Surgery: The hand and the foot Josephine Wing-Yuk Ip Chief, Division of Hand & Foot Surgery Department of Orthopaedics & Traumatology Queen Mary Hospital The University of Hong Kong University of Hong Kong Queen Mary Hospital Department of Orthopaedics & Traumatology Global prevalence of DM & Orthopaedic related complications • 10-15% of DM patient will have one ulcer in their life time • 50-70% of ulcer recurrence within 5 years • Up to 30% of patients with DM ulcers eventually results in major amputation • Every 30sec, 1 leg amputated • 50% of all amputation from DM complications • Painful neuropathy develops in 34% of patients with peripheral neuropathy Data Points Publication series Scope of surgery in diabetic limb • Acute infected ulcer: clearance of infection, improve vascularity with vascular intervention for ischaemia • Major amputation for non-salvagable limb • Limited amputation if possible for functional preservation • After successful debridement, wound coverage procedures for limb salvage • Surgery for chronic ulcers: - provide wound healing environment by surgical means - Charcot foot management • Prevention of recurrence of foot ulcer by surgical offloading in the foot • Reconstructive surgery to improve function in the hand Pathophysiology of DM foot ulcer Motor Neuropathy Sensory Neuropathy Foot deformity Loss of protective sensation Autonomic Neuropathy Loss of sweating Repetitive compression and shear at pressure point Fissuring of skin Formation of callus and corn Rub on the underlying skin and soft tissue Entry of bacteria Hematoma formation, tissue necrosis Ulceration and infection Motor neuropathy giving rise to intrinsic minus deformity High loading pressure points Functional deficit Pathology in diabetic limb • Neuropathy: sensory, motor, autonomic • Angiopathy : Macro & Micro results in limb ischaemia - more serious in lower limb • Immunopathy: rapid progression of infection, multiple organisms, competition with time • Poor wound healing Effect of hyperglycaemia on wound healing • Leads to endothelial cell dysfunction, resulting in local ischaemia • Leads to various cell dysfunction – Impaired fibroblast proliferation and collagen production – Impaired release of growth factors – Impaired phagocytosis and macrophage function Consequence: poor wound healing Diabetic hand infection • Patho-mechanism similar to foot • DM hand is currently not generally considered as common complication of DM • Western literature: (1999) 10% incidence of DM hand infection required hospital admission; such figure is comparable to foot infection • Currently not much literature with high level of evidence to guide management Similarities and differences of diabetic hand & foot problems • Neuropathy occurs earlier in foot as lower limb nerves are longer and nerve endings are further away from the cell body • Vascularity is better in upper limb • Inappropriate foot wear frequently causes skin breakage in foot while the hand gets minor injury during manipulation of the outside world • Hand requires mobility and dexterity while foot requires stability • Amputation causes more functional deficit in upper limb as many tasks requires bilateral upper limb co-ordination The hand • Organ to contact outside world • The most distal part is most prone to injury i.e. the distal phalanx • Compact anatomy in a small volume Hand compartments • Nature’s design to facilitate firm power grip - Fascial layers connecting skin and underlying bone •Multiple small compartments in pulp and many deep spaces • Loculation of infection in a compartment will cause increase in compartment pressure, prone to ischaemia & necrosis of the compartment • Septic embolism will cause necrosis of distal digital tissue • High tension results in rapid spread of infection The pulp - special subcutaneous tissue •Skin connected bone by fibrous tissue forming multiple small compartments • Rich in sensory organs •Nail at back to magnify sensation •Infection causes high local compartment pressure •Wet gangrene of infected compartments •Direct spread of infection to bone Special demand of hand– motion, motion, motion • The hand tolerates immobilization poorly • Adhesion between tissue layers develop easily: no man’s land • Stiff digit affects overall function Types of Infection in hand • • • • • • • • • Cellulitis Paronychia Pulp (Felon) Web spaces Tenosynovitis Palmar spaces: thenar, hypothenar, mid-palmar Osteomyelitis Septic arthritis Necrotizing fasciitis The most common presentation