Staged salvage of diabetic foot with Chopart amputation and intramedullary nailing

Abstract

We present a stepwise surgical approach that can be used, in lieu of a transtibial amputation, to preserve the lower limb in the setting of severe diabetic foot infections. A 63-year-old male status post left midfoot (Lisfranc’s) amputation presented to our hospital with a 4-year history of a left foot diabetic ulcer with associated purulent drainage and intermittent chills. On initial exam, the patient’s left foot amputation stump was plantarflexed, grossly erythematous, and edematous. The associated diabetic foot ulcer was actively draining purulent fluid. Following workup with radiography and ultrasound, the patient was diagnosed with a post-operative infection of the midfoot at the level of the amputation stump secondary to diabetic neuropathy. Our approach to management was a staged and included (1) surgical irrigation and debridement of the distal stump wound, (2) provisional negative pressure therapy, (3) a second-look procedure, and (4) a tibiotalocalcaneal fusion was performed using a lateral transfibular and plantar approach, after wound closure and resolution of active infection was achieved. At 36-month follow-up, the patient was fully weight-bearing in stiff sole sneakers with no gross overt alteration of gait pattern. The patient scored 79 points when assessed by the hindfoot American Orthopaedic Foot and Ankle Society Ankle-Hindfoot outcome score. In the patient with diabetes and cardiological restrictions, a Chopart amputation is preferred due to the decreased level of energy expenditure required for ambulation as compared to over more proximal levels of amputation.

Chopart amputation with tendon balancing

“…However, if the area of necrosis is large and the heel cannot be preserved, there is no choice but to amputate the lower leg. An advantage of Chopart amputation is that the heel can be retained untouched, resulting in no change in leg length 6 , 7) , so the patient can bear weight even without using a prosthetic leg 8 - 10) . A disadvantage of the Chopart amputation is that all dorsiflexor strength is lost, resulting in relatively strong plantar flexor strength and development of equinus deformity.…”