoot, 477, 478, 482, 484, 486
algorithmic approach, 477 hindfoot, 489, 490
flap selection massive, 496
ALT pedicle, 504 midfoot, 489
dead space obliteration, 509 “Advanced reconstruction”, 477
MSAP, 504 Adverse effects, 270
recipient vessel, 504, 507 Aerobic and anaerobic cultures, 454
reulceration, 509 Air plethysmography (APG), 293
SCIP, 505, 506 Akbari, C.M., 1, 251–256, 258–260, 263–265, 267, 268,
suprascarpal plane, 509 270, 271, 273, 275–283
microsurgery, 467, 472, 513 Alfonso, A.R., 305
negative pressure wound therapy, 475 Allergic contact dermatitis, 338
orthoplastic surgery, 481 Allografts, 306
patient population and selection, 468, 470 Alternburg, M.M., 87
pre-operative evaluation Ambulation, 353, 355
counseling, 472 American Diabetes Association (ADA), 91
examination, 473 American venous forum (AVF), 288
history of, 473 Amputation, 1, 8, 58, 59, 75, 178, 349, 521, 587, 603,
interdisciplinary consultations, 474 604, 606, 607, 609, 610
studies, 473, 474 Amputee, 587, 588
preparation for, 474, 475 care coordinator, 353
recipient vessel selection, 500, 502 support group, 587–589

https://doi.org/10.1007/978-3-031-27725-2
616 Index
Amputee mobility predictor (AMP), 552 open surgery, 263–265

Anabolic resistance, 134 patency rates, 275, 276
Anemia, 474 preoperative consideration, 265, 267
Angiogram, 40 quality of life score, 276
Angiography, 259, 479 systemic and local complications, 274, 275
Angiosome, 259, 490 Arteriogram, 457, 459
Angiosome-directed revascularization, 259 Arteriography, 259
Angiosome-oriented revascularization, 278 FTT, 454
Angiosome-specific reperfusion, 475 Arteriosclerosis, 134
Angiosome-targeted revascularization, 278 Arteriotomy, 268
Angiotensin converting enzyme inhibitors, 90 Arthropathy, 238
Angiotensin II receptor blockers, 90 Artificial intelligence, 140
Ankle-brachial index (ABI), 254, 255, 429 Aspergillus flavus, 337
Ankle deformity, 369 Aspirin, 90
Ankle foot orthosis (AFO), 229, 350, 458, 542 Assisted living facility (ALF), 38
Ankle obstacle, 576, 578, 579 Atherectomy, 260
Ankle wounds, 490 Atherosclerosis, 251
Antegrade approach, 279 Atherosclerotic cardiovascular disease (ASCVD), 147
Anterior tibial tendon transfer (ATTT), 380, 381 Atraumatic technique, 165, 166
Anterolateral thigh (ALT), 455, 504, 607 Atrophic nonunion, 564
Antibiotic therapy, 50, 454, 473 Atrophy, 507
Anticoagulation and antiplatelet management Attinger, C.E., 1, 157, 500, 545, 603
antiplatelet agents, 97 Attinger, T., 35
background, 95 Atves, J.N., 157, 360, 521
bleeding risk, 96 Atypical mycobacterial infections, 336
direct thrombin and direct Xa inhibitors, 96 Autogenous ipsilateral saphenous vein, 265
thrombotic risk, 95 Autogenous saphenous vein, 270
venous thromboembolism (VTE) prophylaxis, 97 Autogenous skin grafts, 415
warfarin, 96 Autogenous vein grafting, 264
Anti-depressants, 71 Autoimmune blistering disease, 332, 333
Antidiabetic medications Autolytic débridement, 161, 162
insulin, 92, 93 Autonomic neuropathy, 126
non-insulin medications, 92
perioperative insulin management, 93
Anti-epileptic agents, 70 B
Antimicrobial therapy, 195, 196 Bąk, E., 141
Antiphospholipid antibodies, 452 Bal, A., 109
Antithrombotic therapy, 453 Balloon angioplasty, 280
Aorto-bifemoral bypass, 267 Baumhauer, J.F., 220
Aortoiliac System, 279, 280 Beaulieu, R.J., 359, 522
Area deprivation index (ADI), 594 Below knee amputations
Areeg, A., 1 (BKAs), 455, 504, 545, 546
Argenta, L.C., 436 anatomy, 546, 547
Arizona Brace, 81 calcitonin, 550
Armstrong, D.G., 142, 233, 394, 398 epidural anesthesia, 551
Arrhythmia, 147 gabapentin, 550
Arterial calcification, 474 morbidities, 548, 549
Arterial disease management in limb salvage patient non-steroidal anti-inflammatory drugs, 550
CLTI, 263 nutrition, 551
endovascular revascularization opiate analgesics, 550
anatomic considerations, 277, 278 perineural catheters, 551
choice of, 276 physical therapy, 552
general considerations, 276, 277 psychological therapies, 551
inflow disease, treatment of, 280–283 targeted muscle reinnervation, 549, 550
targets of, 277 Below the ankle (BTA) arteries, 282
technical approaches in, 278, 279 Below the knee (BTK) arteries, 281, 282
treatment of inflow disease, 279, 280 Bertram, K.D., 73
inflow operation, 267, 268 BEST-CLI trial, 260
infrainguinal bypass, 270–273 Beta-blockers, 89, 90, 274
Index 617
Beta-lactamase inhibitor (BLI) clavulanic simultaneous pancreas-kidney transplant (SPKT)

