• LecturehallSurgical Reconstruction Solutions in the Diabetic Foot
  • Lecture Transcript
  • TAPE STARTS – [00:00]

    Harold: Kicking off Sunday morning is Dr. Lee Rogers. I've known Dr. Rogers for many years. He is extremely bright. He is the National Medical Director of the Amputation Prevention Center of America, a division of RestorixHealth. So he is very well recognized in the wound care space and really has podiatry very much involved in that space. He is well written, he has received numerous awards from the American Podiatric Medical Association. He is a accomplished politician which we certainly need in today's world.

    And at this point in time, I'm going to welcome Dr. Rogers who is going to be talking on common reconstructive procedures for the diabetic foot. So please welcome Dr. Lee Rogers.

    Lee Rogers: Thanks, Harold. I'm not quite that accomplished as a politician but for those of you that know my record. The – and also, I had to change my Invisalign this morning so if I slur a little bit, I'm not – I haven't had anything to drink yet. I don't drink before 08:30. So I – it's the braces I have in.

    We're going to talk about the surgical reconstruction in the diabetic foot and what are some of the common procedures and how you can employ them in your practice with your patients to help to offload the foot and get some wounds closed.

    So really – here's my complex of interest as Harold said, I'm a medical director for RestorixHealth. I do consult with some other companies, none of which have anything to do with this lecture. These are the objectives for the lecture.


    And so when you think about the diabetic foot surgery, you know, there have been classifications out there looking at surgery as far as whether it's elective, prophylactic, curative or emergent but I look at it a little differently in the way of whether we're trying to offload pressure to heal a wound, or whether we're trying to use – so whether we're doing some soft tissue procedures to close a wound or whether we're doing osseous procedures to relieve the pressure on the wound both for curative or prophylactic reasons.

    So these are some of the procedures that we're going to discuss today and their role in diabetic foot management. I hear like a clicking up here in the speaker. Do you guys hear that in the back? Yeah. Can you hear it?

    Male Speaker: Not really.

    Lee Rogers: So the – let's first look at one of the most common things that I do in diabetic foot, and that's a tendoachilles lengthening and this is interesting. When I – I do some work in the Middle-East, you probably heard from Bob Frykberg yesterday. And he talked about some of his work over in Dubai. And one of the first times I went over there, the – actually, this was in Dubai as well – Dubai Hospital. They said to me – I was going over, just operating on one specific person but while I was there, he said, "Do you mind? You know, we have a whole hospital full of diabetic foot problems. Do you mind operating on some other people while you're here?" And I, you know, I kind of thought that they were being facetious and so I did rounds with them. And they had a whole hospital full of diabetic foot problems.

    It was amazing. And I operated on maybe 19 or 20 people in the next couple of days and I probably did two things, you know, 90% was two operations.

    One was a tendoachilles lengthening and the other was a Keller arthroplasty.


    And these were – these were used to address problems that were keeping patients in hospital over there for long periods of time and, you know, their rules and regulations were a little different. They couldn't discharge anybody with an open wound, which you think about that in the rule of – with diabetes and if we had that same rule here, you have people in the hospital forever. So they just kind of put people on their back with their feet up until they're healed and then – because they didn't address the pressure, they would re-ulcerate and be back in the hospital.

    So this is one of the more common things that I do and really addresses a common problem in the diabetic foot. So the purpose of an Achilles tendon lengthening is to lengthen or probably more accurately weaken the Achilles tendon that provide some muscle tendon balancing so that your posterior muscle group is no longer overpowering your anterior muscle group. The indications can be equinus, or Charcot foot or plantar forefoot ulcers. And this is probably where I see the biggest utility in the diabetic foot. And even prevention of plantar forefoot ulcer.

    So when you see a pre-ulcer in the foot – and then in some cases too, I'll do this at the same time as I'm doing a TMA in order to prevent a wound dehiscence or complications on the stomach. There are some possible complications, you know, there's – you can over lengthen, there could be an Achilles rupture which leads to calcaneal gait. It can also cause a calcaneal ulcer then and even amputation.

    And I've had a couple of amputations even as a complication of an Achilles tendon lengthening that ruptured. And these are really hard to treat after they've – if you have calcaneal gait.


    So the – here's a case example of patient that had a transmetatarsal amputation but didn't have the Achilles tendon addressed at that time and now has an ulcer. This ulcer is deep, it doesn't probe the bone. You know, there's a lot underneath this superficial macerated tissue.

