Ivan S. Tarkin, MD, Chief of Orthopedic Trauma Surgery, Specializing in Orthopedic Trauma, Professor of Orthopedic Surgery, UPMC, talks about an out-of-the-box surgery solution to save a patient’s foot from amputation.
Interview conducted by Ivanhoe Broadcast News in September 2017.
I want to talk about the patient, tell me how you met Maria and under what circumstances.
Dr. Tarkin: Maria was transferred to our hospital as a level one trauma. She was what we called a polytrauma patient; she had injuries all over her body, specifically in her case in her head, intracranial, as well as a horrible mangled lower extremity. Initially, my on-call partner was consulted to care for her. He temporized her injuries and then I was asked to take over.
What had happened, a car accident obviously, but can you tell me do you know a little bit more about what caused her extensive injuries, especially to her leg?
Dr. Tarkin: Maria was in a high-speed motor vehicle accident, which is a widespread mechanism for the types of traumas that we see at our institution. She came in with a mangled leg. Specifically, in her case, her ankle was shattered into a lot of pieces. She had what’s called an open fracture, meaning that all those bony pieces and the joint were subject to the outside environment and contamination through a large soft tissue wound. Furthermore, beyond having very significant bone and joint injury, she also had a massive soft tissue injury as well, to the skin, to the muscle, and to the tendons, etc.
Did the injury occur from her attempting to brace herself in that high speed impact, or was it actually from the other vehicle coming at her?
Dr. Tarkin: From my understanding, I believe that she was on a mother and daughter trip for her daughter’s birthday. Apparently, it was icy that night, and when she tried to jam on the brakes, she instead hit another car and that ultimately just mangled her ankle.
When you came in and you took a look, what options were you able to give her in terms of repairing the damage?
Dr. Tarkin: Moreover, considering the damage to her ankle joint, I thought amputation was her best reconstructive option. Upon speaking to Maria, she didn’t want to entertain amputation as a first line treatment; she was more minable and wanted to “limb salvage.” Limb salvage is a procedure done to try and keep the leg, knowing that the function may be somewhat variable. In her case, limb salvage, attempting to put all the pieces together in a traditional way, just wasn’t possible. With her, we needed to use an out-of-the-box type solution. We needed to do what’s called a retrograde hind foot nail. Essentially, we bypass those many pieces which were broken and ultimately hope to fuse the ankle in a position that allows it to function. Beyond that orthopedic care clearly, we operate as a team, and we needed all our incredible plastic surgeon also to get the soft tissue wound closed. We worked intimately together as a team to provide her with limb salvage.
Talk to me a little bit about the retrograde hindfoot nail. How does this work?
Dr. Tarkin: Conventional therapy for a bone smashed to pieces, especially in the ankle, is to put all those little pieces together accurately and stabilize it with plates and screws. In her case, that was almost impossible, so I needed to give Maria a stable ankle joint that ultimately would fuse. We used a minimally-invasive technique because we didn’t want to create any further surgical trauma superimposed on her already horrendous injury. I put up a rod from the bottom of her heel bone through where her previous ankle joint was and into the leg. I then secured that rod with screws on either side.
You said you were able to do this in a minimally-invasive way?
Dr. Tarkin: She had a maximally-invasive injury, and the last thing we wanted to do was superimpose another surgical trauma on top of that. We didn’t want to make any unnecessary cuts and dissection. Thus, putting up a rod was the most efficient way to give her a stable ankle and prevent any further trauma that was already occurred in her ankle joint.
How long did it take for her to get back up on her feet, what kind of recovery did she have?
Dr. Tarkin: Maria is an incredible human being. I always argue that the reason why she is doing so well is that she wanted to do well. It took her months just to heal and then she had a very long rehabilitative process. She kept telling me, doc, I’m going to go back, I’m going to be a nurse, I’m going to get back to my life, and she did.
Does she have any restrictions now?