is distal digital infection after minor trauma Paronychia Felon Web space infection Tenosynovitis Beware of deep infection • Tight compartments bound by fibrous tissue, palmar skin looks relatively normal • Deep compartment infection may not be easily recognized and results in delay in intervention • USG, MRI may be required to look for deep seated infection Mid-palmar space infection Thenar space infection Osteomyelitis arising from pulp infection Septic arthritis Necrotizing fasciitis - a frequent cause for amputation Jalil & Ip et.al. 2011 Hand Surg Analysis of hand infection cases 2006-2010 in QMH • • - Retrospective review of 37 DM hand infection Treatment protocol: Rest in boxing glove, elevation in hospital Broad spectrum IV antibiotics covering gram- and anaerobes : initially Ampicillin + Cloxacillin + Gentamycin - Aggressive early debridement if there is pus collection or symptoms of infection not resolving within 24 hours - Liberal re-exploration at intervals till clearance of infection, early decision on digital amputation - Early intervention by hand therapists to regain hand function Aetiology • • • • • • • Trauma 10(27%) Fish fin injury 8(22%) Animal bite 2(5.4%) Acute on chronic nail infection 2(5.4%) Cannula site infection 1(2.7%) Post-operation infection 1(2.7%) Unknown 13(35%) Pathological diagnosis • • • • • • Subcutaneous abscess Felon Tenosynovitis Osteomyelitis Necrotizing fasciitis Septic arthritis 15(40.5%) 9(24.3%) 5(13.5%) 2(5.4%) 2(5.4%) 1(2.7%) Length of hospital stay • Superficial (involving skin & subcutaneous tissue) : 9.6 days • Deep (involving fascial compartments, tendon, muscle, bone & joint) : 15.54 days P=0.002 Micro-organisms • • • • • Mixed growth Gram positive Gram negative Fungus No growth 15 (41%) 8 (22%) 4 (11%) 2 (5%) 8 (22%) Most common organisms in mixed growth: Staphylococcus, Klebsiella No. of operation • Single operation: 37.8% • Multiple operations: 62.2% Flap coverage of distal digit to preserve length was not always preferred as it may delay rehabilitation Digital amputation • 6/37 :16% • Early decision to hasten rehabilitation • 4 with mixed growth, 2 with single/no identifiable organism • 5/6 started with pulp infection • Reported amputation rate in literature:12-38%; depends heavily on management concept Compared with other series- poor prognosis in general Ganzales et. al 1999 JHS(A) • 46 cases: 19 superficial, 27 deep • 50% - 1 OT, 50%- >1 OT • 39% amputation rate Francel et.al. 1990 Annal of Plastic Surg • 41 cases: 73% deep infection • 63% amputation • 63% mixed growth Gunther et.al.1998 Hand Clin • Gram –ve and mixed growth • Aggressive debridement or amputation Foot anatomy is similar to hand • Tight compartments bound by fibrous tissue • Deep compartment infection may not be easily recognized and results in delay in intervention • MRI may be required to look for un-opened collection in compartments Grading of neuropathic ulcer - Meggit-Wagner clinical classification Irrespective status of infection & vascularity Grade 1 ulcer Grade 2 ulcer Superficial ulcer: dorsal, Deep ulcer: Deep ulcer:penetrating dorsal, plantar bone joint toexposed bone, tendon, Grade 3 ulcer Deep abscess involving plantar spaces,tendon sheath, osteomyelitis, septic arthritis Grade 4 ulcer Gangrene in toes or forefoot Grade 5 ulcer Gangrene involving whole foot requiring higher amputation Target in acute surgery: • • • • Assess grading of ulcer on table Eradicate infection by opening the involved compartments Preserve viable tissue, as much as possible in the hand Assessment of the limb and make decision on salvage or amputation • Minimal No of operation, maximal quality of life Prevent Major Amputation Acute supportive treatment • Control infection: appropriate antibiotics • Control hyperglycemia • Improve blood supply – Pharmacological – Surgical, vascular intervention • Correct other comorbidities or risk factors Decision making for emergency operation • Patient: function demand & general condition • Wound: ulcer grading, deformity, predicted function • Severity of infection: identify organisms; XR, MRI to look for osteomyelits & deep pockets of infection • Vascularity: ABI, toe pressure, tcPO2, whether any possibility for vascular reconstruction Non-salvagable conditions - necrotising fasciitis with muscle involvement Gas gangrene, may need open amputation and 2⁰ wound closure Goal of major amputation if deemed necessary • Remove all infected, necrotic and painful tissue • Attain successful wound