Finish the Job: the Use of Amniotic and Other Tissue Technologies in the Operating Room and Clinic When Limb Salvage Complications Arise

Background: We present a challenging case in a 56-year-old male with a history of diabetes mellitus, peripheral neuropathy, end-stage renal disease on hemodialysis with nonhealing forefoot and midfoot ulcerations and diffuse, chronic refractory osteomyelitis of the midtarsal bones. This was complicated by multi-drug resistant Pseudomonas and methicillin-resistant Staphylococcus aureus. Limb salvage was attempted with a Chopart amputation, Achilles tendon lengthening, transfers of the tibialis anterior and peroneus longus tendons, and wound closure with a medial plantar artery angiosome rotational flap. Unfortunately, the rotational flap dehisced and left a large, complex wound in our high-risk patient. Amniotic allograft membrane tissue was used in the outpatient clinic to successfully accelerate wound closure. A tunneling wound which could not be healed in the clinic was successfully closed by application of a flowable, acellular soft tissue scaffold performed in the operating room. 

Results: The patient had ultimate wound closure at 20 weeks following his index surgical procedure and was ambulating with custom molded shoes and plastizote inserts.

Conclusion: This case highlights not only the use of Chopart amputation and tendon balancing for treatment of diffuse midfoot osteomyelitis but also the effectiveness of amniotic and other tissue technologies for post-operative wound complications in the high-risk patient. Creative surgical planning and diligence throughout the post-surgical wound healing period are essential to finish the job in successful limb salvage.