acid, 196 in type 1 diabetes, 219
Bilateral neuropathic pain, 111, 112 skeletal fragility, 219
Bilateral Oedema, 125 diagnosis of, 215
Billing analyst, 19 imaging, 222
Bioavailability, 180, 181 etiology of, 217
Biobrane, 316 history of, 216
Biofilms, 180, 419 inactive phase and recurrence, 217
infections, 178 mortality, 221
Biologic débridement, 162 neuropathy
Biologic skin substitute, 307, 323 on joint capsule, 218
Biomechanical deformities, 513 RANK/RANKL-NFkappaB and Wnt/β-catenin
Biosynthetic dressing, 313, 316, 317, 321 Pathways, 217, 218
Bone concentration, 181 on vasculature, 218
Bone edema, 234 permissive factors, 219
Bone imaging, 184 pro-inflammatory cytokines, 221
Boulton, A.J.M., v, 65 expression, 220
Brand, P.W., 68 Charcot, J.-M., 216
Bunnell, Sterling, 166 Charcot neuroarthropathy (CN), 74, 79, 81, 208, 227,
Bypass versus angioplasty in severe ischaemia of the leg 228, 237, 238, 361, 373, 473
(BASIL) trial, 260 charcot bone, 242, 243
charcot restraint orthotic walker, 231
conventional radiography, 234
C deformity correction, 246
Caisson disease, 401 exostectomy, 245
Calciphylaxis, 341, 345 foot with fractures, 228, 229
Calcitonin, 550 frame orthosis, 231
Callus, 124 hindfoot internal fixation, 246
Candida albicans, 337, 457 indications for surgery, 243, 244
Cardiac biomarkers, 89 midfoot internal fixation, 247
Cardiovascular disease, 305 midfoot stabilization, 246
Carroll, P.J., 360 monitoring, 232, 233
Case management (CM), 35 MRI, 233
Case Management Society of America, 36 orthotic treatment, 229, 230
Case manager, 37, 39, 40 post-operative care, 248
Case Manager Associate (CMA), 36 postoperative follow-up treatment, 234, 235
Casini, A., 263–265, 267, 268, 270, 271, 273, 275–283 prefabricated diabetic walker, 230, 231
Casts, 227, 228, 230 preoperative evaluation, 241, 242
Catanzariti, A.R., 245 radiographic evaluation, 240, 241
Cates, N.K., 239 shoes, 231, 232
Center for wound healing (CWH), 349 surgical management, 239, 240
daily operations, 13, 14 total contact cast, 230
Central nervous system (CNS), 410 two-stage reconstruction, 247, 248
Central scheduling, 27 Charcot reconstructive surgery, 81
Cerebrovascular disease (CVD), 147 Charcot restraint orthotic walker (CROW), 231, 350, 368
Certified medical assistants (CWH), 17 Chiu, E., 305
CFA Chopart’s amputation, 537
BTA arteries, 282 Chronic hyperglycemia, 187
BTK arteries, 281, 282 Chronic inflammation, 134, 135
FP segment, 281 Chronic limb-threatening ischemia (CLTI)
no-option patients with CLTI, 282, 283 CTOs, 278, 279
Charcot bone, 242 with foot ulceration/gangrene, 267
Charcot foot disease, 123 management of, 263
active phase, 216 natural history, 263
clinical presentation of, 216 no-option patients with, 282, 283
diabetes factors PAD, 263
genetic predisposition, 219 treatment of, 263
obesity, 219 Chronic obstructive pulmonary disease, 189
618 Index
Chronic pain after amputation (CPAP), 150 Conway, J.D., 559

Chronic peripheral vascular disease, 402 Cook, J., 208
Chronic total occlusions (CTOs), 278, 279 Cook-Swartz implantable Doppler probe, 462
Chronic venous disease (CVD), 285 Corns, 124
adhesive endovenous closure, 297 Coronary artery bypass graft (CABG), 148
anatomy, 286, 287 Coronary artery disease (CAD), 147, 189
causes and risk factors, 289 Cost per wound, 322
clinical presentation, 290 COVID-19 pandemic, 36, 38–39
complications, 297 C-reactive protein (CRP), 188, 195, 515
compression therapy, 293, 294 Critical limb ischemia (CLI), 418
conservative management, 292 Critical limb threatening ischemia (CLIT), 260
diagnostic workup, 290, 291 Cultured skin grafts, 306, 319, 320
economic burden, 291 Custom accommodative orthotics, 76, 77
elevation, 292 Custom molded orthosis (CMO), 458
epidemiology, 288, 289 Cutaneous malignancy, 339
mechanochemical endovenous closure, 295, 296 Cutler, B., 285
normal venous valves, 287
pathophysiology, 287
post-procedural care, 297 D
quality of life, 291 Daniels, H., 35
thermal endovenous closure, 295 DC Medicaid, 38, 43
Chronic venous insufficiency, 287 Débridement, 523, 524
Chronic wounds, 604 autolytic, 161, 162
Classical approach, 421 biologic, 162
Claudication, 252 contraindications, 335
Claw toes, 122 defined, 157
Clerici, G., 263–265, 267, 268, 270, 271, 273, 275–283 enzymatic, 161
Clindamycin, 197 mechanical, 161
Clinical management, 187 surgical, 163
Clinical Nurse Manager, 16 atraumatic technique, 165, 166
Clinical pool, 22 of bone, 168
Clinical social worker, 37, 38 clinical determination, 171
Collateral-vessel-guided revascularization, 278 of deep tissue, 167, 168
Collateral vessel network, 278 indications, 164
Combination therapy, 71 instrumentation, 164
Commercial insurance, 37 methylene blue, 170, 171
Comorbid, 533 microbiological determination, 171
Complex discharge of skin, 166
barriers, 42, 43 of subcutaneous tissue, 166, 167
case management, 42 staged approach, 168
free-flap (see Free-flap) tissue viability, 171
plan, 42 Deep-learning image processing algorithm, 140
Complex limb patients Deep tissue specimens, 209
hospital administration and limb service, 43–45 Deep vein thrombosis (DVT), 285, 300
mental health diagnoses and substance abuse issues, Definitive prosthesis, 355, 356
38 Deformities, 74, 122, 227–229, 239, 243, 526
targeted discharge date (TDD), 39 correction, 246
visits/conversations, 40 Degree of ischemia, 255
Complex regional pain syndrome (CRPS), 114 Dekker, P.K., 415–427, 449, 450, 452–462, 591
Compression therapy, 292 Del-Corral, G., 429–431, 433–446
Computed tomography angiography (CTA), 258 Deldar, R., 57, 193
Congestive heart failure (CHF), 148, 189, 425 Delirium, 99
Conservative fracture treatment, 228 de Oliveira, A.L., 137
Conservative surgery, 208 Deperio, T., 35
Contact dermatitis, 345 Dermal substitute, 313–317, 319, 321
Context factors, 232 Dermatologic wounds
Contractures, 74 allergic contact dermatitis, 338, 339
Contralateral saphenous vein, 265 autoimmune and inflammatory diseases, 329, 330
Controlled ankle movement (CAM), 42, 77, 78 cutaneous malignancy, 339, 340
walker, 78 fungal infections, 337
Control of infection, 267 Maverakis diagnostic criteria, 332
Index 619
opportunistic infection, 334–336 percutaneous flexor tenotomy, 81, 82

