Interesting case

SDN Members don't see this ad. (About Ads)

I had an interesting patient in the office today. Tell me what you would do... Young guy 26 yr old soldier sustained MVA 18 months ago with severe degloving and burns to lateral and posterior lower leg down to just above ankle level right LE. He had 16 surgeries until now mainly of debridements and multiple STSG to get this covered and is now healed and undergoing PT. He had no osseous trauma. He had damage to the superficial peroneal nerve and has limited ankle dorsiflexion and limited eversion available. Probably max dorsiflexion is about 5-10 degrees plantar flexed. He can dorsiflex against resistance but not past 5 degrees plantar flexed from neutral. He can invert 20 degrees and evert about to neutral. His contractures are flexible and not yet fixed. The STSG are adhered to the gastrosoleal musculature and Achilles and move with the graft. Likewise STSG is adhered to the peroneals which are balled up proximally and to the anterior ankle and move with the anterior tibial musculature. Other than a heel lift accommodation or dropfoot brace, what would you consider surgically?

Originally Posted by newankle

I had an interesting patient in the office today. Tell me what you would do... Young guy 26 yr old soldier sustained MVA 18 months ago with severe degloving and burns to lateral and posterior lower leg down to just above ankle level right LE. He had 16 surgeries until now mainly of debridements and multiple STSG to get this covered and is now healed and undergoing PT. He had no osseous trauma. He had damage to the superficial peroneal nerve and has limited ankle dorsiflexion and limited eversion available. Probably max dorsiflexion is about 5-10 degrees plantar flexed. He can dorsiflex against resistance but not past 5 degrees plantar flexed from neutral. He can invert 20 degrees and evert about to neutral. His contractures are flexible and not yet fixed. The STSG are adhered to the gastrosoleal musculature and Achilles and move with the graft. Likewise STSG is adhered to the peroneals which are balled up proximally and to the anterior ankle and move with the anterior tibial musculature. Other than a heel lift accommodation or dropfoot brace, what would you consider surgically?

What's his TA and PB muscle strength? Can you passively get his foot to neutral and above? Can you put his foot into a neutral position? How is his gait? Before rendering an opinion, knowing that and some more info would be helpful. Likely sounds like a good candidate for tendon transfers if it is truly a supple deformity.

As you know, surgical intervention could be difficult, since there will be so much scar tissue and normal tissue anatomy and tissue planes will be non existent/obliterated.

Since the deformity is flexible, would it be feasible to have aggressive PT with friction massage, ART, Graston techniques, etc., to attempt to free the skin grafts from the underlying soft tissue/muscles/tendons to allow those structures to function slightly more normal???

If surgery was attempted, would it be possible to go in with a scope to try to simply separate the tissues to allow for more movement? Certainly not an orthodox approach, but in a tough situation creativity may be needed. After all, necessity is the mother of invention.

Please keep us filled in on this unfortunate case.

Originally Posted by densmore22

What's his TA and PB muscle strength? Can you passively get his foot to neutral and above? Can you put his foot into a neutral position? How is his gait? Before rendering an opinion, knowing that and some more info would be helpful. Likely sounds like a good candidate for tendon transfers if it is truly a supple deformity.

His TA strength is 4/5. I can passively get him to neutral but can't passively dorsiflex beyond that. I can passively get his STJ to neutral but can't passively evert past that. He can actively dorsiflex to about 5 degrees plantarflexed and actively evert to STJ neutral. His gait is slightly abducted secondary to his lack of ankle dorsiflexion. He has very mild knee flexion secondary to ipsilateral knee contracture from his grafting. He has good hip ROM. STSG is adhered to peroneals, posterior calf, achilles, and anterior tibial surface. Anything else you'd like to know before I reveal what I'm thinking (surgically)?

Sounds like the deformity has progressed since the injury, so I'd be real wary of the deformity worsening (and becoming more and more fixed in increasingly nonfunctional position) since the ankle dorsiflexors and everters are clearly being overpowered.

