This is an audio poster presentation on the pull-through technique, surgical augmentation for debriding mid and forefoot diabetic foot infections. I'm Dolphy Herskovici, Jr., and my co-author is Julia Scuduto. Diabetic foot infections are problematic. They are often due to complications of poorly controlled diabetes and are the primary cause for lower extremity amputations. Management requires an aggressive debridement, often maximizing vascularity and trying to preserve viable soft tissues. Often, large dorsal and plantar incisions may be necessary for an 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 the diabetic foot infection and to evaluate complications and outcomes associated with this technique. From January 2015 through January 2022, all diabetic patients in the diabetic registry with osteomyelitis or abscess were identified. Exclusion criteria were patients with osteomyelitis or abscess of the tibia, ankle, fibula, talus, calcaneus, or navicular, patients with gangrene, or patients who had an amputation of their toe or foot as their primary treatment. Inclusion criteria were patients with an abscess or osteomyelitis of the mid or forefoot who underwent a pull-through technique. Demographics and complications were recorded. This technique uses both dorsal and plantar incisions, sterile beta-9 scrub, and Ray-Tech sponges. After the plantar wound debridement, a dorsal incision is made directly over the plantar wound. In this example, there's a patient with a recalcitrant diabetic ulcer who failed to heal. Osteomyelitis of the fourth metatarsal head was identified. This was resected, and the plantar wound is ready for the pull-through technique. In this technique, a Cochlear clamp is passed from the plantar wound exiting the dorsal wound. In figure A, a beta-9 soaked Ray-Tech sponge is grasped with the Cochlear clamp. The sponge is then pulled through the dorsal wound through the plantar wound as seen in figure B. And in figure C, the beta-9 soaked sponges are demonstrated as being passed once from dorsal to plantar, which is the pull-through technique, mimicking the face of a clock. After the pull-through technique, this is followed by formal irrigation solutions. In the diabetic trauma registry, there were 155 patients who were diagnosed with osteomyelitis or an abscess of the foot or ankle. Eighty-two patients had excluded areas of infection. Twenty-nine underwent a primary amputation or ray resection. There were 34 patients who were only managed with debridements. Overall, 10 patients with 18 procedures, that is 36 wounds and incisions, utilized the pull-through technique. There were seven males and three females with an average age of 63 years. Their BMI averaged 34, with an A1C average of 8.1. The duration of the plantar wound was almost one year, on average, and there was only one patient who could accurately detect a 5.07 monofilament. One patient had a positive smoking history, and six patients were diagnosed with peripheral arterial disease. There were no skin or wound problems as a result of the pull-through technique. No patient required an amputation. Of the 18 procedures, only one plantar wound failed to heal completely. This required a re-debridement. In conclusion, large plantar incisions may not adequately reach dorsal areas of involvement. The pull-through technique allows for small dorsal incisions to augment the plantar debridement. This technique did not produce any skin necrosis or additional wound problems. Overall, 97% of the wounds completely healed. The authors feel that this is an adequate adjunct for the management of mid- and forefoot diabetic infections. Thank you.

pull-through technique

surgical augmentation

diabetic foot infections

osteomyelitis

abscess