    So this patient in the operating room – I usually do an ulcerectomy, so I tried to remove the whole ulcer in one piece. It's nice if you can just kind of make a cone. I find the deepest part of that and make a cone around it and remove that ulcer. And then you can see on the operating room table even when the patient's under anesthesia and supine, you can even see the equinus there and how that would contribute to this ulcer formation.

    The – some people do open the Achilles tendon, I think more with elective reconstructive procedures but for – in the diabetic foot, it's probably safer to do the standard triple hemisection. And in this case, I usually draw it out. And, you know, I do hear people say, "Well, you should do two stabs medially and one stab laterally." Because the proximity of the sural nerve on the lateral side. But if you're operating on somebody with diabetes and foot ulcers and the sural nerve is only a sensory nerve, it does – I don't think it makes any difference on whether do you do too medial or too lateral. You do want to have these incisions be about a centimeter and a half or longer from one another. And then there is difficulty if you get – if you get further proximal because you get up here into myotendinous junction. And it really fans out and then you have difficulty getting all the fibers. So I try to stay in the bulk of the center of the Achilles tendon.


    The same thing down here distally. And you can see how the tendon fibers would, you know, fan out here. And so you want to make your stab incisions. I use an 11 blade, but some people use a 15 blade. They go in perpendicular or parallel with the – with the tendon and turn the blade perpendicular to get the cut. I take an 11 blade and go in perpendicular to begin with. But you want to get more – at least in order for this to work, at least get 50% of the tendon.

    And then – let's see if this video works here. This is – this is on a cadaver by the way. That's why the color of the foot is that way.

    And so I use the 11 blade. You want to have some pressure on the plantar surface of the forefoot because that helps you keep the tendon in one spot. If the tendon – if the patient's moving around or you're moving the foot around, the tendon may not line up with the tiny skin incision that you created and that's going to be harder to find.

    So you can create – you can have somebody put a little pressure there or sometimes I just lean against it with a – with you – I get 30, 40 years old and I got this thing right here now and you just lean against it with this thing underneath and that helps to keep the foot tight.

    And you'll know if you don't get at least 50% of the tendon because when you're leaning into the foot – that's another thing that I do to help get the lengthening, when you're leaning into the foot, you should feel a little kind of – they call it a slide. It doesn't really feel like a slide to me. It feels like a little cracking. Like if you're cracking celery or something but you should feel that there. Now, you don't want to feel a pop, that would be bad. But you do want to feel a little bit of this cracking and again, this is on a cadaver. So I wanted to reopen it up afterwards to show what it looks like.


    And so I said it's really a weakening of the Achilles tendon, that's true. But you do get this length out of it. So when you get that slide, you can see right here, this is probably half a centimeter maybe, so you're getting like a half a centimeter length out of three different stab incisions and so that's a full centimeter and a half of length that you'll get with this Achilles tendon lengthening with the triple hemisection.

    And so I like to do them prone unless it's part of another procedure and then I'll just, you know, do it while the patient is supine and just figure it out from there, but it's harder to do when they're supine. And then you could see here it's how I'm visualizing the tendon, but also leaning in and just giving constant pressure, not a jerky type of pressure, but constant pressure until I feel that slide.

    So, then, post-operatively, these patients really have to be protective and this is going to help to reduce the complication rate. You can use a removable cast walker, but, you know, 90% of the problem with the removable cast walker is in a third of its name. It's removable. And so that's the issue there. If you have somebody you really trust, then, you can use that. You could also render a removable cast walker less removable by wrapping it with Coban or something like that.

    But I like to use a total contact cast. Even if there's no ulcer, you know, I'll use the total contact cast just for mobilization afterwards for an Achilles tendon lengthening and I think that helps to reduce the complications. And I think I don't think you need the cast for longer than four weeks, but I think four weeks is a good – is really a good guide to go with after an Achilles tendon lengthening. So what happens if you either over-lengthen or this guy actually – this was after he was out of the cast.


    He was a pharmacist and there was a little ledge inside like an old style pharmacy where he had to walk up on top of a – you know how the pharmacist's counter was a little higher in those old pharmacies where he stepped with his forefoot on the ledge and then ruptured his Achilles tendon. And after the lengthening, about maybe a month and a half or so and then started to have these problems with his heel – this is a different patient who also developed a calcaneal gait and developed some ulcers.

