The quickest and most effective way to eradicate infection is to amputate far away from the infection. For example, toe infections can be completely controlled with a ray amputation (removal of the toe and part of the metatarsal). However, midfoot infections are very difficult to treat with a single surgery aside from a leg amputation. If limb salvage is the goal, it can be done by a series of staged surgical procedures involving minor open amputation, and then wound closure. Some infections are so extensive that the wound cannot be closed completely, thus requiring partial wound closure, wound vac, and then skin grafts. Below is a great case that demonstrates this process.
We start by removing the infection, creating a large wound. The wound is left open to observe for remaining infection.
2 days postop
partially closed, wound vac started
3 weeks of wound vac therapy
If we don’t see signs of infection after 3 days, the second surgery will then be to close the wound. If the wound is large, we close what we can, and apply a wound vac to cover the rest. The wound vac is then changed 2-3 times a week and continued for about a month. Once the wound is 100% granular (looks like ground beef), it is ready for the final surgery, a skin graft.
1 week after split thickness skin graft
3 weeks after split thickness skin graft
Skin graft surgery is an outpatient procedure. A very thin layer of skin is harvested from the thigh and placed onto the wound. The thigh wound heals quickly without requiring sutures. The wound with the skin graft is then covered with a wound vac for one week to help keep it from shifting. After 1 week, a gauze dressing with ointment is applied and changed several times a week until healing.
This took about 2.5 months to completely recover from the infection. It required a lot of work from the patient and his family to undergo 3 surgeries and several weeks of wound vac therapy. However, he was rewarded with a very functional foot that will serve him for years to come.
