008: Successful Limb Salvage in a Severe Diabetic Foot Infection: A Case Study of Aggressive Surgical Intervention and Grafting Technique 
Submission Category: Limb Salvage 
Submitter and Primary Author: Stephanie Campbell, DPM, AACFAS

Co-authors: Heather V. Tran, DPM, AACFAS, Nikita Gambhir, DPM, Michael Sobolevsky, DPM

Introduction  
53-year-old male with uncontrolled diabetes (A1c 7.9%), housing insecurity, food insecurity presents with severe diabetic foot infection with ascending cellulitis, infectious hemorrhagic bullae, multi-compartment abscesses of the foot and anterior leg. It is known that diabetic patients are at increased risk of both amputations and more surgical interventions than non-diabetic patients in the diabetic space. The patient underwent aggressive surgical intervention to avoid below knee amputation.  

Methods

Serial debridement and interval amputations were performed of the right foot to eradicate multiple sinus tracts of draining, heavy purulence > 200 cc. The patient was maintained on IV antibiotics. Following infectious containment and forefoot amputation, complete loss of dorsal soft tissue envelope, the decision to proceed with limb salvage was continued with serial grafting and close monitoring. The forefoot amputation site was remodeled surgically, and the soft tissue defect was primed with acellular wound particulate graft. With satisfactory clinical response, surgery #4 an antimicrobial fetal bovine dermal repair scaffold was applied due to the complicated nature of injury, degree of soft tissue compromise extending to bone, and social factors.

Results 

The dermal scaffold contributed to expedited wound healing with reduction in wound depth from bone to near complete leveling in 12 days. Following initial hospitalization, surgical intervention, outpatient wound care was continued until split thickness skin grafting was performed. The wounds remain closed with skin turgor and tone of above standard integrity and functional limb. The patient remains ambulatory more than 18 months postoperatively.

Discussion

In severe diabetic foot infections, particularly in the setting of sepsis and necrotizing fasciitis, complicated by multi-compartment infection of the foot and leg, health risk factors, and poor socioeconomic factors, aggressive surgical intervention along with the goals of care are needed to expedite treatment as well as patient expectations. The goal line can initially be obscured due to multi-factorial needs to maintain a functional foot. This case demonstrates successful healing of an at-risk limb due to podiatric surgical intervention with infection control, following by soft tissue management and ultimately split-thickness skin grafting.

009: Investing in Limb Preservation: A Case Study of Successful Foot Salvage in a Vasculopathic Patient
Submission Category: Limb Salvage
Submitter and Primary Author: Stephanie Campbell DPM, AACFAS

Co-authors: Nikita Gambhir, DPM,  Heather V. Tran, DPM, AACFAS, Craig J. Verdin, DPM

Introduction 

Limb salvage and prosthetics play vital roles in restoring function and mobility for patients with severe injuries or metabolic conditions. Limb salvage involves surgical techniques aimed at preserving a limb rather than resorting to amputation, while prosthetics provide artificial devices to replace lost limbs. Key considerations for limb salvage include restoring a functional foot, maintaining patient independence, minimizing hospitalizations, and avoiding bilateral lower limb amputations.

Methods

The patient, already at single-limb status, presented with a necrotic heel ulcer, exposed calcaneus, and necrotic Achilles tendon. After vascular optimization, the risks and benefits of final aggressive measures were discussed, leading to consent for a partial calcanectomy. The procedure utilized a silo-technique with triple antimicrobial bone cement for the residual heel, including curettage of an aneurysmal bone tumor and evacuation of necrotic tissue. Exposed, tunneled structures were covered with collagen wound matrix*, followed by meshed bilayer wound matrix** to support dermal coverage. A modified external fixation device “SALSAstand” for heel offloading was applied [1]

Results 

Inpatient spot grafting addressed compromised tissue viability due to central bleeding at the bone, using dehydrated flaked fish-skin graft. Throughout the postoperative period, careful management of bleeding risks directed wound care before frame removal. Multiple grafts were applied due to wound size and depth, resulting in gradual healing, with notable improvements in tissue tone and turgor. The wound fully healed over approximately six months, initiating rehabilitation and prosthetic gait training through physical therapy. After nearly two years of frequent hospitalizations, the patient has regained functional independence.

Discussion

This case study illustrates the successful management of a vasculopathic patient at high risk for below-knee amputation (BKA) after already experiencing one within the past year. Following bypass surgery, aggressive measures were essential to salvage the remaining limb without compromising the vascular graft. Once healed, the patient transitioned to rehabilitation focused on strength and mobility, primarily for prosthetic gait training on the contralateral limb. This case highlights the critical importance of multidisciplinary management in limb salvage, emphasizing meticulous surgical techniques, surgical offloading, comprehensive rehabilitation strategies, and effective resource allocation for successful limb salvage outcomes.

