Download Case Report :Surgical Approach for Plantar foot wound

Case Report :Surgical Approach for Plantar foot wound with
Modified Hurricane incision (O-Z) Vs. Gaenslin’s incision
Sunghwan Byun, DPM
(S.A.L.S.A. Fellow / Clinical Instructor, Banner University Medical Center, Tucson, Arizona)
Sangbong Ko, MD
( Associate Professor, Department of Orthopedic Surgery, Daegu, South Korea)
Sangwook Lee, MD
(Associate professor, Department of Orthopedic Surgery / President, Korean Foot and Ankle Orthopedic Society, Daegu, South Korea)
Eric J. Lew, DPM
(S.A.L.S.A. Fellow / Clinical Instructor, Banner University Medical Center, Tucson, Arizona)
Homayoon Harati, MD
(Interdisciplinary Consortium on Advanced Motion Performance, University of Arizona College of Medicine, Tucson, AZ )
Disclosure
Author : Sunghwan Byun, DPM; Sangbong Ko, MD; Sangwook Lee, MD;
Eric J. Lew, DPM; Homayoon Harati, MD
My disclosure is in the Final AOFAS Program Book.
I have no potential conflicts with this presentation.
Case Report : Pre-op
M/64
C/C : Septic Arthritis on 1st Metatarsophalangeal Joint right foot
P/I : Failed Diabetic Custom Made Shoe Gear and
Total Contact Cast
PMH : Type 2 Diabetes, CKD, Multiple Incision, drainage and
debridement of right foot due to diabetic foot infection
Physical Exam : Ulcer 4.0cm x 3.5cm fibrotic and granular mixed
Wound bed with purulent drainage and > 2cm
Erythema on periwound. Probing to the bone.
Case Report : Intraop
• Gaenslin’s incision vs. modified hurricane incision
• Plantar foot incision : Lack of movable skin.
• Longitudinal incision : against skin relaxed line
Horizontal incision : interrupting Neurovascular structure.
• Skin relaxed line on plantar aspect of foot runs medial to
Lateral direction.
• Incision on periwound area to resect all fibrotic tissue.
• Extensive incision distally and proximally tangential to the
medial and lateral aspect of circle.
Case Report : Intraop / Radiography
• This procedure was done for right 1st
Metatarsophalangeal joint infection.
• Previous pan metatarsal head resection is
done Vs. Transmetatarsal amputation
• Elongated 1st metatarsal caused
Plantar ulcer on 1st Metatarsal head.
• Thus, adequate surgical exposure with
less tension on skin reapproximation was
concerned.
Case Report : Post-op
• Right 1st metatarsal
2+ proteus mirabilis
2 + staphylococcus aureus coagulase positive (Oxacillin resistant)
2+ beta Hemolytic Streptococci Group B
• Right 1st metatarsal
Acute Osteomyelitis
Proximal margin: acute osteomyelitis
• Antibiotic Therapy
6 weeks of IV Vancomycin, Cefepime, and PO Flagyl per ID
Case Report : Post-op
• No Weight bearing on Bilateral lower extremity for 4 weeks
with wheel chair to reduce the possibility of wound
dehiscence and wound development in contralateral side
• Check the wound in weekly basis for any wound
dehiscence.
• After 4 weeks, total contact cast was applied on right foot
for early ambulation on right lower extremity with
offloading on the surgical site.
Discussion
•
Gaenslin Incision Vs. Modified Hurricane Incision
Plantar foot wound with bone resection.
Adequate surgical exposure for bone resection is challenging.
•
Skin tension should be considered for skin closure
since there is lack of skin movement on plantar aspect of foot.
Also, diabetic patient has other comorbidities such as peripheral vascular disease
, chronic kidney disease and peripheral neuropathy. Therefore, the wound healing
time is greater than normal, healthy patient. Skin tesion has to be concerned.
Conclusion
• Modified Hurricane Incision / O-Z flap is advocated for
Skin closure on plantar aspect of foot ulcer
• When incision is planned on plantar aspect of foot, skin
tension line and neurovascular structures should be
concerned.
• Modified Hurricane incision / O-Z flap has better outcome
with less wound dehiscence compared to Gaenslin’s incision
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