TY - JOUR
AU - MD, Ali Gurlek,
AB - Abstract An unusual postburn contracture, which consists of calcaneal bone dislocation and severe dorsiflexion contracture of foot and toes, is presented. To our knowledge, subtalar dislocation as the result of postburn contracture has not been previously reported in the literature. Subtalar dislocation not associated with a fracture of the talus is uncommon.1,–4 Soft-tissue deficit that may occur after thermal injury to the foot-ankle region may produce serious functional impairment.5 The involvement of particular subunits of the foot and the depth of injury are the primary determinants of both initial therapeutic needs and future reconstructive considerations. Although most burn cases related to the foot-ankle region are seen and managed by healthcare professionals, some neglected cases may occur. We report a case with subtalar dislocation that occurred after thermal burn injury of the foot-ankle region. CASE REPORT An 18-year-old boy with severe burn contracture of his right foot was admitted. Past medical history revealed a thermal injury with hot water to his right lower extremity when he was 2 years of age. At physical examination, the contracture on the dorsolateral aspect of the foot, a disrupted plantar arch, and a palpable solid mass at the distal posterior to ankle region were found. At presentation, the patient ambulated on the medial malleoli and the talus. His activity was limited, and he was unable to wear any shoes (Figure 1). His Achilles tendon was not palpable. Calcaneal bone displacement toward the distal posterior tibial area was clearly observed with the use of x-ray (Figure 2). One and half years ago, a series of operations was initiated for correction of the deformity in another center. Figure 1. View largeDownload slide Preoperative photo showing the severe dorsiflexion contracture of foot and toes. Figure 1. View largeDownload slide Preoperative photo showing the severe dorsiflexion contracture of foot and toes. Figure 2. View largeDownload slide X-ray of the ankle region, lateral view; the calcaneal bone displacement with disrupted plantar arch is seen. Figure 2. View largeDownload slide X-ray of the ankle region, lateral view; the calcaneal bone displacement with disrupted plantar arch is seen. Surgical Technique Multiple Z-plasties and transfer of medial proximally based fasciocutaneous flap and full-thickness skin grafting were planned for correction of the dorsiflexion contracture of the foot. At the first stage, the lateral contracture band was released by multiple Z-plasties under tourniquet (Figure 3, top and middle panels). This resulted in the elongation of the scar but not enough to cause the subject to have a plantigrade foot. Then, a decision was made to release underlying structures, and a transverse incision was performed on the dorsum of the foot toward the lateral malleoli. A further dissection revealed shortened tendons of extensor digitorum communis, tibialis anterior, and peronealis. All tendons were elongated with Z-plasties after the tibiotalar joint was released anterolaterally. During the exploration, the dorsalis pedis artery could not be identified. Having the ankle joint in a neutral position resulted in a large soft tissue defect in the diameter of 6 × 9 cm. To cover the defect, a fasciocutaneous flap was elevated from the superior medial leg to the level of the junction of the middle or distal third of the leg based on septocutaneous perforating vessels of the posterior tibial artery at the flap base (Figure 3, bottom panel). The saphenous vein was preserved within the medial fasciocutaneous flap. The flap dimension was 5 cm in width and 14 cm in length. Distal extend of this flap was just behind the medial malleoli, and after the initial incision was made on the posterior vertical flap margin, the incision was extended through the deep fascia, the two septocutaneous perforating vessels that were located 4 to 8 cm superior to the medial malleolus were identified, and the posterior tibial nerve was preserved. Distal and anterior flap incisions then were made. The flap was rotated 90 degrees into the dorsal foot defect. The tourniquet was flashed to assure arterial bleeding at the distal skin edge of the flap. The donor site was covered with full-thickness skin grafting. Figure 3. View largeDownload slide a. Schematic drawing shows the deformity. b. The flap transposition toward the dorsum of the foot and Z-plasties for dorsolateral scar contracture (dotted lines represents the Z-plasties). c. After flap transposition, the donor area in the