PREOPERATIVE DIAGNOSES:
1. Diabetic ulcer of the right great toe.
2. Deep infection of the right great toe involving the first
metatarsophalangeal joint.
3. End-stage osteoarthritis of the right first metatarsophalangeal joint.
4. Diabetes mellitus.
PROCEDURE:
1. Irrigation and debridement of the right great toe ulcer including bone
resection of the first metatarsophalangeal joint.
2. Repair and closure of the ulceration.
This 53-year-old gentleman who developed an ulceration over the dorsum of the
right great at the first metatarsophalangeal joint. He did develop infection
and was being treated as an outpatient with intravenous antibiotics through a
peripherally inserted central catheter (PICC) line as well as oral
antibiotics. He subsequently developed some exposed bone and on x-ray was
noted to have end-stage osteoarthritis with a fractured osteophyte exposed in
the wound. Because of the obvious risks of progressive deep infection and
loss of limb, it was felt that the patient would best be served through
operative intervention in the form as described above. A complete discussion
of all risks, benefits, alternatives was undertaken with the patient. He
understood the risks and they wish to proceed with the operation, therefore an
informed consent was obtained prior to surgery.
FINDINGS AT SURGERY:
The fractured osteophyte was easily identified in the wound. It was
dorsomedial. It was removed. The joint was exposed beneath this bone. No
frank pus was encountered. The actual appearance of the foot appeared much
better than on initial consultation, reflecting improvement on the antibiotic
regimen. This included decreased swelling and decreased erythema. The bone
resection was continued all around the dorsum of the first metatarsophalangeal
joint appropriately contouring the dorsum of the joint so as to remove any
bony pressure on the area of ulceration. The joint itself was explored and
noted to be severely arthritic with eburnated bone. Careful attention was
taken to identify that there was no residual bone pressure on the skin and
ulceration prior to closure, ensuring that the bone resection was
satisfactory.
PROCEDURE:
Once informed consent was obtained from the patient, he was taken to the
operating room and laid supine on the operating table. General anesthesia wasachieved and appropriate intravenous prophylactic antibiotics were continued.
All bony prominences were padded well as a tourniquet was placed high on the
right thigh and the right lower extremity was prepped and draped in the usual
sterile fashion from the tips of the toes to above the knee. The right lower
extremity was elevated then for approximately 5 to 7 minutes and the
tourniquet was inflated to 300 mmHg. The area of ulceration was then
debrided. The exposed bone was immediately removed with a rongeur and the
joint was explored. The joint was debrided. Heterotopic hypertrophic bone
was debrided all around the first metatarsal head and slightly around the
proximal phalanx but the majority was around the first metatarsal head. This
included the use of rongeurs and also reciprocating rasp.
Once the bony resection was completed, some infected granulation tissue was
also debrided. The area was then copiously irrigated with antibiotic
irrigation and closure ensued. The Penrose drain was placed with a small stab
incision over the tip of a hemostat. The drain was then tied off. Closure
was then performed. The deep periosteal and fascial tissues were closed with
absorbable suture creating a satisfactory seal of the joint. Then the skin
itself was closed with nylon suture over the drain. Care was taken to avoid
sewing in the drain. The wounds were then dressed with Betadine ointment,
Adaptic, sterile gauze with gauze in the first web space. The tourniquet was
then deflated as the bandage was further secured with sterile Sof-Rol and an
Ace wrap around the ankle. The patient was recovered from general anesthesia,
extubated and safely moved to the recovery room awake, alert and in stable
condition. Of note: Needle and sponge counts were correct at the end of the
case. Again there were no complications.