    This guy developed some problems with his heel first just started as a big callous and then a small ulcer. You can see there. And then when we look at it with thermographic imaging which we do a lot now to determine risk for ulceration, you can see that this heel, 90 degrees and this one is 79 degrees, 11-degree difference, 4 degrees difference is significant for prediction of ulceration. And so he actually went on to develop a large ulceration, even calcaneal osteomyelitis and he ended up having a below-the-knee amputation which again is not uncommon in this group when you do have some of the bad complications from Achilles tendon lengthening.

    Now, those are very and frequent. Now, these are actually the only two cases I've ever had probably in maybe, you know, 300 or 400 that I did follow up on. The patients I've done in the Middle East, I don't have any follow up on, but – so I only had a couple that turned out like this. To treat this, you know, is very difficult. Could you go in and try to repair the Achilles tendon or graft it? Yes. But in somebody with diabetes and all of this risk and then at that point, you're casting them in equinus and so you're recreating that problem that you were trying to fix in the first place.

    And so – and this guy, I actually had to fuse his ankle joint in order to prevent any complications there from the calcaneal gait.


    So an alternative to that, if you – and I think that there are people that rightly so think that this is a little bit less risky of a procedure, the procedure itself is more complicated, but it's probably less risky in the post-operative period. You could do a gastrocnemius recession and a gastrocnemius recession is done higher up on the leg. And so here's the – the heel is just off of the picture here. Here's the Achilles tendon and then this is using a pediatric vaginal speculum.

    So they always wonder why a podiatrist is going for a pediatric vaginal speculum, but it's great to help visualize the tendon. So I'll make the incision here medially and then identify the myotendinous junction of the gastrocnemius tendon of the Achilles tendon and isolate the gastrocnemius tendon. You can either use a hemostat or your finger to separate it from the underlying soleus muscle.

    And once you do that, you stick the vaginal speculum in, turn it sideways, open it up, and the gastrocnemius tendon is then underneath this or deep to it. So here's anterior and here's posterior and then you can just use either scissors or I tend not to use a scalpel. I know some people will stick a scalpel blade in there and transect it all the way across, but I think it's a little risky and especially with some of the veins in the area. And if you nick one of those veins, it's really hard to stop the bleeding. So I'll use a scissor and just cut it all the way across. And then you should notice an immediate effect on the Achilles tendon.

    Post-operatively, this is probably easier to deal with. I don't cast these people. I will put them in a removable cast walker, but I'll still let them walk.


    And so it is a – you can see here. Here's the underlying muscle belly of the soleus and here's the gastrocnemius tendon after it's been transected. And so then, another really common procedure that I think is very useful in a diabetic foot is a Keller arthroplasty. The purpose of this is to increase the range of motion in the first metatarsophalangeal joint, reduces pressure underneath the hallux. And, you know, the common indications are hallux limitus or rigidus, even in the diabetic foot, if functional hallux limitus, I'll still do it for that – in those cases.

    But these people with diabetes neuropathy aren't having the same symptoms that somebody else would have who had sensation and coming in complaining of pain with range of motion in their first metatarsophalangeal joint. And instead probably the earliest sign that you see is a callous underneath the ulcer underneath the hallux especially in the medial side – the medial plantar side of the hallux and that's due to them abducting a bit and rolling off the inside of the hallux and they don't really know that they're doing that because of the neuropathy.

    So the possible of complications, you can destabilize the hallux. There's always the risk of getting a transfer lesion pretty much anytime you do any of these diabetic foot balancing. Whether it's osseous or myotendinous, there's always a risk of transfer lesions and then getting a floppy toe.

    So this is a real common presentation. Pretty much anytime I see an ulcer – neuropathic ulcer underneath the hallux, you know, I'll just bet you that there's hallux limitus there again either structural or functional. And so whenever you test for this, you want to make sure that you load the forefoot. So loading the forefoot here and attempting to dorsiflex the hallux and sometimes you'll say, “Well, there's a little bit of dorsiflexion there.” But really you might just be getting a little motion in the IPJ and not in the metatarsophalangeal joint.


    But, you know, normally, you should see somewhere around 45 degrees or more of dorsiflexion for normal ambulation and in these people who develop these foot ulcers, they're just putting extra pressure on the distal hallux as they're walking.