quadrangular shape was skin grafted (dotted lined area). Figure 3. View largeDownload slide a. Schematic drawing shows the deformity. b. The flap transposition toward the dorsum of the foot and Z-plasties for dorsolateral scar contracture (dotted lines represents the Z-plasties). c. After flap transposition, the donor area in the quadrangular shape was skin grafted (dotted lined area). Through the posterior incision of the flap, the displaced calcaneal bone and shortened Achilles tendon were explored, and a Z-plasty to the Achilles tendon was made. Then, the displaced bone was easily replaced to its original site. Through a distal edge incision, the articular faces of calcaneal and talar bones were destroyed by a high-speed abrader to make an arthrodesis of the joint. To stabilize the calcaneal bone, a Kirshner wire was passed through calcaneal, talar, and tibial bones. Primary uncomplicated wound healing was achieved within 3 weeks (Figure 4). After the wound healing was complete, a custom-fitted ankle-foot orthoses was used by the patient for a 4-week period. Radiographic examination was performed postoperatively (Figure 5). The pin was removed 12 weeks after surgery. The patient was able to ambulate bare footed without pain in the first year. Although the patient had no ankle motion, he had good ankle stability. Figure 4. View largeDownload slide The foot in plantigrade posture after the corrective surgery and the soft tissue release; note that the donor site of the flap was skin grafted. Figure 4. View largeDownload slide The foot in plantigrade posture after the corrective surgery and the soft tissue release; note that the donor site of the flap was skin grafted. Figure 5. View largeDownload slide Calcaneal bone replacement and intramedullary pinning with Kirshner wire is observed with plain x-ray. Figure 5. View largeDownload slide Calcaneal bone replacement and intramedullary pinning with Kirshner wire is observed with plain x-ray. DISCUSSION Complex postburn deformities of the foot and ankle remain a challenge for even the most experienced surgeon. Each deformity is unique, and the surgeon should be capable of using multiple techniques to provide the most appropriate treatment.6 Many of the long-term sequelae and deformities are preventable by early wound care, closure, and aggressive physical therapy. Serial casting was reported as an effective method for burn contractures.7,8 If the contractures cause functional limitations, surgical release is indicated.9 At this stage, consideration of each specific case focuses on the severity of contracture. Postburn scar contractures in the lower extremity can be categorized based on the joint involved by the scar:10 Hip joint contracture and adductions. Knee joint: popliteal contractures and lateral–medial bands. Ankle joint: dorsiflexion contractures, contracture in equinus. Foot and toes: dorsiflexion contracture, web space contractures. Because the patient did not receive burn care and rehabilitation at the acute phase of the injury, healing by wound contraction developed gradually. In these cases, if the contracture is permitted to persist, deeper structures, including neurovascular structure, ligaments, and tendons, will develop permanent shortness, and secondary to these changes, bone and joint deformities will be observed in the long term. Patients need to be followed closely and frequently until the scar is maturated and stretched sufficiently to permit full function or a decision is made to surgically release the scar. To obtain a plantigrade foot, Manoli et al11 performed scarred muscle excision for the treatment of established ischemic contracture of the lower extremity for the deep posterior compartment of scarred tendon-excision in nine patients with rigid equinocavovarus contractures of the foot and ankle after ischemic contractures resulting from tibia-fibula fractures, burn, and cardiac bypass surgery. Erdog an et al12 used external fixators in major foot contractures to bring into anatomic position and reported their experience on gradual correction of foot dorsiflexion contractures. There do not seem to be any reports in the literature related to isolated tarsal or calcaneal bony dislocation around the ankle joint as a result of scar contracture. Kanda et al13 reported anterior dislocation of the subtalar joint, and they considered the cause of the injury as forceful supination of the foot. Splinting of such wounds appears efficacious until remodeling of the wound bed and graft has occurred. In this way, the contractile cells in the connective tissue matrix and/or the