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ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 128-132

Management of complex diabetic foot wound by external fixation: An effective way for limb salvage


1 Department of Neurosurgery, Apollo Hospital, Bhubaneswar, Odisha, India
2 Department of General Surgery, Shri Ramachandra Bhanj Medical College, Cuttack, Odisha, India
3 Department of Physiology, Shri Ramachandra Bhanj Medical College, Cuttack, Odisha, India

Date of Web Publication7-Apr-2016

Correspondence Address:
Biswaranjan Nayak
Plot No. 350/3137, Aradhana Nagar, Ebaranga, Sundarapada, Bhubaneswar, Odisha
India
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DOI: 10.4103/1658-600X.179828

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  Abstract 

Background: Diabetic foot is a potentially limb-threatening disorder that is being recognised with increasing frequency in persons with long-standing diabetes and concomitant peripheral sensory neuropathy.
Aim and Objective: Evaluation of the adjunctive role of external fixation in soft tissue reconstruction to ensure healing and limb salvage.
Materials and Methods: Thirty-two patients with complex diabetic foot wound who underwent external fixation as a limb salvage procedure were studied prospectively.
Results: External fixation of the foot made it stable such that the patient became ambulatory early with support. Hence, limb amputation can be avoided with early closure of the wound resulting in improved quality-of-life.
Conclusion: External fixation provides limb off-loading, immobilization, skeletal fixation, wound care, preservation of vascular structures and simultaneously allow the soft tissue healing in complex diabetic wound. So it is a better method of limb salvaging than the traditional methods with encouraging results.

Keywords: Diabetic foot infection, diabetic ulcer, external fixation, limb loss, limb salvage


How to cite this article:
Nayak B, Mahapatra KC, Das RR. Management of complex diabetic foot wound by external fixation: An effective way for limb salvage. J Health Spec 2016;4:128-32

How to cite this URL:
Nayak B, Mahapatra KC, Das RR. Management of complex diabetic foot wound by external fixation: An effective way for limb salvage. J Health Spec [serial online] 2016 [cited 2019 Jul 19];4:128-32. Available from: http://www.thejhs.org/text.asp?2016/4/2/128/179828


  Introduction Top


Twenty percent of all diabetic patients' admissions to a hospital are caused by foot problem(s) or ulceration(s) at certain point in their lifetime. Traditionally, the treatment for complex lower extremity wounds and major soft tissue defects has been amputation of the affected limb. Complex wounds caused by infection, vascular insufficiency, compromised immune status and unstable skeletal framework require multiple operations by different specialities and prolonged healing period to salvage the limb with no guarantee that the result yields a functional limb.[1] Amputations are a rapid solution to complex wounds, which enable the patient to ambulate in a short duration. Amputations, however, carry risks of their own: Increased expenditure, decreased life expectancy and increased risk of contralateral limb amputation.[2],[3] To address lower-extremity wounds that result from trauma, ischaemia or infection, the first task is to convert the existing wound into a healthy wound. This often requires a multidisciplinary effort with vascular surgeons that help re-establish adequate blood flow for healing, orthopaedic surgeons that help re-establish skeletal stability by external fixation, infectious disease clinicians that address existing infection(s), and medicine clinicians that help stabilise the patient. The wound is aggressively debrided and then covered with an appropriate dressing to promote healing. Closure should be considered only when the wound is clean and healthy granulation tissue is conspicuous. Most wounds are then closed using soft tissue reconstruction such as delayed primary closure, skin grafts, local flaps and free tissue transfer.

Aims and objective

In our study, we tried to evaluate the adjunctive role of external fixation in soft tissue reconstruction to ensure healing in patients requiring reliable off-loading or immobilisation of joints and its role in limb salvage in a complex diabetic wound.


