PMC8450981_01
Figures (a)-(l) showing clinical aspects and surgical technique. (a) Clinical picture of the infected foot during admission to our outpatient clinic. Plantar view:extensive distal stump ulceration, purulent drainage, probe-to-bone test positive for cuneiforms and cuboid. (b) Surgical debridement of infected soft tissues and bones. (c) Specimens collected from soft tissues (superficial and deep) and from bones (navicular, cuneiforms, and cuboid) submitted separately for culture. (d) Clinical condition after first surgical irrigation and debridement (I&D). Resection of all infected tissues. Note the healthy exposed talar head and calcaneal anterior process and healthy soft tissues maintained. (e) Plantar view complete closure of ulcer. (f) Incisional negative pressure wound therapy applied above surgical site. (g) Plantar view during TTC arthrodesis showing plantar incision for intramedullary nail stabilization. (h) Total contact cast applied on right lower limb 2 weeks after TTC fusion. (i) Clinical picture anterior view of surgical sites 6 weeks post-op. (j) Clinical picture plantar view of surgical sites 6 weeks post-op. (k) Clinical picture showing patient wearing regular footwear and total weight-bearing. (l) Final clinical outcome. Note the symmetrical alignment in hindfoot with complete healing of the soft tissue.
10.1177_2050313X211046732-fig1.jpg
PMC8450981_01_10.1177_2050313X211046732-fig1.jpg
fig1-2050313X211046732
Lower extremity physical examination revealed erythema and edema of a midfoot (Lisfranc's) amputation stump with active purulent drainage from a DFU (Figure 1). Achilles tenotomy was performed percutaneously, the wound was primarily closed, and then provisional negative pressure wound therapy (PICO , Smith & Nephew, London, UK) was installed (80 mm Hg) and set to continuous mode for 72 h (Figure 1). We then performed a tibiotalocalcaneal fusion using lateral transfibular approach and a plantar approach (Figures 1 and 2). We then performed a total contact casting (TCC_EZ , Integra, 1100 Campus Road, Princeton - NJ08540) and the patient initiated a weight-bearing rehabilitation protocol (Figure 1). When assessed by the hindfoot American Orthopaedic Foot and Ankle Society (AOFAS) outcome score, patient reached 79 points (Figures 1 and 2).
Figures (a)-(l) showing radiographic features. (a) Radiographic findings at admission in the outpatient clinic:lateral view. (b) Radiographic findings at admission in the outpatient clinic:anteroposterior view. (c) Intraoperative fluoroscopic lateral view of foot and ankle after infected soft tissues/bones resection and percutaneous Achilles tendon lengthening:first procedure. (d) Intraoperative fluoroscopic lateral view of foot and ankle during ankle and subtalar joint prepared for tibio-talo-calcaneal (TTC) fusion. (e) Intraoperative fluoroscopic lateral view of foot and ankle getting stump anatomical position for arthrodesis with K-wire. (f) Intraoperative fluoroscopic anteroposterior view of foot and ankle after intramedullary stabilization with intramedullary nail. (g) Intraoperative fluoroscopic lateral view of foot and ankle after intramedullary stabilization with intramedullary nail. (h) and (i) Radiographic findings lateral and anteroposterior view 6 weeks after TTC fusion. (j) and (k) Weight-bearing radiographic findings lateral and anteroposterior view 3 months after TTC arthrodesis. Note total fusion of subtalar and ankle joint. (l) Weight-bearing lower limbs panoramic X-ray showing lower limbs symmetry. Note 0.2 cm difference between right and left lower limb.
10.1177_2050313X211046732-fig2.jpg
PMC8450981_01_10.1177_2050313X211046732-fig2.jpg
fig2-2050313X211046732
After clinical, radiographic (Figure 2), and ultrasound assessment, patient was diagnosed with a post-operative infection at the amputation stump of midfoot of a neuropathic diabetic foot. We then performed a tibiotalocalcaneal fusion using lateral transfibular approach and a plantar approach (Figures 1 and 2). Radiographs revealed good bone healing (Figure 2). When assessed by the hindfoot American Orthopaedic Foot and Ankle Society (AOFAS) outcome score, patient reached 79 points (Figures 1 and 2).