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Post clubfoot release skin necrosis: a preventable disaster.
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MedLine Citation:
PMID:  21526037     Owner:  NLM     Status:  PubMed-not-MEDLINE    
Abstract/OtherAbstract:
Complications of pedal wounds closed primarily after release of neglected cases of club foot are well known in literature. We treated a 12-year-old boy presenting with widespread necrosis involving medial aspect of foot after release of neglected talipes equinovarus. Such widespread necrosis is even known to end up in amputations and permanent disabilities. In our case, the foot was successfully salvaged by resorting to dedicated wound care, multiple debridements, use of topical negative pressure (vacuum-assisted closure - VAC), and skin grafting. Various means to prevent such adverse events are also presented. The aim of publishing this case is to stress the need to:Take proper measures preoperatively in neglected club feet to decrease the impact of deformity.To be aware of various different flaps and methods of closure as mentioned in literature and to reaffirm the fact that primary closures done under tension are bound to fail and end up in disasters.To be patient and use the modern concepts of wound management like topical negative pressure if such unfortunate complications do occur and thereby attempt to salvage the feet.
Authors:
Sajad Ahmad Salati; Bandar Al Aithan
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Publication Detail:
Type:  Journal Article     Date:  2011-04-20
Journal Detail:
Title:  The Libyan journal of medicine     Volume:  6     ISSN:  1819-6357     ISO Abbreviation:  Libyan J Med     Publication Date:  2011  
Date Detail:
Created Date:  2011-04-28     Completed Date:  2011-07-14     Revised Date:  2013-05-29    
Medline Journal Info:
Nlm Unique ID:  101299403     Medline TA:  Libyan J Med     Country:  Sweden    
Other Details:
Languages:  eng     Pagination:  -     Citation Subset:  -    
Affiliation:
King Fahad Medical City, Riyadh, Saudi Arabia.
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Journal Information
Journal ID (nlm-ta): Libyan J Med
Journal ID (publisher-id): LJM
ISSN: 1993-2820
ISSN: 1819-6357
Publisher: CoAction Publishing
Article Information
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© 2011 Sajad Ahmad Salati and Bandar al Aithan
open-access:
Received Day: 19 Month: 2 Year: 2011
Accepted Day: 03 Month: 4 Year: 2011
Electronic publication date: Day: 20 Month: 4 Year: 2011
collection publication date: Year: 2011
Volume: 6E-location ID: 10.3402/ljm.v6i0.6415
ID: 3081856
PubMed Id: 21526037
Publisher Id: LJM-6-6415
DOI: 10.3402/ljm.v6i0.6415

Post clubfoot release skin necrosis: a preventable disaster
Sajad Ahmad Salati Affiliation: King Fahad Medical City, Riyadh, Saudi Arabia
Bandar al Aithan Affiliation: Military Hospital, Riyadh, Saudi Arabia
Correspondence: Email: docsajad@yahoo.co.in
Correspondence: Email: alaithanbander@hotmail.com

A 12-year-old boy with a neglected right club foot had been operated upon under general anesthesia and proximal tourniquet control and release of soft tissues, multiple osteotomies, and lengthening of tendons had been done. At the end of the procedure, there was a wide gaping wound over the medial side of foot that had been closed primarily after undermining and advancement. The patient on the seventh postoperative day reported with foul smelling discharge from the wound (Fig. 1A). On examination, the patient was hemodynamically stable and on local examination there was right pedal edema with necrosis of skin and underlying muscles and purulent discharge. Debridement was done under general anesthesia multiple times over a period of 2 weeks and multiple tendons and metatarsals got exposed in the process (Fig. 1B). Pus culture revealed multiple flora including staphylococcal growth and antibiotics were administered as per the culture/sensitivity studies. After final debridement, VAC (vacuum-assisted closure) was applied for 15 days and when the wound was deemed fit for grafting (Fig. 1C), split thickness skin graft harvested from right thigh was applied. The graft take was 95% (Fig. 1D) and the residual raw area measuring about 1 cm × 1 cm healed by secondary intention within about 1 week.

Dehiscence and necrosis are known complications of medial wounds closed primarily after release of neglected club foot. This is primarily due to extreme tension on the skin edges in an attempt to acutely correct the deformity in the face of skin shortage and a poor understanding of the vascular anatomy in clubfoot. Various methods of avoiding tension on the medial skin flap have been devised, each with its own advantages and disadvantages.

The use of distraction osteogenesis (Ilazarov method) for correction or to prime the patient for subsequent surgical release has been widely illustrated in literature (1, 2). Similarly encouraging results have been reported in the last few decades by the use of Ponseti method (3). This method has proven to be cost effective and safe and it involves serial casting and stretching over months to achieve full correction or else to decrease the deformity to levels where after surgical release the skin deficits are minimized and rendered manageable.

Regarding the surgical options to manage the widely gaping wounds created after correction over medial side of the club foot, it is important to stress that primary closure under tension needs to be avoided for the complications like the one from which our patient had to suffer. One option is either to under-correct the deformity initially to decrease the tension and then to cast the foot in full correction after a period of 2 weeks. The disadvantages include the need for prolonged postoperative casting, loss of initial correction, and the inability to splint in under-correction if the sub-talar and talonavicular joints have been transfixed in the corrected position. The second option involves partial closure of the gaping wound (4) and to manage the rest by dressings to heal by secondary intension or by coverage with skin grafts, but this method is time consuming and can lead to recurrence due to secondary contraction of the healing area.

