1. Midfoot Surgery in Diabetic Osteomyelitis
Authors :Paisey RB,Davis J, McCarthy R, Gornall R, Fadl, A
Institution Torbay hospital, South Devon Healthcare foundation Trust, Torquay, TQ2 7AA

2. Introduction
Background: Diabetic peripheral neuropathy and neuroischaemia are often complicated
by foot infection with osteomyelitis.
Prolonged antibiotic therapy can be curative, but ray excision, or leg amputation
are frequently necessary, leading to an unbalanced foot , abnormal gait and
foot pressures or need for prosthesis respectively.
Co morbidities including cardiovascular disease,
nephropathy, psychiatric and social problems all present challenges to
successful outcome in terms of prompt rehabilitation with good
long term mobility. Mid foot surgery to eradicate osteomyelitis
can result in a good functional limb with broad area for weight
bearing and rapid rehabilitation potential. Eight patients from
the Torbay Hospital multidisciplinary foot clinic were offered
mid foot surgery between Jan 2005 and December 2007.

3. Patients
Ninety five subjects with diabetes were
reviewed in the foot clinic over the 3 year
period, 40 with osteomyelitis, of whom 8
had metatarsal infection not responsive to
clindamycin, or rifampicin and
minocycline. They consented to undergo
foot surgery.

4. Patient Characteristics
-8 patients
-7 males,1 female
-5 type2 DM,3 type1 DM
-Duration of DM range 8-26 years, mean of
20 years
-Age range 45-80 years, mean of 62.5 years

5. Comorbidities
6 nephropathy one haemodialysis
6 retinopathy
4 hypertension
3 hypercholesterolemia despite statin
1 Previous stroke
1 morbid obesity
1 myocardial infarction 3 ischaemic heart disease
2 previous Charcot joints

6. Ulcer Features
• Texas wound score:
-2 patients had 3B
-6 patients had 3D
• Ulcer nature:
-2 neuropathic
-3 ischaemic
-3 neuroischaemic

7. Infection
• All patients had preoperative osteomyelitis
• 5 patients had postoperative osteomyelitis
• All treated with long term antibiotics
• 2 developed Charcot changes after
surgery
• Surgery aimed to excise all infected bone
and preserve insertion of anterior tibial
muscle.

8. Pre operative
• 3 patients had contralateral right below
knee amputation
• 1 patient had contralateral left above knee
amputation
• 6 had ipsilateral Angioplasty
• 3 had previous toe amputation
• 2 had hyperbaric oxygen treatment

9. 17 months preoperative Pt 1

10. 16 months preoperative Pt 1

11. Preoperative Pt 1

12. Post-op weight bearing Pt 1

13. Postop-weight bearing Pt 2

14. Sitting Pt 3

15. 1 y post amputation Pt 4

16. Follow up
• 6 had right MTA
• 2 had left MTA
• 3 have > 2yrs follow up
• 5 have 10-12 months follow up
• 2 had recurrent ulcers
• 1 proceeded to BKA after one week,
another after 10 months.
• 4 required bespoke footwear

17. Current Mobility
• 4 walk unaided
• 4 walk with the aid of sticks and/or support
• 1 drives a normal car
• 1 able to drive an adapted car and
transfer only

18. Conclusion
Midfoot amputation even in complicated
subjects with intractable diabetic foot
infection has resulted in good mobility for
up to 3years in 8 subjects.
MRI scan in all cases preoperatively may
have identified the two with early
recurrence and subsequent BKA.