vascular diseases, 341–343 tendoachilles lengthening, 82
Dermatomes, 421 tendon transfers, 83
Dermody, M., 298 sound offloading principles, 75
De Vries, F.E.E., 396 staging, 129
Diabetes conference, v total contact cast, 78–80
Diabetes mellitus, 73, 237, 238 ulceration, 74
frailty Diabetic foot attack (DFA), 209
biomechanics of lower extremities, 135, 136 Diabetic foot infections (DFIs), 175, 203
emerging technologies, 139 antibiotics, 196, 197
frailty phenotypes and frailty index, 138, 139 antimicrobial therapy, 195–197
impact of, 141 applied anatomy of, 205, 206
mobility degeneration in, 136, 137 biomarkers of, 195
pre-frail diabetic patients, 142 management, 189, 190, 195
screening frailty, 137 microbiology of, 194
glucose management, 91 soft tissue infection, 193
glucose range, 92 biofilm, 199
hyperglycemia, 91 diagnosis, 194
hypoglycemia, 91 microbiological assessment of, 194, 195
Diabetic foot, 251–253, 255 surgical debridement of, 206
Arizona Brace, 81 surgical treatment of, 206
bilateral neuropathic pain, 112, 113 Diabetic foot osteomyelitis (DFO), 179
biomechanics of, 74 with antibiotic therapy, 179
callus, 124–127 duration of therapy, 182, 183
Charcot restraint orthotic walker, 80, 81 epidemiology of, 176
classification, 110 intra-osseus/topical antimicrobials, 183
complex regional pain syndrome, 115 microbiology, 176, 177
components of examination, 74, 75 outcome of treatment, 184
controlled ankle movement, 77, 78 pathophysiology, 176
custom accommodative orthotics, 75–77 route of administration, 180
custom shoes, 77 specific agents, 180, 182
débridement surgical treatment, 178, 179
wound bed preparation, 160 systemic antibiotic therapy, 179, 180
wound healing, 158, 159 treating DFO, 184
deformity, 122–124 Diabetic foot reconstruction, 467, 468
diabetic shoes, 77 Diabetic foot ulceration (DFU), vi, 1, 2, 4, 73, 190, 203,
drug history, 116 404, 417, 418, 591
examination, 116–128 amputation, 59
family history, 116 economic analyses, 58
felt padding, 75 guideline-based management, 59
femoral nerve, 114 healthcare costs, 58, 59
footwear assessment, 128 mortality, 60, 61
gait, 128 prevalence, 58
infection, 119–121 socioeconomic, 60
ischaemic pain, 115 treatment algorithm, 73
lumbar Spinal Stenosis, 114 Diabetic foot wounds, 57
past foot history, 116 Diabetic healing boot, 350
past medical history, 116 Diabetic healing shoe, 350
patellar tendon brace (PTB), 81 Diabetic limb salvage (DLS), 605, 606
presenting complaint, 110 communication barriers, 9
psychosocial history, 116 endocrinologist, 4 (see also Free tissue transfer
saphenous nerve, 114 (FTT))
simple staging system, 109 infectious disease, 5
skin, 117–118 intraoperative risk mitigation, 149, 150
breakdown, 119 location, 7, 8
soft tissue procedures multidisciplinary needs, 7
external fixation for offloading, 84 multidisciplinary team, 3, 4
MIS invasive floating metatarsal osteotomy, 83, pediatric/orthopedic surgery, 4
84 phantom limb pain, 150
modified Keller resection arthroplasty, 83 plastic and reconstructive surgery, 4
offloading options, by wound location, 85 pre-operative optimization, 147, 148
620 Index
Diabetic limb salvage (DLS) (cont.) Endothelial growth factor (EGF), 159
residual limb pain, 150, 151 Endothermal heat-induced thrombosis (EHIT), 298
team communication, 8, 9 Endovascular revascularization, 457
vascular surgery, 4 aortoiliac system, 279, 280
wound management pathway, 6 CFA
Diabetic neuropathy, 66, 67, 69, 71, 252 BTA arteries, 282
classification, 67 BTK arteries, 281, 282
diagnosis, 67 FP segment, 280, 281
foot ulceration, 68, 69 no-option patients with CLTI, 282, 283
pathogenesis, 66 choice of, 276
pharmacological treatment, 69, 70 chronic total occlusions crossing strategy, 278, 279
symptoms and signs, 68 evaluation of collateral vessels, 278
Diabetic shoes, 77 general considerations, 276, 277
Diabetics, perfusion assessment and treatment metabolic demands of tissue loss, 278
history, 251–253 multivessel versus single-vessel, 278
invasive diagnostic imaging, 259, 260 targets of, 277
noninvasive diagnostic imaging, 254, 255, 258, 259 vascular territories of lower leg, 279
PAD, 251 Endovascular therapies, 260
physical examination, 251, 253, 254 Endovenous glue- induced thrombus (EGIT), 299
symptomatic and asymptomatic, 251 Endovenous laser ablation (EVLA), 295
therapeutic options, 260 End stage renal disease (ESRD), 512
Diabetic ulcers, 305 End-to-end (ETE) anastomosis, 489, 512, 513
Dickkopf-1, 218 End-to-side (ETS) technique, 512
Dieckman, C., 306 Enhanced recovery after surgery (ERAS), 152
Direct polymerase chain reaction (PCR), 195 Enterobacteriaceae, 177
Direct revascularization (DR), 277 Enterococcus faecalis, 196
Discoid lupus erythematosus (DLE), 333 Enzymatic débridement, 161
Distal endovascular intervention, 268 Epidural anesthesia, 551
Distal metatarsal metaphyseal osteotomy (DMMO), 366 Equinus contracture, 482
Distal superficial femoral artery, 264 Erythrocyte sedimentation rate (ESR), 188
Division of Economic and Community Outreach Ethics of case management, 39
(DECO), 38 Ethylene vinyl acetate (EVA), 76
Donor sites, 416 European guidelines, 90
Doppler waveform, 258 Evans, K.K., 59, 415–427, 449, 450, 452–462, 603
Dorsalis pedis artery, 253 Executive assistant (EA), 21
bypass, 265 Exostectomy, 245
Dramploas, E., 209 Extensor digitorum brevis (EDB) muscle flap, 433, 434
Drug coated balloons (DCBs), 260, 280 Extensor digitorum longus (EDL), 433
“Drug delivery”, 280 Extracellular matrix (ECM), 306
Drug eluting stents (DESs), 260, 280
Duke activity score index, 89
Duplex arterial scanning, 258 F
Duplex ultrasound, 258, 265, 454, 473, 502 Fan, K.L., 449, 450, 452–462, 591, 603
Durable medical equipment (DME), 37 Fasciocutaneous flaps, 455, 509
Dysvascularity, 349–350, 354 Felder, J.M., 467, 468, 470, 472–475, 477–482, 486,
489, 490, 500, 502, 504, 505, 507, 509, 511–516, 518
Felt padding, 75
E Femoral nerve, 114
Ecthyma gangrenosum, 338 Femoro-Popliteal (FP) segment, 280, 281
Edema, 419, 424, 425 Fernandez, A., 522
Edmonds, M., 107 Fernando, M.E., 137
Eichenholtz stages, 230 Ferraresi, R., 263–265, 267, 268, 270, 271, 273, 275–283
Electronic medical record (EMR), 9, 19 Fibroblast growth factor (FGF), 159
Ellis, A., 13 Fibrofatty padding depletion (FFPD), 123
Emergency Department (ED), 39 Fillet flap of toe, 442, 443
Emergency Medicaid, 42 First dorsal metatarsal artery (FDMA) flap, 435, 436,
Endocrine Society, 91 484, 500, 501
guidelines, 92 Flexor digitorum brevis (FDB), 435
Endocrinology, 457 muscle flap, 434, 435
Index 621
Flexor tenotomy, 364 Georgetown NP Program, 43

