Saving a Limb

A 38-year-old woman had been struck and dragged by an MTA bus before arriving at Harlem Hospital with a devastating injury to her left foot. She had suffered an open fracture and a severe degloving injury that stripped away skin and soft tissue, exposing the bone. New York College of Podiatric Medicine’s Dr. Anthony Jabra remembered the damage in stark terms.

"Her bone was basically on the side of the road," said Dr. Jabra, a podiatric surgeon.

After evaluating the injury, the vascular surgery team recommended a below-the-knee amputation. But one finding gave Dr. Jabra and the rest of the limb salvage team hope: despite the severity of the trauma, blood flow to the foot remained intact.

"We looked at it and everything looked great," Dr. Jabra said. "So, I thought: let's try to stabilize the foot."

That decision began a months-long effort involving podiatric surgeons, orthopedic trauma surgeons, plastic surgeons, vascular surgeons and wound care specialists to save the patient's foot.

The case was presented at New York College of Podiatric Medicine's Annual Research Day by student-doctors Mohamad H. Mohyuddin and Muhammad Abraar Vaid under the mentorship of Dr. Jabra. The presentation examined the staged reconstructive approach that ultimately allowed the patient to keep her leg.

When the patient arrived, the wound extended from the tarsal tunnel to the first web space of the foot, leaving bone and other structures exposed. Although pain limited the sensory and motor examination, all of the patient’s toes remained warm with brisk capillary refill, indicating that circulation had been preserved. Her Mangled Extremity Severity Score (MESS), a tool used to help evaluate severe limb injuries, was five, supporting an attempt at limb salvage.

The team's first priority was stabilizing the foot.

During the initial surgery, doctors removed nonviable tissue, applied an external fixator and started antibiotics. The patient returned to the operating room several times over the following days for additional debridement as surgeons removed damaged tissue while preserving as much healthy tissue as possible.

Repairing the wound proved just as challenging as rebuilding the missing bone.

To protect the exposed structures, the team used fish skin and temporarily filled the missing section of the first metatarsal (the long bone between the ankle and big toe) with antibiotic bone cement. Jabra knew some of the overlying tissue would not survive, but the temporary reconstruction protected the foot while the patient underwent weekly wound care and the surgical team planned the next stage of reconstruction.

Once the wound had stabilized, Dr. Jabra partnered with a plastic surgeon on the next phase of the operation.

Using the Masquelet technique, surgeons performed a flap procedure to restore soft tissue coverage before reconstructing the missing bone. They then harvested a 6-centimeter section of bone from the patient's iliac crest and carefully shaped it to replace the destroyed first metatarsal.

"We basically fashioned it to become a first metatarsal," Jabra said.

The staged reconstruction required months of surgeries and recovery. The Research Day presentation included postoperative photographs and radiographs documenting the reconstructed foot. Today, Dr. Jabra said, the patient is walking on her own leg.

For Dr. Jabra, the case demonstrates what can happen when multiple specialties work toward the same goal.

"As podiatrists, we call ourselves the foot specialists," he said. "Here we are working hand in hand with orthopedics."

The patient's care brought together podiatric surgeons, orthopedic trauma surgeons, vascular surgeons, plastic surgeons, nurses and wound care specialists over the course of months. Jabra said those collaborative cases also give students an opportunity to see how different specialties contribute to treating complex injuries and how patient care benefits when they work together.

Today, months after an accident that initially led one surgical team to recommend amputation, the patient is walking.

"She's very happy," Jabra said. "We did our job."