  Materials and Methods Top


Patients with complex diabetic foot wound admitted to the Department of General Surgery, Sriram Chandra Bhanj Medical College, Cuttack, Odisha, India over a 3-year period (from July 2010 to July 2013) were studied in this group prospectively. A total of 32 patients with complex diabetic foot, who were hospitalised were included in the study. Informed consent was taken from each patient, and the study protocol confirmed to the ethical guidelines of the 1975 Declaration of Helsinki. Age of the patients ranged from 31 years to 80 years. The subjects included 19 males and 13 females. The foot ulceration was classified into mild or non-limb-threatening, severe or limb-threatening, and complex wounds. Non-limb-threatening was characterised as superficial with cellulitis, no significant ischaemia, and no bone or joint involvement, with no systemic toxicity. The complex limb-threatening ulceration was characterised as full-thickness ulceration, serious ischaemia/gangrene, bone or joint involvement with systemic toxicity. The features of systemic toxicity included systemic clinical features along with raised erythrocyte sedimentation rate (ESR), leucocytosis and polymorphonuclear cytosis. The investigations were done according to the diabetic clinic protocol. They included random blood sugar, fasting and post-prandial blood sugar, glycosylated haemoglobin, routine urinalaysis, renal function test (blood urea nitrogen, serum creatinine), liver function tests, chest X-ray (posterior-anterior) view, electrocardiography and fundus examination. Aerobic and anaerobic culture and antibiotic sensitivity, complete blood count with ESR were done in each case. Probe to bone test was done in these cases to characterise the ulcer and for evidence of bone involvement. X-ray of the foot was done in all patients. Severe or limb-threatening ulcers were selected for the external fixation in our study. Patients' ability to safely use assistive walking devices should be evaluated and optimised perioperatively, preferably before any elective reconstructive surgery. The first determinant for limb salvage in a diabetic patient is determination of inflow. In our patient, along with thorough clinical examination, we performed selective angiography for determining vascularity of the distal part. Patients with psychiatric illness, gross non-compliance, impending mortality, morbid obesity, lack of coordination, incapacitation of the contralateral limb, neuropathy and spasticity are poor surgical candidates for external fixation.

Surgical procedure

It depends on the type of wound and part of the foot and ankle involved. Usually, we construct a multiplanar external fixation after a thorough debridement. Two pins are introduced into the shaft of the tibia, one pin at the base of the 2nd metatarsal, one pin in the calcaneum through and through. Then, the pins are connected by a rod as shown in [Figure 1], [Figure 2], [Figure 3], [Figure 4]. It produces a very stable construct with minimum instrumentation at minimal cost to the patient. Then, regular dressing is done until the wound becomes healthy and the foot becomes stable, which usually takes 6 - 8 weeks. During this period, the patient is made ambulatory. After this period, skin grafting of the wound is performed [Figure 5]. Once the foot becomes stable, the emphasis must shift to prevention of recurrent ulcers. Custom braces and orthoses such as the Charcot restraint orthotic walker (CROW) can be an effective method to brace a deformed extremity. We recommend using CROW devices or ankle-foot orthoses for at least 4 - 6 months after reconstructive surgery; some patients may require the device for a longer period depending upon the status of their foot. Critically important, appropriately designed or fitted shoes with weight dispersing accommodative insoles are necessary for protection and gentle support. These patients are at high risk for subsequent ulceration and therefore require close follow-up and life-long surveillance. In our study group, we monitored the wound healing time, time for secondary wound closure and time of ambulation with bipedal weight bearing.
Figure 1: Diabetic foot with ankle subluxation

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Figure 2: Subluxed ankle joint fixed with external fixation

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Figure 3: Diabetic foot infection involving lower one-third of leg, ankle and foot

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Figure 4: Fixation with external fixation

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Figure 5: Skin grafting after removal of external fixator

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  Results Top


In our series, we have performed external fixation in 32 patients after wound debridement. Fixation of the foot made it stable such that the patient became ambulatory with support. Thus, there is an improvement in the patient's quality-of-life. With regular dressing, the wound gradually converted into a healthy wound and was ready for skin grafting, which was approximately within 6 - 8 weeks' time. After skin grafting, our patient used various types of orthoses for normal day-to-day activities. In our study, time for wound healing, time for secondary wound closure and time of ambulation with bipedal weight bearing were early. In our series, we witnessed a high level of patient satisfaction as they were back to their near normal life after the procedure, avoding the psychological and social stigma of amputation. Potential documented complications of external fixation in patients with diabetes include pin tract infection, hardware failure, iatrogenic ulcerations, scarring, sepsis, fractures, muscular atrophy and deep vein thrombosis. In our patient group, there were five complications including four pin site infections and one failed salvage that ultimately required amputation. Wound recurrence was seen in two patients, which was controlled by conservative method. Most of these complications were minor and could be avoided with proper pin insertion, biomechanically sound constructs, decreased duration in frame, pin care, and general care of the patient including bladder, bowel and skin care. When used for a short period of time, pin tract infections are negligible when compared to the advantages provided by external fixation. Muscular atrophy during the period of immobilisation was minor, which improved with physical therapy.


