SYMPOSIUM

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Amputation partial or not
Controversial Case Presentations
S Y M P O S I U M
SYMPOSIUM
PD Dr Mathieu ASSAL Division of Orthopaedics and
Trauma Surgery University Hospitals of
Geneva, Switzerland
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• M.P., 64 yo ?
• Paraplegic (secondary to spinal cord ischemia of
  unknown etiology) (2006)
• Heel ulcer of increasing size for 28 months
• with no tendency towards healing despite wound
  
• dressing 3x/wk and off-loading measures.

Case 1
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Patient afebrile Locally no purulence WBC
count Normal range CRP lt10
Q
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Off-loading Ex-Fix
1mo later no clear tendency to healing or
ulcer contraction. Ulcer clean.
1mo
1mo
Q
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Partial calcanectomy primary closure
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• R.C., 21 yo ?
• Past Medical History None
• Acutely ill with flu-like syndrome
• Admitted to ICU with meningococcemia

Case 2
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• Patient survived and was transfered to
  Orthopaedic Service 2 wks later.
• Clinical examination revealed areas of patchy
  necrosis of both lower extremities

2wks
8
L foot
R foot
3 wks
3 wks
Q
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L foot
R foot
5 weeks
5 wks
5 wks
5 wks
Definitely not progressing as a necrotic forefoot
in a PVD patient!
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11 weeks
11 wks
OR for toes amputation
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Postop views
(11wks)
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18 wks
Message meningoccemic lesions and frosbite
lesions are rarely full-thickness ? WAIT before
making any decision to amputate !
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• W.H., 55 yo ?
• IDDM
• Diabetic peripheral neuropathy
• Past hx of 3rd ray amp. for penetrating ulcer
• Admitted for new penetrating ulcer L forefoot

Case 3
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On admission Febrile (38.8C) WBC 24.500
/mm3 Blood Glucose Level 23mm/L CRP
280m/mm3 TCPO2 gt25mmHg
Q
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Intra-op view
Irrigation, débridement of infected and dead
tissue. 2nd ray removed.
Q
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12 days
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• W.H., 56 yo ?
• IDDM, obese
• Diabetic peripheral neuropathy
• Admitted for non-healing ulcer L foot gt25mos
  duration

Case 4
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Conservative ttt consisted of Wound dressing
3x/wk TCC trial for 3 months had to be
discontinued because of draining ulcer CROW 6
months patient refused to continue Surgical
options?
A/ Boyd or Syme Amputation B/ Plantar
exostosectomy C/ Realignment with Ex-Fix D/
Realignment with Extended midfoot fusion
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Post Op
Plantigrade foot No ulcer recurrence
5 yrs
Assal M, Stern R. Realignment and Extended Fusion
with Use of a Medial Column Screw for Midfoot
Deformities Secondary to Diabetic Neuropathy.
The Journal of Bone and Joint Surgery (American).
200991812-820
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Amputation partial or not
S Y M P O S I U M
SYMPOSIUM
Thank you !