SINGAPORE – Ng Teng Fong General Hospital (NTFGH) has performed an innovative combination of novel surgical procedures to save a severely infected diabetic foot from major amputation. This is the first-ever combined orthoplastic procedure of its kind for treating severe infection and restoring foot structure in Singapore.
This novel orthopaedic procedure, Transverse Tibia Transport (TTT), involves creating a small bone window in the tibia and using a specialised device to stimulate controlled movement of the bone window. This increases blood flow to the affected limb, prevents further tissue death and reduces the need for amputation. This procedure was introduced to Singapore for the first time by the team from NTFGH in May 2024. This technique was crucial in reversing the vicious cycle of progressive gangrene in 43-year-old Lau Ming Jie's ( 刘铭杰) foot, enhancing vascularization, and aiding in the recovery. The TTT procedure was followed by a reconstruction using a double-barrel free fibula flap, which involved utilising a section of the fibula from Ming Jie’s left leg to reconstruct his missing metatarsals. This helps to recreate the foot arches that are necessary for normal walking. With his infection under control and his foot reconstructed, Ming Jie regained the ability to walk on his own. This marked the first time both procedures have been performed locally on a single patient. The success of his treatment not only saved his leg but also signifies a notable achievement in medical practice in Singapore, setting a precedent for future diabetic foot management. It suggests that this method for staged reconstruction, combining a TTT with the free fibula flap can become a useful approach in orthoplastic surgery, offering hope to patients with severe diabetic foot infections, who may have otherwise lost their limbs to a major amputation.
Ming Jie was not aware that he is suffering from Type 2 diabetes. Save the occasional thirst and fatigue after a long day at work, Ming Jie had not felt particularly unwell. He only sensed that something was amiss when his right foot became very swollen after stepping on a metal nail while visiting a renovation site. Subsequently, he developed a high fever and had to be admitted to the Emergency Department. He only found out that he had diabetes after going to the hospital with a severely infected right foot.
Ming Jie went through a series of toe and forefoot amputations as the tissues at his foot progressively turned black due to worsening gangrene. As the gangrene continued to progress despite the operations, it became imminent to amputate below the knee to save the rest of his right lower limb. By the second month of his foot injury, Ming Jie could not walk or stand properly as he was not able to maintain his balance. He got depressed at the prospect of losing his leg.
After undergoing four surgeries, Ming Jie, who was then 42 years old, was referred to the specialised team at NTFGH, which members include Adjunct Associate Professor Chen Yongsheng (Prof Chen), Consultant, Orthopaedic Trauma Surgery, NTFGH and Adjunct Assistant Professor Vigneswaran Nallathamby (Prof Vignes), Head of Division & Senior Consultant, Plastic, Reconstructive & Aesthetic Surgery, NTFGH. Prof Chen began the staged reconstructive process with the TTT procedure. After the procedure, the worsening gangrene was soon halted and the infection quickly came under control. Before long, new healthy tissues started growing on the wound bed. Once the worsening gangrene was halted, the next stage was performed.
Prof Chen, Prof Vignes and their teams carried out the Midfoot Fusion and Application of Circular Frame with a Double-Barrel Free Fibula Osteocutaneous Flap Reconstruction procedure on 19 June. This involved Ming Jie going through a 15-hour surgery to insert a metal circular frame from below his knee, followed by the transfer of a fibular bone flap to reconstruct his missing metatarsal bones. He then underwent rehabilitation post-surgery. In July, Ming Jie started to learn to walk again and in August, the frame was removed. Eventually, he could remove his crutches and start to walk unaided. This significantly improved his quality of life.
Ming Jie underwent the following procedures to reconstruct his infected foot:
Ming Jie required extensive rehabilitation during his four-month stay to prevent muscle deconditioning, which was essential for preserving muscle strength and aiding his ability to walk again. This innovative surgical approach reduced the risk of infection, facilitating a smooth recovery and improving his quality of life.
“The innovative surgery was a turning point for Ming Jie. As with many diabetic patients, there remains a risk of future complications, such as new infections or wounds because the transferred skin in Ming Jie's case lacks sensation, which increases the risk of unnoticed injuries and subsequent infections. Efforts have been made to connect a sensory nerve to the flap skin in Ming Jie's case to promote sensation and this process can take one to two years. Continuous monitoring and proactive management of his diabetes are essential to prevent recurrence and maintain foot health,” said Prof Chen. Ming Jie will also require continued physical therapy to strengthen his foot and leg muscles, further enhancing his mobility and preventing muscle deconditioning.
“It was truly a miracle that I can stand on my right foot and walk out of the hospital on my own. I am very grateful for the wonderful care I received from Prof Chen, Prof Vignes and the rest of the healthcare team in NTFGH who helped me to walk again,” said Ming Jie. Ming Jie’s surgery is a high-risk treatment that would not have succeeded without a multidisciplinary team of healthcare professionals from disciplines including plastic surgery, orthopaedics, vascular surgery, nursing and podiatry, who tirelessly helped and supported him throughout this journey.
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