    So, you know, remove the base of the proximal phalanx, sometimes, we remove up to a third of the proximal phalanx and it really depends on how tight the surrounding soft tissue is and whether I think I'll get adequate range of motion afterwards. And, you know, you're probably – I said a floppy toe is one of the complications of this, but you are kind of making the tow floppy on purpose in order to reduce the pressure on the distal hallux.

    So, then, the – oftentimes, the ulcer plantarly heals before the sutures even come out dorsally and that shows you just what the contribution of that type of pressure is on the plantar surface of the foot and contributing to this ulcer. And so here it is on that same day. So this is maybe the first or second post-op visit and you could see the ulcers are already healing and looks pretty clean. And then here it is maybe this is like a couple of weeks later but completely healed.

    And these types of patients, I still will put in a total contact cast not because I need immobilization of that joint, but I consider the total contact cast the best practice for offloading diabetic foot ulcers. And so even in very few instances, do I use a post-operative shoe in a diabetic foot ulcer? I think that the only time that's really appropriate is for a dorsal toe ulcer. Pretty much everything else should have something that immobilizes the ankle, but after a Keller arthroplasty, a post-operative shoe is probably okay.


    But I still go overboard, I think and use the best practice which is a total contact cast. You don't need it very long, really, you just need it until the sutures are removed or until the ulcer heals which, generally, is very quick.

    And then post-operatively you can kind of see what the X-rays look like and how much of the base you removed. This guy really had a long – you can see how long his – the proximal phalanxes of his second toe. He really had a long – he has long proximal phalanges. And this was almost a third of the third phalanx.

    Skin expansion surgery, this is something that I – one of my favorite things to do that's the soft tissue surgery in order to heal wounds. What we do is we stretch the skin to primarily – to get primary opposition, the indications are for skin areas and in skin defects and areas where the skin has expansile ability. It's a little bit more difficult on the plantar surface on the foot that you can still use it but it doesn't expand as well and so you have to either – if it's part of another surgery, where you're removing some bone and you're getting a little bit of redundancy, that's fine or you leave it on longer on the plantar surface of the foot and that will help to stretch but otherwise, it stretches pretty easily and quickly.

    You know, possible complication is not really due to the expander itself but just to the wound complications, you can have, you know, dehiscence failure and infection. So this is somebody who had a lateral ankle ulcer that was debrided and in then VACed, you can obviously tell this wound had a VAC on it because of the quality of the granulation tissue and it was deep and the bone wasn't exposed here but it was still really deep on the lateral ankle. This is like right by the lateral malleolus. And so I want to get this thing closed but it's taking a long time with the VAC and if this was shallow and granular, I would do a split-thickness skin graft there.


    But it's not shallow and so I need to get this thing closed. And so what I usually do is I create a ellipse – I ellipse out the wound and I'm using a VERSAJET here to do that and then you measure this and about 1.5 centimeters across, I put a little mark – # mark and then implant the – these are like anchors – the skin anchors, so, you put them in. They have really sharp spikes that go into the skin here and then you staple them into place, then they have a hook. And then this device here is derma closed. I think it's the only really effective topical skin expander and so then, you put this on – there's wires that – and I just kind of create a bridge here so that this usually goes directly against one of these hooks but in certain parts due to contour of the foot or the ankle, it's difficult to do that and it sticks up a lot. So I create a little bridge here just with oxygen tubing. And then, you can see the wire that's coming out and you shoelace it through all of this and you start twisting this knob and it acts kind of like a corset and it just pulls the wound close.

    And in many cases, the wound will close in the operating room on the same visit. There's still too much tension to close it with suture so you just leave it for, like, three days and you bring them back to the operating room and then you can just close down. This was three days later and you can just close it with sutures under minimal tension at that point.

    Splitting skin grafts are very useful in the diabetic foot as well. You know, sometimes people complain about the failure rate of splitting skin grafts in the diabetic foot and I think that that can be one just understood that even if you have some failure, it's still a success with splitting a skin graft.


    Even if you have a very large wound and you put a splitting a skin graft on it and 10% of it fails. You still made that wound 90% smaller and it's a more manageable wound now. And then, also, I think with better wound bed prep ahead of splitting a skin graft. Using things like, wound VAC even for three days. A lot of time I'll just prep a wound with VAC before putting a skin graft on and I think that improves the take as well.