Fluoroquinolones, 197 Glaser, J.D., 523
Folestad, A., 220, 221 Global Vascular Guidelines (GVGs), 277
Fontaine and Rutherford classifications, 254 Glucose control, 468
Food and Drug Administration (FDA), 197 Glucose levels, 451
Foot ulceration, 65–68 Glycemic control, 451
Foot vein arterialization (FVA), 283 Gosh, A., 330
Forefoot osteomyelitis, 207 Grabb, W.C., 436
Forefoot wounds, 476–478, 482, 484, 486 Graft infection, 270
Frame orthosis, 231 Gram-negative bacilli (GNB), 196
Free-flap, 39 Granulation tissue, 392
background on, 41 Great saphenous vein (GSV), 286
case management, 41 Greenhagen, R.M., 242
plan, 41 Grewal, G.S., 142
Free tissue transfer (FTT), 605, 607
comparison to non-diabetic patients, 450
free flap reconstruction, 449, 450 H
indications, 450 Haffner, Z.K., 58
intraoperative optimization Hallux valgus, 123
anesthesia, 455 Hammer Toe, 122
flap choice, 455, 461 Harding, J.L., vi
flap inset, 462 Haydek, J., 87
microvascular anastomosis, 461 Hayes, C., 550
for lower extremity, 449 HbA1c, 426
multidisciplinary approach, 451 Hemodialysis, 474
multiple debridements, 457, 459 Hemoglobin A1c (HbA1c), 417, 474
postoperative flap monitoring, 462 Hemostasis, 420
preoperative stage Heparin-induced thrombocytopenia (HIT), 343
endocrine pathways, 452 Herbst, S.A., 242
medicine, 451–453 Herlin, C., 442
podiatric and orthopedic surgery, 454 Herscovici, D., 373
surgical debridement, 454 Higgs, B.G., 349
vascular, 453, 454 High stakes defects, 502
risk-stratified anticoagulation protocol, 453 Hindfoot wounds, 489, 490
targeted antimicrobial therapy, 457 Hoh, T.K., 521
viability of, 449 Hollenbeck, S.T., 455
Fried, L.P., 137, 138 Hong, J.P., 467, 468, 470, 472–475, 477, 482, 486, 489,
Front Desk, 18 490, 500, 502, 504, 505, 507, 509, 511–516, 518
F-Scan systems, 77 Horn, D.M., 376
Full-thickness skin grafts (FTSGs), 416 Hospital Consumer Assessment of Healthcare Providers
aesthetic advantages, 416 and Systems (HCAHPS), 54
benefits of, 416 Hubley, K.S., 1, 47
disadvantages, 416 Huffman, S.S., 603
Functional morbidity, 455 Hyperbaric oxygen therapy (HBOT), 14, 425, 475, 507,
Furlow, L.T., 435 517
adverse effects, 409, 410
clinical practice, 407–409
G diabetic foot ulcerations, 404, 405
Gabapentin, 550 limb salvage, 403
Gabriel, A., 397 lipid peroxidation, 403
Gait analysis, 74 microvascular cell walls, 403
Game, F., 215 physiology, 402
Garada, F., 587 skin grafts and flaps, 405, 406
Gastrocnemius recession, 378 Hyperbarics Program, 18
Gastrocnemius-soleus recession (GSR), 380 Hypercoagulability, 452, 457, 459
Geirsdottir, O., 142 Hyperglycemia, 91, 252, 305
General internal medicine (GIM), 40 Hyperlipidemia (HLD), 40
General Medicine (GM), 36 Hyperspectral imaging (HSI), 257
Genotypes, 452 Hypertension (HTN), 39–40
Georgetown Home Care, 43 Hypertrophic nonunion, 564
622 Index
Hypertrophic obstructive cardiomyopathy Kevin, G., 1

(HOCM), 149 Kiguchi, M., 286
Hypoglycemia, 91, 305 Kim, K.G., 283, 449, 450, 452–462, 545, 591
Hypotension, 455 Kim, P.J., 391–399
Kiparizoska, S., 87
Kleiber, G.M., 545
I Kleinpell, 47
Ibrahim, A.M., 593 Koller, A., 227
IGCA, 260 Kripalani, S., 50
Iliac obstructive disease, 279 Krishnan, S., 3
Ilizarov-type external fixation, 516 Kugler, M.C., 47
Immediate post-operative prosthesis (IPOP), 353
Immune system, 187
Incompetent perforator veins, 299 L
Indocyanine green angiography (ICGA), 260 Lateral calcaneal artery (LCA) skin flap, 436, 437
Infected nonunion, 567–569, 572 Lawrence, P.F., 299
Infection, 523 LeDran, Henry, 157
Infectious disease (ID), 5, 36 Left ventricular ejection fraction (LVEF), 88
Infectious Diseases Society of America (IDSA), 188, 204 Length-of-stay (LOS), 35
Inflow operation, 267 Lesser digits, 364
Infrainguinal arterial reconstruction, 264 arthroplasty, 364
Infrainguinal bypass, 270 Lessing, M.C., 393
Inherited/acquired traits, 452 Levine’s technique, 194
Inosculation and capillary ingrowth phase, 417 Lewi, M.J, 2
Instability, 229, 231 Liao, A., 147
Insulin, 92, 93 Life-threatening condition, 252
Insulin dependent diabetes mellitus (IDDM), 39 Limb salvage, 47, 50, 54, 57, 59–61, 349, 359, 361, 387,
Insulin resistance, 134, 135 609
Integrated model of care (IMOC), 37 complications, 581, 582
Interleukin-6 release, 187 history, 559–561
Intermittency, 392, 394 imaging, 561, 562
Internal fixation, 564, 576 laboratory studies, 562
Internal tissue expansion, 443–445 physical examination, 561
International Working Group on Diabetic Foot (IWGDF), diabetic foot population, 592
178, 179, 194, 204 geographical location
classification, 188 access to care, 592, 593
Interqual Criteria, 36 comorbidities, 595
Interventional procedures, 189 race and ethnicity, 594
Intramedullary hindfoot nail (IMHN), 246 socioeconomic status, 594
Intravascular ultrasound (IVUS), 300 hypertrophic nonunion, 564, 565
Intrinsic muscles, 430 inpatients, 101
Isaac, A.L., 58 lower extremity nonunion, 563, 564
Ischaemia, 120, 253, 424, 524, 525 malunion, 572, 573
foot, 107 multidisciplinary, 595, 596
postoperative management, 584
Lipsky, B.A., 175
J Lisfranc amputation, 536
Jeffcoate, W., 215 Local antibiotic delivery, 208
Johnson-Arbor, K., 401 Local flaps for foot and ankle reconstruction
Joret, M.O., 595 ABH muscle flap, 431–433
Joslin, E.P., 3 ADM muscle flap, 430, 431
angiosomes, 429
EDB muscle flap, 433, 434
K FDB muscle flap, 434, 435
Kalani, M., 256 FDMA flap, 435, 436
Kaloderm, 320 fillet flap of toe, 442, 443
Kang, G.E., 133, 139, 141, 142 internal tissue expansion, 443–445
Karlakki, S.L., 396 intrinsic muscles, 430
Kavarthapu, V., 203, 237 LCA skin flap, 436, 437
Kesavan, R., 107 medial plantar artery flap, 438–440
Index 623
pathologies management, 429 Mittlemeier, 240

