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This case shows a man in his 60s with diabetes, who developed a necrotizing soft tissue infection with bacteremia, needing emergent transmetatarsal amputation with wide debridement of the plantar soft tissues. The infection was tracking superficially along the plantar fascia, so that had to be removed. Makes sense since he did end up culturing staph aureus, which is an aerobic bacteria, likes to stay close to skin. He did have triphasic 3-vessel flow so he did not require vascular surgery. My colleague did a TMA revision to shorten the bones so on the 3rd surgery, I was able to close over the bony stumps and cover the rest of the wound with a scaffold skin substitute (Theragenesis). He was discharged on a PICC line for his endocarditis.

There was a little setback with lateral wound necrosis that needed in office debridement, but he eventually granulated in 3 months. He was compliant about non-weight-bearing restrictions for that time which helped with successful wound healing. I didn’t use a wound vac in this case. Humans have been granulating before the wound vac was patented in 1991 and we can continue to granulate without it. Getting source control is the hard part, once it’s clean enough, it’s remarkable how well patients heal with little effort afterwards.

See next post for the final healing photos

See previous post to see how we got to this point.

The donor site where the ABductor muscle belly lies re-granulated that defect in time for STSG in a month. He eventually was able to get the whole thing healed in 4 months from time to presentation to the hospital. He will still need a lot of work to let that TMA stump soft tissue mature to be able to withstand the shear of walking, and will need to be closely monitored, high chance of re-ulceration, but we gave him the a good chance of long-term meaningful ambulation with the severity of infection he had.

Lots of questions about if I used wound vac. I did not use wound vac for this case. Not wrong to use it, but there are so many issues with the wound vac that I decided to cut it out from my practice altogether, I have not applied or ordered one for 2 years and it has not impacted my ability to get good results. There’s even a recent Lancet article talking about how wound vacs do not help with post-surgical secondary wound healing.

For STSG, I use xeroform gauze wrap, I don’t do tie-over bolster dressings anymore, found out a simple wrap works. There’s plastic surgery articles to support that. There’s a Georgetown article that suggest 3:1 mesh ratio has the least complications, I haven’t noticed a big difference so I used 1.5:1 in this case, sometimes 3:1 for larger wounds. There’s another Georgetown article that suggests STSG for plantar foot wounds are a viable option. I think this is true, because so many other factors contribute to longevity of a plantar wound, such as distance between skin and bone (need soft tissue bulk to cover bone for high level ambulators).

Lastly, it’s important if you want to specialize in this, to eventually build a reliable team around you that are like-minded, hard-working, and passionate about limb salvage. Because it’s difficult to do this alone and you can handle only so much. Emergency surgeries never happen at convenient times, and you’re never always available (nor should you be). We have a staggered schedule of availability of limb salvage podiatrists that work together in private practice and we are thriving while helping the community.