healing as fast as possible • Facilitate rehabilitation of patient by providing a stump for prosthesis Level of amputation Level of amputation No universally accepted method to determine level of amputation 1. * Clinical judgement (patient’s condition, pulse, capillary refill, bleeding) 2. Digital subtraction angiogram is the gold standard for investigation of vasculature - Duplex study (triphasic wave form) 3. Ankle brachial index (at least 0.45 as minimal requirement for wound healing) - Diabetic patients often have falsely raised ABI 4. Transcutaneous oxygen tension, thermography, etc Upper limb amputation • • • • • Vascularity is usually adequate Greater functional implication Prosthesis cannot replace hand function Myoelectric hand does not have sensation Preservation of short rays still useful Key issues to winRadical debridement • Know the compartment anatomy of the hand and the foot • Infection spreads fast and you need to fight with time - Convert an infected wound to a clean wound - As often as necessary - Surgical blade, hydro-knife, maggot - Until wound clean and ready for reconstruction • Bacteria innoculated from puncture wound • Pumping action during walking hastens spread of infection • Septic embolism cause gangrene Timely aggressive repeated debridement preserve essential parts of foot Major amputation can be prevented Subsequent management after converting an infected wound to a clean wound -acute or chronic wounds • Facilitate wound healing by 2° intention: stimulate regeneration capacity of the body for granulation tissue formation & re-epithelialization: modern dressing, molecules, growth factors, cells, VAC, PRP, hyperbaric oxygen, total contact cast • Surgical procedures to achieve wound healing by 1° intention • Rehabilitation to gain maximal function Reconstructive matrix to preserve length if the wound size exceed regeneration capacity of the body Complex Distant /Free flap Local /Regional flap Skin graft Simple Direct closure Augmentation with modern dressing , VAC, growth factors , stem cells, etc Limited amputation at various levels to achieve rapid primary wound healing with minimal scar Added bony procedures like ankle fusion can preserve the foot Skin graft • Radical debridement of tenosynovium up to mid-calf; excision of necrotic extensor tendons & peroneal tendon • Wound takes skin graft Local rotation flap for coverage Pedicled perforator flap for wound coverage at wrist Reverse flow flaps based on smaller vessels accompanying cutaneous nerve is the workhorse for diabetic foot defect requiring coverage Saphenous nerve, superficial peroneal nerve & sural nerve Biopsy in human sural nerve & perineural tissue of 75-year-old patient with 20 years DM Spared of microangiopathic effect No thrombosis No dilatation of vascular wall No atherosclerosis Extend the flap reliability to add a perforator from lower limb vessels • Can cover more distal part of the foot • Can be used in patients with angiopathy To salvage weight bearing part- metatarsal heads Reverse flow of saphenous nerve accompanying vessel + one perforator flap Prophylatic surgery • • • • • • • • Surgical offloading Stability Realignment Plantigrade foot amendable by bracing Forefoot: sesamoidectomy, exostectomy Hallux: arthroplasty, arthrodesis Mid-foot Hind foot: triple arthrodesis Preventive procedureExtrinsic Tendon Release Preventive procedureBony Realignment Excision Osteotomy bony prominences in Charcot foot for off-loading Reconstructive surgery for intrinsic minus hand Target to improve hand function by muscle rebalancing & restore proper hand posture • Weakness of intrinsics to thumb • Restore thumb posture and balance at IPJ & CMCJ: Split FPL to EPL to intrinsics & extrinsics at IPJ - EPL re-routing to 1st compartment to decrease adduction force from EPL Restoring thumb posture with passive procedures Split FPL to EPL Relocation of EPL to position of 1st compartment Relocation of EPL to position of 1st compartment Intrinsic tenodesis using PL graft to restore IPJ extension Lasso procedure for correction of claw hand Lasso procedure Bring home message • Understand the anatomy and pathology of DM hand & foot to do a good job • Acute radical eradication of infection is the key for limb salvage • Early decision for limited or major amputation to facilitate rehabilitation • Wound coverage procedure has a role for limb salvage • Preventive and reconstructive surgery improve functional outcome. 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