(CS-036) Tale of Two Soles: Critical Decision Making for Like Wounds in Unlike Patients
Co-Author(s):
Valarie Samoy, DPM; Jodi Walters, DPM
<b>Introduction</b>: <p class="MsoNormal"><span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin; color: black;">The fifth ray is a common site of ulceration in the neuropathic foot due to the prominence of the fifth metatarsal head and base, frequently requiring amputation. Long term prognosis of lateral column amputations is complicated by Cavo-varus foot structure, lateral column instability due to loss of the fifth metatarsal head and in the case of total fifth ray amputation, resection of the peroneus brevis tendon. Due to these complications, re-amputation rates for fifth ray amputations are reported to be as high as 58.3%. We present two contrasting cases for consideration in healing and long-term prognosis of lateral column resections.</span></p><br/><br/><b>Methods</b>: <span style="font-size: 11.0pt; line-height: 107%; font-family: 'Calibri',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; color: black; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">Two patient are discussed. The first, a 90-year-old male with complicated medical history including DM-II, PVD, Cavo-varus foot type who developed lateral column wounds and infection requiring partial amputation of the fourth and fifth ray. The second case, a 38-year-old male who presented with lateral column wound and infection. On presentation, patient was a diagnosed as IDDM-II with peripheral neuropathy. Patient underwent partial fifth ray amputation. Both patients underwent numerous treatment modalities postoperatively to heal large defect secondary to amputation. Treatments included negative pressure wound therapy, larval therapy, chorion-free amniotic membrane allograft, and prolonged stay in sub-acute rehabilitation facility.</span><br/><br/><b>Results</b>: <span style="font-size: 11.0pt; line-height: 107%; font-family: 'Calibri',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; color: black; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">Post operatively the first patient failed to heal after 15 weeks of wound care. The patient was given the decision to have a below knee amputation vs palliative management. The patient chose palliative care and died approximately 6 weeks later. The second patient proceeded to heal, with completely epithelized tissue within 12 weeks. The patient was fitted for custom orthotics with ray filler and diabetic shoes and remained free of ulceration for the follow up period.</span><br/><br/><b>Discussion</b>: <span style="font-size: 11.0pt; line-height: 107%; font-family: 'Calibri',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-theme-font: minor-latin; color: black; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">When planning surgical amputation of the fifth ray, surgeons should be aware of high rate of complications which may lead to additional surgical resection. Further consideration is crucial to evaluate the patient for potential complications including Cavo varus foot type, lateral column instability and vascular status. In the period of post-operative wound healing, as well as after the surgical wound has healed, preventative measures are necessary to sufficiently offload the lateral column to prevent re-ulceration. The second patient has successfully remained without complications due to utilization of custom orthotics, fifth ray shoe filler, and diabetic shoes.</span><br/><br/><b>Trademarked Items</b>: <br/><br/><b>References</b>: 1. Boffeli, T. J., & Peterson, M. C. (2013). Rotational flap closure of first and fifth metatarsal head plantar ulcers: adjunctive procedure when performing first or fifth ray amputation. The Journal of Foot and Ankle Surgery, 52(2), 263-270. 2. Boffeli, T. J., & Abben, K. W. (2012). Complete fifth ray amputation with peroneal tendon transfer—a staged surgical protocol. The Journal of foot and ankle surgery, 51(5), 696-701. 3. Carlson, R. M., Smith, N. C., Stuck, R. M., & Sage, R. A. (2012). Dislocation of the fifth metatarsal base following partial fourth and fifth ray amputation: a case report. Journal of the American Podiatric Medical Association, 102(1), 71-74. 4. Kim, J. H., Ko, H. T., & Suh, J. S. (2015). Treatment Result of Foot Amputation Stratified by Level of Amputation. Journal of Korean Foot and Ankle Society, 19(1), 18-22. 5. Macedo, R. S., Macedo, L. S., Sakaki, M. H., Sposeto, R. B., Ortiz, R. T., de Andrade Corsato, M., ... & Fernandes, T. D. (2021). Common late complications of longitudinal forefoot amputations in neuropathic foot treatment. Journal of Wound Care, 30(6), 498-503.<br/><br/>