  Discussion Top


Twenty percent of all diabetic patients' admissions to the hospital are caused by a foot problem or ulceration at a certain point in their lifetime. Traditionally, the treatment for complex lower extremity wounds and major soft tissue defects has been amputation of the affected limb. Uncontrollable wounds caused by infection, size, vascular insufficiency, compromised immune status and unstable skeletal framework require multiple operations. A number of surgical techniques can maximise the success of wound healing. The most important is aggressive debridement of all infected tissue and bone, while sparing the healthy tissue for closure. If the wound is grossly infected at the initial debridement, serial surgical debridement is necessary until the wound responds and starts to heal. Leaving large wounds to heal by granulation and secondary intention may take several months or years for complete closure.[4],[5] External fixator may be used in complex diabetic foot wounds, which is usually difficult to salvage using the conservative method. External fixation has an established role in the treatment of trauma and osteomyelitis.[6],[7],[8] In these clinical applications, the external fixator allows salvage of severely infected or traumatised bone or joints that required major amputation in the past.[9] The fixator maintains bone and joint alignment through rigid external fixation despite significant bone resection for osteomyelitis or skeletal realignment. It does that without having to resort to internal fixation with plates and screws that are contraindicated in infected wounds. Motion along a joint where there is soft tissue reconstruction often leads to dehiscence or breakdown. Immobilisation with a cast makes it difficult to follow the wound and could place pressure on the reconstruction. Placing external fixators across a given joint immobilises that joint while allowing excellent wound care. The fixator can then be removed upon wound healing. Premature weight bearing on a reconstructed site also leads to breakdown. If the reconstruction involves the sole of the foot, off-loading for 6 weeks is often necessary to ensure healing.

Careful pre-operative planning with regards to timing and location of the pin placement is required. The fixation can be placed after the wound has been debrided and cleaned. If an open wound persists, initial debridement is performed and, patient should be started on antibiotics with regular wound dressing. If infection persists (either clinically or based on culture results), wound debridement is repeated and dressing is continued until the wound is clean with evidence of healing. Only then is the wound considered ready for reconstruction.[10]

Potential documented complications of external fixation in patients with diabetes include pin tract infection, hardware failure, iatrogenic ulcerations, scarring, sepsis, fractures, muscular atrophy and deep vein thrombosis. Most of these complications are minor and can be avoided with proper pin insertion, biomechanically sound constructs, decreased duration in frame, pin care and general care of the patient. When used for a short period of time, pin tract infections are negligible when compared to the advantages provided by the external fixation. Muscular atrophy during the period of immobilisation is minor, which improves with physical therapy.[11]


  Conclusion Top


Diabetic limb salvage with large soft tissue defects with exposed tendon, joint or bone lies beyond the limits of conventional techniques. External fixation provides a protected environment by simultaneously off-loading, immobilising joints, providing skeletal fixation, and protecting vascular repairs, permitting repeated soft tissue and vascular surveillance, wound care and improved patient comfort, which otherwise is difficult to achieve with traditional methods. Following strict fundamental principles, including proper pin placement, frame construction and application are of utmost importance to minimise the potential risks and complications associated with methods of external fixation in patients with diabetes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Holden CE. The role of blood supply to soft tissue in the healing of diaphyseal fractures. An experimental study. J Bone Joint Surg Am 1972;54:993-1000.  Back to cited text no. 1
[PUBMED]    
2.
Ikonen TS, Sund R, Venersmo M, Winell K. Fewer major amputations among individuals with diabetes in Finland in 1997-2007: A population-based study. Diabetes Care 2010;33:2598-603.  Back to cited text no. 2
    
3.
Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop Relat Res 1989;243:92-9.  Back to cited text no. 3
    
4.
Roukis TS, Zgonis T. Skin grafting techniques for soft-tissue coverage of diabetic foot and ankle wounds. J Wound Care 2005;14:173-6.  Back to cited text no. 4
    
5.
Pinzur MS, Sage R, Stuck R, Osterman H. Amputations in the diabetic foot and ankle. Clin Orthop Relat Res 1993;296:64-7.  Back to cited text no. 5
    
6.
Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg Am 1995;77:835-46.  Back to cited text no. 6
    
7.
Ghoneem HF, Wright JG, Cole WG, Rang M. The Ilizarov method for correction of complex deformities. Psychological and functional outcomes. J Bone Joint Surg Am 1996;78:1480-5.  Back to cited text no. 7
    
8.
Agarwal S, Agarwal R, Jain UK, Chandra R. Management of soft-tissue problems in leg trauma in conjunction with application of the Ilizarov fixator assembly. Plast Reconstr Surg 2001;107:1732-8.  Back to cited text no. 8
    
9.
Vasconez HC, Nicholls PJ. Management of extremity injuries with external fixator or Ilizarov devices. Cooperative effort between orthopedic and plastic surgeons. Clin Plast Surg 1991;18:505-13.  Back to cited text no. 9
    
10.
Clemens MW, Parikh P, Hall MM, Attinger CE. External fixators as an adjunct to wound healing. Foot Ankle Clin 2008;13:145-56.  Back to cited text no. 10
    
11.
Kim D, McAlister J, Kim PJ. Assessing the use of ex-fix for offloading in diabetic limb salvage. Podiatry Today 2012;25:22-6.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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