The Pull-Through Technique: Surgical Augmentation for Debriding Mid- and Forefoot Diabetic Foot Infections

Abstract

Category: Diabetes; Midfoot/Forefoot Introduction/Purpose: Diabetic foot infections (DFI) are complications of poorly controlled diabetes and are the proximate cause of lower extremity amputations. Wounds lead to bacterial colonization, the development of a biofilm and antibiotic resistance. Management requires aggressive debridement, maximizing vascularity and preserving viable soft tissues. Large dorsal and plantar incisions may be necessary for adequate debridement. The purpose of this paper is to discuss a technique that allows both dorsal and plantar approaches, using smaller incisions, for the management of diabetic foot infections and to evaluate complications and outcomes with this technique. Methods: From January 2015 through January 2022, diabetic patients with osteomyelitis or abscesses were identified. Exclusion criteria were osteomyelitis or abscesses of the tibia, ankle, fibula, talus, calcaneus, or navicular; gangrene; or patients who underwent an amputation of their toe(s) or foot as primary treatment. Inclusion criteria were patients with abscesses or osteomyelitis of the mid- or forefoot who underwent a pull-though technique. This Technique uses dorsal and plantar incisions, sterile betadine scrub (soap) and RAY-TEC sponges (Johnson and Johnson, Dublin, Ohio, U.S.A). After plantar wound debridement, a small dorsal incision is made over the plantar wound. The betadine soaked sponges are then individually passed, one time, from dorsal to plantar (pull-through), mimicking the face of a clock (12-1-2, 3, etc.), followed by formal irrigation solutions. Demographics and complications were recorded. Results: 155 patients were diagnosed with osteomyelitis or abscess of the foot or ankle. 82 patients had excluded areas of infection. 29 patients underwent a primary amputation as index procedure. 34 patients only had debridements leaving 10 patients, with 18 procedures, utilizing the pull-through technique. All pull-though patients presented with plantar wounds in the forefoot or midfoot. The 7 males, 3 females averaged 62.8 years (29-81). BMI averaged 34.1(25-48.8), with an A1C of 8.1 (6.3-12.9). Plantar wound duration was 11.4 months (3-36) and only one patient accurately detected a 5.07 monofilament. One patient had a positive smoking history, 6 patients had peripheral arterial disease. No skin or wound problems occurred as a result of the pull-through technique and no patient required an amputation. Of the 18 procedures (n=36, incisions plus plantar wounds) only one plantar wound (3%) failed to completely heal. Conclusion: DFI leads to production of biofilms and bacterial tissue adherence by various organisms. Surgical debridement is a key part of the treatment. Plantar wounds need larger incisions for acceptable debridement but may not adequately reach dorsal areas of involvement. The addition of a pull-through technique allows for the placement of small dorsal incisions to augment the plantar debridement, providing more debridement of the involved DFI. This technique did not produce any skin necrosis or additional wound problems, with 97% of wounds plus incisions completely healing. The authors feel this is an adequate adjunct for the management of mid-and forefoot DFI.