principles of, 429 Modi, N., v
random skin flaps, 443, 445, 446 Modified Keller resection arthroplasty, 83
reverse sural artery flap, 440–442 Molines-Barroso, R.J., 245
selection, 430 Moore, Z., 137
Logemann, N., 329 Morrato, E.H., 136
Low-density lipoprotein (LDL), 147 Morykwas, M.J., 392
Lower extremity, 1, 6 Motor neuropathy, 126, 468
biomechanics, 136 Muchna, A., 135
reconstruction, 605–607, 609 Mucormycetes spp, 337
Lower extremity amputations (LEA), vi, 187, 313, 323 Mueller, M., 83
Lumbar spinal stenosis, 114 Multidisciplinary approach, 450
Multidisciplinary care team (MDT), 1–3, 8, 604, 609
limb salvage
M care delivery optimization, 596, 597
Macrodeformation, 393 collaborative initiatives, 597
MacRury, S., 8 Multidisciplinary diabetic foot care team (MDFT), 239
Magnetic resonance angiography (MRA), 258, 259 Multidisciplinary discharge rounds (MDRs), 37, 49
Magnetic resonance imaging (MRI), 205, 221 Muscle flaps, 476, 502, 507–509
Major adverse cardiovascular events (MACE), 148 Musuuza, J., 595
Malunion, 572 Myocardial infarction (MI), 61, 148
Marjolin’s ulcer, 340 Myocardial injury after noncardiac surgery (MINS), 88
Martin, D.Z., 429–431, 433–446
Massive wounds, 496, 497
Mathes-Nahai type B, 438 N
Mathes-Nahai type I flap, 440 Nails, 125
Mathes-Nahai type II flap, 430, 431, 433, 434 Najafi, B., 133, 136, 137, 141, 142
Maturation phase, 417 National Fire Protection Association (NFPA), 408
Maximillian, 8 Ndip, A., 216
McCraw, J.B., 435 Necrobiosis lipoidica diabeticorum (NLD), 426
Mechanical débridement, 161 Necrosis, 121
Mechanochemical endovenous closure (MOCA), 296, Negative pressure wound therapy (NPWT), 40, 50, 51,
297 419, 420, 423, 425, 511
Medial arterial calcification, 258 advantages and disadvantages, 392
Medial plantar artery flap, 438–440 incisions, 391, 393, 394, 396
Medial sural artery perforator (MSAP), 455, 504 indications
Medicaid, 38, 42 chronic wounds, 395
Medical Grand Rounds, 35 closed incisions, 395, 396
Medical therapy, 263 infected/contaminated wounds, 396, 397
Megas, N.R., 47 wound healing, 393, 394
Meta-analysis, 280, 282 innovation, 397, 398
Metabolic equivalents (METs), 148 for mechanisms of action, 392–394, 397
Metatarsophalangeal joint (MTPJ), 362, 438 wound bed preparation, 395
Methicillin-resistant S. aureus (MRSA), 177 Negative pressure wound therapy with instillation
nasal carriage, 195 (NPWTi), 392–397
Methylene blue, 170, 171 Neglen, P., 301
Methylthioninium chloride, 170 Neovascularization, 159
Metronidazole, 197 Neuropathic foot, 107
Microdeformation, 393 Neuropathic plantar ulcers, 207
Microvasculature, 507 Neuropathy, 126, 217, 241, 244, 248
Micro water jet device, 165 Neuropathy disability score (NDS), 67
Middle ear barotrauma (MEBT), 409 Neurothesiometry, 127
Midfoot exostectomy, 368, 369 Neutrophilic vasculitis, 205
Midfoot internal fixation, 247 Neville, C., 135, 136
Midfoot obstacle, 575, 577 New molecular techniques, 195
Midfoot wounds, 489 Ngwe, 208
Milisits, T.F., 73 Nil per os (NPO), 148
Miller, J.D., 359 N-methyl D-aspartate (NMDA), 550
Minimal inhibitory concentration (MIC), 196 Noncompliance, 473
Mitochondrial dysfunction, 135 Non-insulin medications, 92
624 Index
Non-osteomyelitic soft tissue diabetic Patel, H., 49

