09/30/2013    Richard Gosnay, DPM

Update on Gangrene S/P Cast Complication

In dealing with catastrophic loss of tissue,
sometimes we let our desire to help heroically get
the best of us. Dead tissue is dead forever. It is
never coming back. It's only remaining function is
to provide sustenance for bacteria. Ruthless
removal of all dead tissue is always required
because no modality is going to reanimate dead
tissue. So the decision to not use HBO therapy is
reasonable.

On the bright side, all remaining live tissue is
going to make it unless there is another
catastrophic event (like infection or sickle cell
crisis) because this patient is so young.
Hyperbaric oxygen is not needed to improve the
prognosis for this live tissue.

I believe that preserving the foot is indicated
because of the known cardio-vascular morbidity and
mortality associated with proximal lower extremity
amputations. In this case, there is still some
persistent black, dead tissue that must be
debrided. The remaining stump has very little
plantar tissue, which is a problem with respect to
function. I would send this patient to a plastic
surgeon who does free muscle flaps in order to get
some beefy mass to the plantar aspect of his foot.
If his family is able to travel to New Haven, I
understand that the Podiatry Department at Yale
does these flaps.

It is probably in this patient's best interests to
get his foot closed and into a shoe with a filler
as soon as possible. But he will certainly acquire
more deformity in the future. An ankle fusion is
likely to be needed eventually. For the time
being, a percutaneous tenotomy of the unopposed
peroneus brevis and of the Achilles tendon at the
time he receives his flap will push revision
surgery off into the future.

I wish the best of luck to this young man and his
physicians/surgeons. Calamities like this can take
an emotional toll on all who are involved with
them. I am sure that the entire podiatric
profession empathizes with the medical/surgical
team and looks forward to hearing that this young
man has resumed an active and happy life.

Richard Gosnay, DPM, Danbury, CT
glabroushead@gmail.com

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