Trademarked Items 
*Integra© Flowable Wound Matrix, Newark, NJ, USA **Integra© Meshed Bilayer Graft, Newark, NJ, USA +Synthecure© Rapid Cure Synthetic Calcium Sulfate, Austin Medical Ventures, Memphis, TN, USA 

References 
Clark J, Mills J, Armstrong D. A Method of External Fixation to Offload and Protect the Foot Following Reconstruction in High-Risk Patients: The SALSAstand. Eplasty. 2009;9:e21. 

012: Prevention of Foot Amputation by Minimally Invasive Surgery in a Diabetic Patient with Osteomyelitis and Peripheral Vascular Disease with a History of Previous Amputations
Submission Category: Limb Salvage
Submitter: Orlexia Thomas – Yale New Haven Health Bridgeport Hospital

Primary Author: Orlexis Thomas, DPM

Co-authors: Francois Lokenye, DPM, Lady Paula DeJesus, DPM

Introduction 
This study aims to demonstrate the efficacy of minimally invasive surgical interventions in preventing foot amputation and promoting wound healing in a diabetic patient with osteomyelitis and peripheral vascular disease, compounded by a history of ray resection. Effective management of these conditions is crucial to preserve limb integrity, improve outcomes, and achieve wound closure. 

Methods

The focus was a chronic wound on the right foot, complicated by osteomyelitis. Initial intervention involved resection of the first metatarsophalangeal joint (MTPJ) with vancomycin antibiotic beads to control the infection. This was followed by further surgical management to prevent transfer lesions which would lead to further ulcerations, possible infections. Surgical management of painful right foot bunion, metatarsalgia, and hammertoes, including minimally invasive surgical offloading via floating metatarsal osteotomies of the 2nd, 4th, and 5th metatarsals, hammertoe correction of the 2nd and 4th toes, an Akin osteotomy, and flexor and extensor tenotomies. These techniques were chosen to prevent transfer ulcerations and infections, promote healing, and minimize complications ultimately preventing transmetataral amputation.

Results 

The patient's wound is with complete closure and no longer experiences pain. The interventions successfully prevented foot amputation and facilitated complete wound healing. Post-operative follow-ups show improved foot function and mobility, with no recurrent infections or complications.

Discussion

Minimally invasive surgical approaches are effective in managing complex diabetic foot conditions. In this case, they prevented amputation, ensured wound healing, and resolved pain. These findings suggest minimally invasive surgery as a viable option in similar high-risk patients to enhance outcomes and preserve limb integrity.

016: Evaluating the Impact of a Remote Monitoring Service on Limb Salvage Outcomes in Diabetic Foot Management and Care

Submitter: Maria Ryan – Bluedrop Medical 

Primary Author: Ronald Scott, MD

Co-authors: Chris Sandroussi, BA, Chris Murphy, MSc, Maria Ryan, MSc

Introduction 

The diabetic foot is a critical and challenging area in diabetes management, with diabetic foot ulcers (DFUs) significantly contributing to lower limb amputations and mortality (1,2). Prompt identification of issues through continuous monitoring is key to effective limb salvage.

We have evaluated use of a “smart scale” home use device that remotely monitors patient foot health by capturing daily visual images and temperature data of the soles of the feet to detect risk factors associated with developing a DFU or other complications. This data is used to alert patients to early signs of foot complications and assist clinicians in proactive management of diabetic foot health to mitigate the risk of ulceration and amputation.

Methods 

Real world data collection via healthcare providers who enroll patients in the monitoring program. The program includes daily at-home scanning with the device and interactions with the Monitoring Service team as needed, based on data that may indicate early signs of potential issues.

Data from thirty of these patients, enrolled from April to October 2024, is analysed and reported.

Results 

Analysis shows high levels of patient compliance in using the device and engaging with the Monitoring Service team.  The severity of issues identified and addressed are generally low, resulting in reduced cost of care for this highly vulnerable population through early detection and action.

Discussion

This product represents a promising step forward in limb salvage for diabetic patients with peripheral neuropathy. Lifestyle integration of a novel, easy to use remote monitoring technology enables a proactive approach to foot care, potentially transforming outcomes for those at high risk of foot complications.

References 
1. Armstrong DG, Boulton AJ, and Bus SA. (2017). Diabetic Foot Ulcers and Their Recurrence. New Eng J Med. 2017;376(24): 2367-2375 

2. Pecoraro RE, Reiber GE, Burgess EM. Causal pathways to amputation: basis for prevention. Diabetes Care. 1990;12:513-521.