In an attempt to solve this problem of wide wounds created after club foot release, a wide range of fasciocutaneous flaps have been designed by workers all over the world. Milan Rhejolic has given the concept of the rhomboid flap method and involves modification of classical posteromedial (Turco) incision and creation of a rhomboid-like flap that can be mobilized and stretched to cover the raw area. D'Souza DD et al. have devised a rotation fasciocutaneous flap (5) that they found to be technically easy, scientifically logical, reproducible, and effective. Gyorgy Szabo et al. found that the medial rotation fasciocutaneous flap can be effectively combined with the Cincinnati incision (6). Similarly Khan and Chinoy treated severely deformed club feet by making double zig-zag incisions (over medial foot and tendo Achilles) with no significant complications (7).

Soft tissue expansion has also found a role in management of neglected club feet. The tissue expander is inserted over posteromedial foot and is gradually expanded over weeks. Roposh A achieved successful closure in 12 out of 13 cases and concluded this method to be highly reliable if the proper technique is used (8). However, some workers reserve tissue expansion as the last resort due to increased chances of expander complications likes infection and extrusion in distal extremities.

Once the wound complications have occurred, it needs to be detected early and managed by proper debridement and control of infection. If these complications are not given due attention, the wounds might deteriorate and even up in disasters like amputation (9) of feet/limbs and lifelong disabilities. We managed our case with multiple sessions of wound debridement, antibiotics as per the culture reports, use of VAC (vacuum-assisted closure/negative pressure), and split thickness skin grafting harvested from ipsilateral thigh. Topical negative pressure (vacuum-assisted closure) therapy has emerged in recent years as a very useful concept for wound management. Complex effects at the wound-dressing interface following application of a controlled negative pressure have been documented. These include changes at both the microscopic (molecular) as well as macroscopic (tissue) levels and cause enhanced interstitial fluid flow, edema reduction, increase in wound perfusion, positive changes in protease profiles, growth factor, and cytokine expression and cellular activity, all leading to enhanced granulation tissue formation and overall improvement in wound-healing (10).

To conclude it is recommended that the neglected club feet be initially primed and prepared for soft tissue release by techniques like the Ponseti method and only than corrected surgically to minimize the resultant raw areas over the medial side of feet to manageable levels. Furthermore, it is stressed that wound closure under tension be avoided in all circumstances. The surgeons treating the cases of neglected club feet need to be acquainted with different local flaps and recent concepts of wound management to improve the outcome of surgical management.


Acknowledgements

We acknowledge with thanks the cooperation of the guardians of this patient in permitting us to take images of this patient and to use these images and details for publication.


References
1. Heurta F. Correction of the neglected clubfoot by the Ilizarov techniqueClin Orthop.Year: 199430189938156702
2. Franke J,Grill F,Hein G,Simon M.. Correction of clubfoot relapse using Llizarov's apparatus in children 8–15 years oldArch Orthop Trauma Surg.Year: 19901103372288803
3. Gupta A,Singh S,Patel P,Patel J,Varshney MK. Evaluation of the utility of the Ponseti method of correction of clubfoot deformity in a developing nationInt Orthop (SICOT)Year: 200832759
4. Palaniappan L,Phillips SJ,Thomas RH,O'Doherty DP. Partial wound closure of the Cincinnati incision in clubfoot correctionEur J Orthop Surg Traumatol.Year: 2005152831
5. D'Souza HH,Aroojis AA,Yagnik MG,Nagda TV. Rotation fasciocutaneous flap for neglected club feet – a new techniqueJ Postgrad Med.Year: 19964211249715312
6. Szabo G,Mester S,Toth F. Cincinnati incision combined with medial rotation fasciocutaneous flap for clubfeet with pathologic soft tissuesOrthopedicsYear: 2005283687015887581
7. Khan MA,Chinoy MA.. Treatment of severe and neglected clubfoot with a double zigzag incision: outcome of 21 feet in 15 patients followed up between 1 and 5 yearsJ Foot Ankle Surg.Year: 2006451778116651198
8. Roposch A,Steinwender G,Linhart WE.. Implantation of a soft-tissue expander before operation for club foot in childrenJ Bone Joint Surg (Br)Year: 199981-B39840110872354
9. Hootnick DR,Packard DS Jr,Levinsohn EM. Necrosis leading to amputation following clubfoot surgeryFoot Ankle.Year: 19901031262358260
10. Banwell PE,Musgrave M.. Topical negative pressure therapy: mechanisms and indicationsInt Wound J.Year: 200419510616722882

Figures

[Figure ID: F0001]
Fig. 1 

(A) Wide necrosis over medial side after release of club foot, (B) same wound as in (A) after debridement, (C) wound after 2 weeks of application of VAC, and (D) wound 1 month after split thickness skin grafting.



Article Categories:
  • Letter to the Editor

Keywords: club foot complications, necrosis, topical negative pressure, vacuum-assisted closure (VAC), flaps.

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