foot infections, 198 Patel, N., 285
Nonsalvageability, 452 Patellar tendon brace (PTB), 81
Non-steroidal anti-inflammatory drugs (NSAIDs), 550 Pathergy, 330
Nonunion, 560 Patient-centered care plans, 39
No-option patients with CLTI, 283 Patient-controlled analgesia (PCA), 151
Nurse coordinator, 18 Patient discharge
Nurse practitioners (NPs), 47, 49–51, 53 education, 93, 94
Nutrition, 551 goal hemoglobin A1c ranges, 94
screening, 452 home medication management, 94
outpatient follow-up, 94
prevention of atherosclerotic disease, 94
O Patient Portal, 22
Obesity, 255, 468, 507 Patient registration associates (PRAs), 18
Obstacles, 574 Patient-reported outcomes (PRO), 606
Obstructive sleep apnea (OSA), 149 Patient services coordinators (PSCs), 19, 21
O’Donovan, M., 141 Patient Services Manager (PSM), 16
Oedema, 125 Patients’ admission, 203
Offloading, 73 Peer support, 351, 352, 588
Oh, T.S., 59, 449 Percutaneous coronary intervention (PCI), 148
Ollier, 415 Percutaneous flexor tenotomy, 81, 82
Open endarterectomy, 280 Perforator flaps, 504
Operating room (OR), 14 Performance-based outcome measure (PBOM), 552
Opioid induced constipation (OIC), 100 Perineural catheters (PNCs), 551
Opsonophagocytosis, 187 Perioperative cardiac risk
Oral antibiotics, 180 condition, 87
Orbital atherectomy, 281 functional capacity, 88
Osteomyelitis (OM), 190, 203, 429, 434, 468, 473, 475, MINS protocol, 88
484, 491, 514, 518, 522, 523, 530 risk of procedure, 87
Osteoprotegerin (OPG), 217–218 tools, 88
Outcomes, 349, 352, 354 Perioperative cardiac testing
OVIVA study, 180 Ace-I/Arb, 90, 91
Oxidative stress, 135 aspirin, 90
beta-blocker, 89, 90
cardiac biomarkers, 89
P cardiac catheterization/CTA, 89
Pantalar arthrodesis, 373, 374 cardiac stress testing, 88, 89
Paola, L., 208 EKG, 88
Parenteral antibiotics, 189 statin/lipid-lowering, 90
therapy, 196 transthoracic echocardiography, 88
Partial calcanectomy, 509 Peripheral arterial disease (PAD), 57, 65, 251, 260, 263,
Partial foot amputation, 475, 521 276, 418, 594
Chopart’s amputation, 537–539 screening, 254
deformity, 526, 527 Peripheral edema, 255
indications, 521–523 Peripherally inserted central catheter (PICC), 41
infection, 523, 524 Peripheral nerve stimulation (PNS), 151
ischemia, 525 Peripheral neuropathy, 73
Lisfranc amputation, 536 Peripheral vascular disease (PVD), 40, 470, 471, 476,
partial foot amputations, 528 502
partial ray amputation, 531–533 Periwound tissues, 475
toe amputation, 529 Pes cavus, 122
transmetatarsal amputation, 535, 536 Petrofsky, J., 136
vertical contour calcanectomy amputation, 540–542 Phantom limb pain (PLP), 150, 151, 548, 550, 551
wound, 523 Physical therapy, 552
Partial-foot amputee, 39 Plain radiographs, 209
Partial ray amputation, 531 Plantar aponeurosis, 205
Pasieka, H.B., 329 Plantar Callus, 74
Past medical history (PMH), 39 Plasmatic imbibition phase, 417
Index 625
Plastic Surgery (LIMB) service, 40 Raspovic, K.M., 361, 522

Platelet-derived angiogenesis factor (PDAF), 159 Razmjou, K., 147
Platelet-derived growth factor (PDGF), 159 Reactive nitrogen species (RNS), 402
Plethysmography, 255 Reactive oxygen species (ROS), 402
Polyarteritis nodosa (PAN), 342 Readmission, 49, 54
Polymyositis, 115 Reconstruction, 237, 238
Polyurethane, 398 Red–amber–green (RAG) model, 206
Population dynamics, 591, 592 Reducing Amputation in People with Diabetes
Portability, 398 (RAPID), 8
Post-amputation rehabilitation, 552 Rehabilitation, 351, 352
Posterior interosseous artery (PIA) flap, 505 Rehab discharges, 38
Posterior tibial (PT) artery, 254, 384 Relative risk (RR), 592
Postoperative complications Remission, 361
acute kidney injury (AKI), 98 Remote monitoring, 398
antibiotics associated diarrhea, 101 Removable rigid dressings (RRD), 353
delirium, 99 Residual limb pain (RLP), 150, 548
opioid induced constipation (OIC), 100 Residual volume fraction (RVF), 293
postoperative ileus (POI), 100, 101 Restless legs syndrome, 115
postoperative nausea and vomiting (PONV), 99 Retiform purpura, 341
Postoperative ileus (POI), 100, 101 Retrograde approach, 279
Postoperative nausea and vomiting (PONV), 99 Revascularization phase, 417
Posttraumatic stress disorder (PTSD), 587 Reverse sural artery flap, 440–442
Potter, J., 74 Revised Cardiac Risk Index (RCRI), 88
Powell, S.K., 39 Rheumatoid arthritis, 115
Prader-Willi syndrome, 497 Rifampi(ci)n, 182
Prefabricated diabetic walker, 230 Roberts II, A.H., 35
Preparatory prosthesis, 354, 355 Robust soft tissue, 450
Prevention, 350, 351 Rockwood, K., 138, 139
Primary revascularization, 417
Procalcitonin, 195
Prosthetic grafts, 273 S
Prosthetist consultation, 351 Safavi, P., 239
Provider Clinic Coverage schedules, 23 Safety, 472
Provider Clinics, 13 Safety Director, 21
Pseudomonas aeruginosa, 177, 196, 427 Sammarco, V.J., 246
Pseudomonas spp., 194 Samsell, B., 322
Psychosocial assessment, 38 Sanchez, J.A., 203
Pulse volume recording (PVR), 255 Saphenofemoral junction (SFJ), 286
PVD, see Peripheral vascular disease (PVD) Saphenopopliteal junction (SPJ), 286
Pylon, 355 Saphenous nerve, 114
Pyoderma gangrenosum, 329–331, 344, 402 Saphenous vein, 260
graft, 270
Sayyed, A., 415–427
Q Sayyed, A.A., 57
Quality adjusted life years (QALYs), 322 Schon, L.C., 233
Quality of life (QOL), 69 Schwenk, M., 137
Sclerostin, 218
Senneville, E., 193
R Sensory neuropathy, 126
Radiofrequency ablation (RFA), 295 Shan, H., 587
Radiographs, 361 Shanahan, 438
evaluation, 74 Shaper, 604
Rahemi, H., 137, 142 Shiroky, J., 50, 51
Rahnama, A., 521, 559 Siah, M.C., 251–256, 258–260, 263–265, 267, 268, 270,
Random skin flaps, 443, 445, 446 271, 273–283
Randomized controlled multicenter trial, 180 Siddiqui, N.A., 376, 559
Randomized controlled trials (RCTs), 70 Simon, S.R., 239
Range of Motion, 74 Singh, T., 545
RANKL/OPG/NFKappaB pathway, 220 Skin and soft tissues (SSTs), 193
Rasmussen, L.H., 295 Skin flap, 403, 406
626 Index
Skin grafting, 404–406 operating room (OR), 14