    These really are for shallow granular wounds that don't have infection and they don't have exposed deeper structures because any deeper structure, the skin graft is not going to adhere. So wounds like this was a dorsal foot infection that had an IMD and a big debridement. Now, it's been VACed and it's shallow and granular, putting a splitting skin graft here and you can see I had to, you know, I took one and it didn't quite fit all the way, so I had to take another little bit and put it here. And these are meshed to be expanded typically in the foot, we do 1.5 to 1 but if you – I've had some really large circumferential leg ulcers that I've had to do and mesh it 3 to 1 in order to get a better coverage from a smaller graft.

    And then, I use VAC as bolster dressing, I think that also really improves the take and then this is when the VAC is discontinued only seven days later. Here we have the VAC off and you can see this is healing very nicely.

    You do have to worry about donor site morbidity in these patients but I don't think you have to worry that much about donor site morbidity. People will say, "Well, it's, you know, I'm creating another wound." Usually, I'm harvesting from the high and you might say – depends on what state you're in but you say, well, that doesn't sound right, your podiatrist – what's your scope of practice?


    And a lot of the states, especially out west, like in California, the law is really a treatment based law. So, if I'm treating the foot or ankle, then I'm within the scope of practice. If I harvest Iliac Crest or skin from the thigh and it's being used to treat the foot or ankle by any means – medical, surgical, or physical, or I used hyperbaric oxygen to treat a foot or ankle problem then I'm within the scope of practice to do that.

    And so, I do think it's better to harvest from the thigh anyway, as opposed to where some podiatrist do in certain states where they feel like they're scope of practice may not allow them to do that. They'll harvest from the posterior calf and I think that that does cause some increase donor site morbidity, one, because it's more distal and, two, because you're getting some rubbing there if the patient's sleeping or when they – if they put a boot – a cast boot on.

    So I think I have the other option here which is epidermal grafts. So these epidermal grafts are used to cover shallow wounds. They don't have the same complications as a splitting a skin graft does. It is better also with the epidermal grafts to harvest from the thigh but you can use a device that just does it in the clinic or in your office.

    This is an example of patient and this was a splitting of skin draft that had a partial take. I didn't put the skin graft here. I don't like to put splitting the skin grafts and weight bearing areas. Some of the plantar surfaces of the foot is not weight bearing, like the arch and we'll put grafts there but here under cuboid, these are, you know, predictively fail here.

    So, this patient came in after having this done and having this wound shut. It had to be debrided and VACed and prepped and once it's prepped, then I used this device to create suction blisters on the thigh and then this is when the head comes off of the device and you put – it created the head to head suction and heat. You put a Tegaderm here and it sticks to all the tops of all these blisters.


    So what you have are just these tiny little epidermal blister and then you – there's a blade that blue lever goes back and it chops off the top of all these blisters. So, now, you have a Tegaderm with about a 120 little islands of epidermis on it and then you move that to wherever you need for a transplant.

    So here's a donor site. The donor site heals, usually within 24 hours. You can't even tell that there's any problem here in the donor site. And then, you know, I'd like to do bolster dressing wit VAC but sometimes it's not possible, you know, in this case it was difficult because I was worried about the surrounding skin so I just bolstered it here with some foam and some steri-strips. And here was the first visit back. And he's, you know, I actually had this guy in a total contact cast, so I'm mitigating the pressure but you can see what in effect with mitigated pressure and the epidermal graft has in that case.

    And some – run out of time and I never like to go over especially when I'm moderating later because it causes some problems for me. So I'm going to skip through all of this stuff here. So Charcot foot reconstruction, I think Nick Bevilacqua is talking some of that later today and a lot of these are cases that Nick and I did together in fellowship or afterwards in practice.

    And I'll just draw your attention to one part of this that relates to something I've said earlier which is the Achilles tendon lengthening which does really help to reduce the pressure underneath the forefoot and the mid-foot but in the Charcot foot, there's such a strong component of equinus to the deforming force of the mid-foot Charcot that it doesn't make any sense to do a Charcot foot reconstruction without addressing the Achilles tendon and sometimes that means that the Achilles tendon just has to be transected. You just have to do a tenotomy. And as long as they're immobilized afterwards and they're in a frame and these are types of people who are going to be in a crow boot forever. Then that's still appropriate.

    So I'll leave it there and thank you very much.

    TAPE ENDS - [30:22]