Based on the info available, I'd probably offer him either more PT and bracing or an ankle desis (probably anterior approach lock plate since lateral soft tissue envelope sucks and it's almost surely too malaligned for scope desis... although you could consent for both scope/open if you think a lot of your scope skills and have good assistance in the case). You could put it in 5deg+ of valgus to offset the limited STJ ROM. He obviously has to know that he'll need a rocker sole shoe to protect his knee and his hindfoot will likely need conversion to a pantalar - or at minimum agressive bracing - down the line too. And since he's somewhat insensate and with compromised soft tissue envelope + progressive imbalances, I'd flat out tell him that he's at very high risk for eventual ulcer or surg leading to infection leading to a BKA at a relatively young age. Yes, I guess I'm Dr. Doom, but that is the fact of the matter here.

The soft tissue corrections like Bridle procedure or similar superhero procedures are going to (not possibly... definitely) need revision down the line, and I wouldn't want to really mess around in all that scarred graft skin. A lot of stuff looks good on the drawing board, but this is a young guy with fairly high demand here. His ankle joint motion as it is sucks and isn't too functional (even if the joint itself is fine, it's clearly locked up from muscle imbalance and skin contractures).

Then again, he's has a lot of surg already, so it'd be easy to talk him into (and a lot of surgeons might) putzing around with gastroc recession, PT transfer, sTJ and ankle capsulotomies, skin plasties, etc etc with much physical therapy and bracing before eventually moving to the ankle +/- rearfoot arthrodesis. No real right or wrong I guess, but it's not my style to tell a revision revision case that's had a severe injury that everything will turn out kittens and rainbows. Every bone/tendon surgical procedure has its own physical/financial/emotional cost and its own convalescence period where he will undergo more and more cast dz of muscle wasting, contracture, and osteopenia.. and risk for osteo/amp etc. JMO

Real cool case... definite food for thought.

I'd like to avoid ankle and rearfoot fusion given right now those joints appear good on imaging and are not yet painful. I explained that sometime in the future he may need this fusion. Right now I see the less risky approach to be attempted Achilles lengthening however I expect to have to do a V to Y advancement of the skin, SC, and tendon all together as trying to separate this STSG from the underlying tendon will likely lead to wound issues. I'd like to do a TP transfer posterior to anterior but would have issues with the anterior exposure and passing down so more likely will do a percutaneous STATT dissecting from known good anteromedial structures subfascially. IF I considered a fusion in his case I would go with an IM nail but I'm not pushing that yet.

Originally Posted by newankle

I'd like to avoid ankle and rearfoot fusion given right now those joints appear good on imaging and are not yet painful. I explained that sometime in the future he may need this fusion. Right now I see the less risky approach to be attempted Achilles lengthening however I expect to have to do a V to Y advancement of the skin, SC, and tendon all together as trying to separate this STSG from the underlying tendon will likely lead to wound issues. I'd like to do a TP transfer posterior to anterior but would have issues with the anterior exposure and passing down so more likely will do a percutaneous STATT dissecting from known good anteromedial structures subfascially. IF I considered a fusion in his case I would go with an IM nail but I'm not pushing that yet.

OR you can strap him with a low dye, doesn't that cure everything???

Originally Posted by newankle

...what would you consider surgically?

Nothing.

Originally Posted by newankle

I'd like to avoid ankle and rearfoot fusion given right now those joints appear good on imaging and are not yet painful. I explained that sometime in the future he may need this fusion. Right now I see the less risky approach to be attempted Achilles lengthening however I expect to have to do a V to Y advancement of the skin, SC, and tendon all together as trying to separate this STSG from the underlying tendon will likely lead to wound issues. I'd like to do a TP transfer posterior to anterior but would have issues with the anterior exposure and passing down so more likely will do a percutaneous STATT dissecting from known good anteromedial structures subfascially. IF I considered a fusion in his case I would go with an IM nail but I'm not pushing that yet.

Why would you prefer a TCC fusion with a nail versus an isolated ankle AD? I know the ankle fusion will lock up some of the already limited STJ ROM anyway, just wondering. Thanks for the case.

Concern for continued inversion contracture of STJ if not fused with more stress on the STJ after AJ fusion and also less dissection/exposure needed with nail/more stability.