classifications of, 415, 416 Outlook Master Calendar, 25
complications patient registration associates (PRAs), 18
factors impairing healing, 424, 425 patient services coordinators (PSCs), 19
revisional procedures, 425 patient services manager roles and responsibilities,
diabetic foot ulcers, 417, 418 16, 17
healing, 417 Plans of the Day, 28
PAD, 418 Provider and Orthotic/Prosthetic Coverage
postoperative healing Template, 25
donor sites, 423 scheduling, 23
recipient site, 423, 424 triage, 18
presurgical evaluation triage desk, 21–23
infection control, 418, 419 upcoming clinic numbers, 26, 27
nutritional status, 419 Staggered Staff Schedules, 13
vascular supply, 418 Standard of care (SOC), 305
soft tissue reconstruction, 415 Stannard, J.P., 396
Skin temperature, 232, 233 Staphylococcus aureus, 177, 193
Slit arteriotomy, 512 Statin/lipid-lowering, 90
Smoking cessation, 452 Steinberg, J.S., 1, 359, 444, 603
Social vulnerability index (SVI), 593 Sterile bone biopsy, 190
Social Work (SW), 35, 39 Streptococcus agalactiae, 193
Society of Vascular Surgery (SVS), 290 Subacute rehab facility (SAR), 40
Socket, 355 Subfascial endoscopic perforator vein surgery (SEPS),
Soft tissue reconstruction, 84 299
Spillerova, 278 Superficial circumflex iliac artery perforator (SCIP) flap,
Spinal cord simulation (SCS), 151 455, 478, 481, 500, 505, 506, 511
Split-thickness skin grafting (STSG), 415, 427, 458 Superficial circumflex iliac artery perforator (SCIP) free
advantages of, 416 flap, 458–460
benefits, 416 Superficial circumflex iliac vein (SCIV), 484, 505
conservative approach, 416 Superficial inferior epigastric artery (SIEA) flap, 493
disadvantages of, 416 Superficial inferior epigastric vein (SIEV), 505
donor site, 423 Supermicrosurgical flaps, 504
healing of, 424 Support group, 587, 588
indications, 416 Supramalleolar osteotomy, 376
operative steps, 420 Surgical consultation, 189
application, 422, 427 Surgical débridement, 163
harvesting stage, 420–422 indications, 164
wound bed debridement, 419, 420 Surgical intervention, 81, 359
Split tibialis anterior tendon transfer (STATT), 381, 382 Surgical management
Squamous cell carcinoma, 339 clinical assessment and classifications, 203–205
Staffing and day-to-day management of DFO, 206
associate engagement, 30–32 of diabetic foot attack, 209
attendings/residents coverage, 14 forefoot osteomyelitis, 207, 208
billing analyst, 19, 21 of infected heel ulcers, 208, 209
certified medical assistants (CWH), 17
clinical staff schedules, 28
CWH/HBOT staffing structure, 14–16 T
daily operations, 13, 14 Tahan, H.H., 39
executive assistant (EA), 21 Takeji, Y., 141
hyperbaric oxygen therapy (HBOT), 14 Talectomy, 374
hyperbaric technicians and safety director, 21 Tamir, E., 83
leadership, 16 Target arterial path (TAP), 277
managerial tracking of clinic operations, 30 Targeted antimicrobial therapy, 459
managers’ perspectives, 32–34 Targeted discharge date (TDD), 39
nurse coordinator, 18 Targeted intravenous antibiotic therapy, 209
nurse manager roles and responsibilities, 16 Targeted muscle reinnervation (TMR), 549
nurse practitioners, 18 Target lesion revascularization (TLR), 280
nurse specialists, 17, 18 TcPO2, 256
Index 627
Tendon Achilles lengthening (TAL), 82, 377, 457 V

Tendon transfers, 83 Vacuum assisted closure (VAC) device, 40
TGF-beta, see Transforming growth factor (TGF-beta) Vainieri, E., 209
Thiersch, 415 van Asten, S.A.V., 175
Thonse, R., 576 Van Eekeren, R.R., 296
Thoracodorsal artery perforator (TDAP) flap, 486 Van Epps, P., 141
3-step algorithm, 477 Vascular endothelial growth factor (VEG-F), 159, 402
Tibiotalocalcaneal arthrodesis, 370, 372 Vascular insufficiency, 187
Tinea incognito, 336, 337 Vascular intervention, 475
Tinea pedis, 337 Vascular network, 417
Tissue handling, 529 Vascular surgery, 4, 457, 459
Tissue necrosis, 205 Vasculitis, 342
Tissue product, 306 Vasculopathies, 343
Tissue-engineered skin grafts, 415 Vasopressors, 455
Titrating therapy, 92 Vastus lateralis free flap, 455, 457
TNF-alpha, 187 Vein harvest incision, 264
Toe amputation, 529 Venous clinical severity score (VCSS), 292, 296
Toe-brachial index (TBI), 255 Venous duplex studies, 459
Toe systolic pressure measurements (TSP), 255 Venous obstruction, 290
Toosizadeh, N, 139 Venous studies, 457
Topical oxygen therapy, 410 Vertical contour calcanectomy (VCC), 541
Total contact casting (TCC), 78–80, 230, 350, 516, 517 amputation, 540
Traditional angiography, 473 Verzella, A.N., 305
Traditional workhorse type flaps, 500 Viability, 449, 453
Transcutaneous electrical nerve stimulation Viable tissues, 172
(TENS), 151 ViOptix Tissue Oximeter, 462
Transcutaneous oxygen measurements (TCOMs), 518 Vitamin D, 560
Transcutaneous partial oxygen pressure measurements V-Y advancement flap, 444
(TcPO2), 255, 257
Transcyte, 316
Transforming growth factor (TGF-beta), 159 W
Transmetatarsal amputation (TMA), 59, 475, 476, 478, Wallace, T., 13
486, 513, 533 Warfarin, 96
Transport media, 343, 344 Weaver, N.K., 87
Transthoracic echocardiography (TTE), 88 Weight-bearing films, 74
Transverse partial latissimus flap, 505 Wheeler, M.G., 87
Traumatic amputee, 353 White blood cell count (WBC), 188
Tricyclic antidepressants (TCAs), 150 WIfi classification system, 254
Trigger toe, 122 William, H., 216
Trough, 512 Wnt/β-catenin pathway, 218, 220
T-shaped/flow through anastomosis, 513 Workhorse flaps, 482, 504, 512
2020 ADA Standards of Care and Endocrine Society World Health Organization, 133
guidelines, 92 Wound Center Staffing, 15–16
2009 NICE-SUGAR trial, 92 Wounds, 523
Type II diabetes mellitus, 426, 497 ankle, 490
bed preparation, 160
forefoot, 477, 478, 482, 484, 486
U healing, 158, 159, 321, 404, 405
Ucci, A., 263–265, 267, 268, 270, 271, 273, 275–283 hindfoot, 489, 490
Ulceration, 73, 522, 531 massive, 496
debridement, 209 midfoot, 489
gangrenous area, 252 Wrobel, J.S., 136
Ultrasound, 258 Wukich, D.K., 237
United States, 73
US Veterans Health Administration, 182
Utilization Review (UR) Nurse, 36 X
Xenografts, 306, 313
628 Index
Y Z
Yang, C., 394 Zahiri, M., 139, 140
Yang, F., 329 Zarick, C.S., 73, 415–427
Yavuzer, G., 137 Zhang, C.Q., 588, 594
Yazdanpanah, L., 522 Zhou, H., 142, 143
Zulbaran-Rojas, A., 142