Dr. Tarkin: She has no restrictions. Fortunately, by the grace of God, all those pieces around her ankles all fused together as one big bone. So she has a stable platform to walk on. A fused ankle is not a normal ankle, but I think in Maria’s case, she’s just happy to have her leg despite the little bit of disability that she continues to have.
Does she need a cane, a walker or any kind of assistive device to get around?
Dr. Tarkin: At least around me, she never uses a cane. She’s always very appreciative; she’s always smiling, she’s always very grateful for the care from God and her surgeons. She doesn’t show any disability despite her probably having some.
You talked about the process the retrograde hindfoot nail process, what kind of injury is this normally used for? I know you said you went out of the box a little bit on this one.
Dr. Tarkin: We do a retrograde hindfoot nail procedure to do an elective ankle fusion. Meaning, when a patient comes in, and they have arthritis in the joint, it’s a great way or a way to stabilize the ankle joint to encourage it to fuse. But it’s rarely used as a tool in acute trauma although some people are doing this across the country for different unique situations like this.
When it’s done in the elective realm is the rod, does it go up as far? I think you mentioned it went up almost to her knee?
Dr. Tarkin: Well, in her case, we had to bypass a lot of broken bone. I used an excessively long rod for her injury. Again, what’s great about being an orthopedic trauma surgeon is that we frequently have to customize surgery to the patient’s injury, to their current situation, to their general health, to their physiology. It gives us a little bit of creative license, especially when we’re performing limb salvage. There isn’t a textbook point by point on how to do these things, sometimes; we have to be very creative. For instance, in Maria’s case which was extraordinarily devastating, we had to do a lot of other things beyond putting up the rod. The main thing we had to do for her was figured out how to close that massive soft tissue wound. She had a fair amount of tissue loss. I worked with our plastic surgeon, and we figured out the best ways to do this. To get the wound to close, I shortened her leg a little bit. It was a perfect opportunity. I had an exposed wound; I was staring at all the bone, so I manicured it down a little bit, trimmed it down because it made sense in her case. Then I collaborate with the plastic surgeon and other members of the team to finally get the bone where I wanted it to be and also to get that soft tissue closed. If we have a problem with the soft tissues, that equals infection and amputation almost every day of the week.
Had this not worked what would have been the ultimate outcome?
Dr. Tarkin: Certainly at Maria’s request we could have tried other things, but in the most typical case, this ends up in amputation. I tell Maria that we got a little lucky and we got a lot of grace from God and certainly her believing in the process and her wanting to succeed, at least in my eyes, is everything.
Have you done this procedure on any other trauma patient since her?
Dr. Tarkin: I have used the hindfoot nail procedure in many different circumstances. I would reserve this technique for older more sedentary people, especially with a lot of medical co-morbidities. I guess where Maria is different is that she’s younger and more active. When I was purposing this as an option for her, I made sure she understood that her ankle wouldn’t be perfect. In fact, it will be fused. But she was willing to accept that fate for her legs, and we decided to take this journey together.
Is there anything I didn’t ask you that you want to make sure people know about this? About Maria’s case or about the procedure?
Dr. Tarkin: Orthopedic trauma is a team approach; our general surgeons, our plastic surgeons, orthopedic trauma surgeons, we’re all one big think tank. For unique cases like Maria, we all get together informally and figure out if this was my sister here, if this was my mother, what would be the best option? Especially, regarding a complex case of limb salvage.
Talking about fusing, she can’t go up and down, or right and left, it’s just straight on? What kind of mobility does she have with a fused ankle?
Dr. Tarkin: When you fuse an ankle, the ankle joint itself does not move. However, there are multiple joints in the foot. Typically over time, people develop motion in those other joints. Many people don’t even demonstrate a limp when they have an ankle fusion for elective reasons. In Maria’s case, she has compensated somewhat, but she still has a bit of stiffness in the foot.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Ivan Tarkin
Rick Pietzak
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