Tight Post-Operative Bandages Cause Patient Gangrenous Toes

This case involves a 66-year-old male with a history of diabetes who underwent a metatarsophalangeal joint fusion, a dorsal flexor shortening wedge osteotomy, and hammertoes arthrodesis. The patient felt the bandages were too tight on his foot but kept them on until his first post-operative appointment two weeks after surgery as instructed. The podiatrist removed the bandages and noted concern of gangrenous toes. In spite of this noted concern, the podiatrist did not perform cultures or place the patient on antibiotics. The podiatrist recommended follow-up in one week. During the follow-up appointment, the patient’s toes looked gangrenous and sanguineous drainage was noted. The patient was referred to a wound care center and was told that some toes would have to be amputated secondary to gangrene.

Question(s) For Expert Witness

1. How long do dressings stay on post-metatarsophalangeal joint fusion, a dorsal flexory shortening wedge osteotomy of metatarsals 2-5 and hammertoes arthrodesis of 2-5?

2. What actions can the podiatrist take to mitigate against toe necrosis from tight dressings?

3. Once toe gangrene is suspected, what are the immediate next steps in management?

Expert Witness Response E-008033

I am a board-certified by the American Board of Podiatric Medicine, and I am board-certified in foot and ankle surgery by the American Board of Podiatric of Foot and Ankle Surgeons. I am the former president of the American Board of Podiatric Medicine. I serve as the chief of podiatry at a large hospital. This complication could likely have been avoided with pre-operative work up. That being said, monitoring the area to see the extent of the gangrene, vascular surgery referral, etc can mitigate the risk of toe necrosis. Initial dressings are checked 3 -7 days following but are changed weekly thereafter until the wound edges are coated -- usually 3 weeks to 1 month. Patients are instructed to check digital circulation by checking the capillary return of the distal aspect of the toes in addition to visual inspection of the digits.