A 61-year-old female with a past medical history significant for bipolar disorder, poorly controlled type II diabetes with neuropathy, heart failure, hypertension and posttraumatic stress disorder with compulsive skin picking was initially referred to podiatry for a left subacute forefoot Charcot. At that time, she was being followed by the wound care center at our institution for chronic plantar forefoot ulcers on the contralateral extremity that had been present for many years due to compulsive skin picking. The patient had a history of bilateral lower extremity osteomyelitis, which previously had resulted in a right third toe amputation and left great toe amputation.
Offloading presented a challenge due to the patient’s bilateral foot conditions as well as social/psychiatric factors, resulting in an inability to use multiple offloading devices. She refused both a Charcot Resistant Orthotic Walker (CROW) boot and total contact cast (TCC). We ultimately agreed on a bivalve walking cast for the left foot and a post-op shoe with adhesive felt offloading pads for the right foot. Unfortunately, she missed several scheduled podiatry appointments with these wounds remaining stable for another six months.
The patient ultimately developed recurrence of osteomyelitis to the right forefoot and was admitted for infection management. At this time, the left foot was in the coalescence stage of Charcot. She was told she would require a below-knee amputation (BKA) because of uncontrolled, repeat infection in conjunction with the inability to offload. However, our limb salvage program took her case.
We began by ensuring psychiatry was on board to curtail the baseline issues that led to compulsive skin picking. Psychiatry worked with the patient, mainly through behavioral therapy, to address issues around anxiety that contributed to her skin picking.
Vascular surgery evaluated the patient’s distal flow with toe pressures and ankle-brachial indices (ABIs) as well as arterial duplex ultrasound. The patient had a toe pressure of 72 mmHg. Vascular surgery and podiatry performed a joint case to remove the infected tissue and cast the foot to manage the offloading and skin picking issues. Vascular surgery was involved in performing the resection while the podiatry team performed a complex wound closure and casting.
Due to compromise of the plantar skin flap with ulcers and significant extension of osteomyelitis, we performed a very proximal transmetatarsal amputation (TMA). We took caution to maintain an anatomic parabola of the metatarsals while preserving attachments of the tibialis anterior, tibialis posterior and peroneal tendons. The flexor hallucis longus tendon was anastomosed with the extensor hallucis longus tendon. We were able to obtain adequate skin closure with a dorsal skin flap. The patient was placed in a posterior splint in the operating room. Two days later, a short leg fiberglass cast was applied and the patient was instructed to maintain non-weightbearing for the right foot.
The patient was subsequently seen on a biweekly outpatient basis for wound monitoring and cast changes. The patient had full weightbearing with the cast without any assistive device on each of these visits. We noted no recurrence of infection and the incision site healed at nine weeks post-op.
At 11 weeks post-op, the patient walked into our clinic wearing clogs on both feet without gait instability. Her lower extremity muscle strength was 5/5 in all planes. There were no varus or equinus deformities, and there were no pre-ulcerative calluses to the surgical foot.
On this visit, however, we did note a new ulcer to the distal tuft of the left fourth toe (contralateral side), which had a claw toe deformity. A percutaneous flexor tenotomy of the fourth toe was performed in the office and one week later, the wound was nearly epithelialized. We then performed percutaneous flexor tenotomies of the second, third and fifth toes to prevent ulcer formation in the setting of claw toes. She went on to heal all wounds.
Final Notes
We found casting of this patient to be very beneficial in that it prevented contractures and foot deformities and provided a barrier to prevent compulsive skin picking. Interestingly, the fact that the patient was fully weightbearing almost immediately post-op (despite our recommendations) likely allowed her to maintain muscular strength and gait . We would, however, not recommend this as it likely led to delayed incision healing.
Ultimately, a multidisciplinary approach was crucial in the care of this patient. In addition to the collaboration between vascular surgery, podiatry and infectious disease, the close relationship between psychiatry and the primary care provider aided in the patient’s successful outcome.
Dr. Rose-Sauld is affiliated with the Department of Foot and Ankle Orthopedics at Massachusetts General Hospital in Boston.
Dr. Dua is an Assistant Professor of Surgery at Harvard Medical School and the Massachusetts General Hospital in Boston. She is the Director of the Vascular Lab, Co-Director of the Peripheral Artery Disease Center, Associate Director of the Wound Care Program and Director of the Lymphedema Center at the Massachusetts General Hospital.