Functional Limb Salvage

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ISBN 978-3-031-27724-5 ISBN 978-3-031-27725-2 (eBook)

© Springer Nature Switzerland AG 2023

Diabetes: The Twenty-First Century Epidemic

8. Bullock A, Sheff K, Hora I, et al. Prevalence of diagnosed diabetes in American Indian

Division of Diabetes, Andrew J. M. Boulton

Washington, DC, USA John S. Steinberg

Areeg A. Abu El Hawa, Kevin G. Kim,

Background approximately 23% of new DFUs will ultimately

© Springer Nature Switzerland AG 2023 1

Multidisciplinary Interdisciplinary Transdisciplinary

Successful implementation of a MDT has led to a

only increases postoperative complications in the or intermittent suppressive antibiotic therapy to

Identifying the Patient Location

• Electronic Medical Record (EMR): A  atient Centered Care and Role

The success of a multidisciplinary care team is Conclusion

Amara Ellis and Tara Wallace

© Springer Nature Switzerland AG 2023 13

• Weekday outpatient clinic visits.

Wound Center Staffing (Fig 2.1)

Hyperbaric Cerfied Medical

Hyperbaric Tech Paent Srvcs Outpaent NP #2

Paent Reg Inpaent NP #2

Execuve HBOT Nurse

Fig. 2.1 Org Chart

Page 3: Who Does What? (b) Attends various Hospital/Administrative

of daily schedules edits as necessitated 8. Implements cross-training schedules between

Fig. 2.2 Fee ticket

Fig. 2.3 Clinic master calendar

Fig. 2.4 Outlook master calendar

Page 11: Scheduling Page 12: Scheduling

Outlook Master Calendar (Fig. 2.4) Provider and Orthotic/Prosthetic

Updated Provider Templates as of 1/4/21

Monday Tuesday Wednesday Thursday Friday

Benedict AM Benedict Benedict

PM Nicole NP Clinic KKE Clinic Nicole NP Kerry NP Clinic JSS Remote/Tele

Hanger Coverage as of 11/3/20

Monday Tuesday Wednesday Thursday Friday

Elisa 8:30-2:30 8:30-2:30 8:30-2:30 8:30-2:30 8:00-5:00

Hanger Schedule for CWH, 2021

Jan 4 John Jan 7 Charlie

Fig. 2.5 Provider and orthotic/prosthetic coverage template

does an overview of the numbers and uses a

Fig. 2.6 Upcoming clinic numbers

PLAN FOR THURSDAY, 1/28/21 Page 14: Scheduling

LUNCH: These are the weekly clinical staff scheduling

Fig. 2.7 Plans of the day

Monday Tuesday Wednesday Thursday Friday

Fig. 2.8 Clinical staff schedules

 age 16: Managerial Tracking

need to give any associate feedback, we are –– Be Present, Be Visible, Be Accountable:

© Springer Nature Switzerland AG 2023 35

The Complex Discharge Plan

Case This patient had several outside case managers

hospital-of-origin. At the time of the original Conclusion

Nancy R. Megas, Katherine S. Hubley,

Introduction other services and responding to patient and fam-

Diabetes: The Twenty-First Century Epidemic

Washington, DC, USA John S. Steinberg

Background approximately 23% of new DFUs will ultimately

Identifying the Patient Location

• Electronic Medical Record (EMR): A atient Centered Care and Role

The success of a multidisciplinary care team is Conclusion

Wound Center Staffing (Fig 2.1)

Hyperbaric Cerfied Medical

Hyperbaric Tech Paent Srvcs Outpaent NP #2

Paent Reg Inpaent NP #2

Execuve HBOT Nurse

Page 3: Who Does What? (b) Attends various Hospital/Administrative

Page 11: Scheduling Page 12: Scheduling

Outlook Master Calendar (Fig. 2.4) Provider and Orthotic/Prosthetic

PLAN FOR THURSDAY, 1/28/21 Page 14: Scheduling

age 16: Managerial Tracking

The Complex Discharge Plan

Case This patient had several outside case managers

hospital-of-origin. At the time of the original Conclusion

Introduction other services and responding to patient and fam-

Conclusion plinary rounds. Prof Case Manag. 2019;24(2):83–9.

Introduction DFUs serve as a major source of global mor-

Introduction (a) Why does DPN result in diabetic foot ulcer-

nephrine and serotonin reuptake inhibitor, Conclusions

I ntroduction to Offloading and Its generally used to describe decreasing pressure to

patient flexes the toe to cause a “bowstring” Tendoachilles Lengthening

ffloading Options Categorized by

M. M. Alternburg · J. M. Haydek · S. Kiparizoska · onditions That Confer Risk

Preoperative Cardiac Testing Cardiac Stress Testing

Inpatient care for limb salvage patients often Hyperglycemia

oal Glucose Range

Antidiabetic Medications Basal insulin Basal-bolusb

Bleeding Risk din can be reversed. Oral or IV vitamin K

Antiplatelet Agents Venous Thromboembolism (VTE)

Delirium where possible [65]. Current recommendations

pioid Induced Constipation

ntibiotics Associated Diarrhea

Introduction 1. The neuropathic foot

Simple Staging System 1. Normal foot

Classifications of the Diabetic Foot resenting Complaint (Be Aware That

ilateral Neuropathic Pain

The rest of the history is devoted to gathering Past Medical History

Skin and Skin Breakdown