Post clubfoot release skin necrosis: a preventable disaster.

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.

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.

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.

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.