matrix itself has lost its contractile features and returned to normal. This case presents an example for long-term sequelae of neglected severe burn injuries of the foot-ankle region in the developing child. The contractile forces produced by wound contraction lead to subtalar dislocation. During surgical exploration, the muscles of soleus and gastrocnemius with Achilles tendon were observed as shortened and fibrotic. This could have been caused by some compartmental syndromic process that occurred at the acute phase of the initial injury. The ultimate goal in these severely scarred and deformed cases must be to obtain a plantigrade foot. Reconstruction of a good functional foot can be achieved only by preserving neuromusculotendineous and skeletal units, and this is true for early cases, not for late ones. However, in all cases, protective sensation must be protected and supplied. The primary reconstructive goals for the burned foot are unimpeded ambulation and weightbearing on a pain-free limb, although amputation may be the only alternative solution in cases with extensive necrosis and thermal burns complicated by infections.14 Burn patients with associated limb amputations present demanding rehabilitation problems, many of which might be expected to lead to chronic diffuclties.15 The goal of any method of reconstruction should be the restoration of function within a reasonable aesthetic appearance with the foot. In addition to adequate healing, the goal should be the ability to walk again and wear normal footwear. Some soft-tissue defects of the lower extremities can be covered reliably with local flaps. Five such flaps are tensor fascia lata, gastrocnemius, soleus, posterior tibial artery fasciocutaneous, and dorsalis pedis flaps. Of those flaps, the posterior tibialis flap belongs to the family of perforator flaps, which are nourished by one or more perforating vessels perforating the fascia, muscle, or intermuscular septum. This type of flap has been used in forms of the medial island fasciocutaneous flap or the medial island fasciocutaneous flaps to cover the defects of lower leg.16,17 D'Sousa et al18 used a medial pedicled fasciocutaneous flap (not an island flap) for correction of a neglected clubfoot. We used the same flap with only one difference, that being the rotation arc. Their rotation arc of the flap was situated inferiorly and ours was lateral to the dorsum of the foot. In such deformed cases, a careful consideration should be made for a possible arthrodesis of the foot obtained after complex bone transports and soft-tissue corrections or an amputation. Each alternative has its advantages if it is executed appropriately. In an observational study to determine the outcomes of amputation and reconstruction after leg-threatening injuries, the results were found to be equal.19 The negative impact on psychological adjustment from the chronic strain of living with limb deficiencies appears to be mediated by perceived social support. Clinical experience with energy-storing prosthetics suggests that this type of prosthesis provides a very high performance on gait balance. A poorly designed or badly fitting prosthesis is as disabling as the actual amputation. However, a careful soft-tissue correction adds to a successful arthrodesis procedure while reducing risk and increasing the potential for healing without complications. Studies related to long-term outcomes after successful arthrodesis shows that most patients are satisfied with their outcomes, although some suffer from pain and degenerative changes elsewhere in the foot.20 Primary or revisional complex arthrodesis should be performed by experienced surgeons in dealing with these problems. ACKNOWLEDGMENTS The authors thank Dr. Mustafa Celik, Director of Family Medicine, for his artistic drawings. REFERENCES 1. Buckingham WW Subtalar dislocation of the foot. J Trauma  1973; 13: 753– 65. Google Scholar CrossRef Search ADS PubMed  2. Christensen SB, Lorentzen JE, Krogsoe O, Sneppen O Subtalar dislocation. Acta Orthop Scand  1977; 38: 707– 11. Google Scholar CrossRef Search ADS   3. Janssen T, Kopta J Bilateral recurrent subtalar dislocation. Case report. J Bone Joint Surg Am  1985; 67A: 1432– 3. Google Scholar CrossRef Search ADS   4. Mattingly DA, Stern PJ Bilateral subtalar dislocations. A case report. Clin Orthop  1983; 177: 122– 4. 5. Zachary LS, Heggers JP, Robson MC et al.   Burns of the feet. J Burn Care Rehabil  1987; 8: 192. Google Scholar CrossRef Search ADS PubMed  6. Thompson DM, Calhoun JH Advanced techniques in foot ankle reconstruction. Foot Ankle Clin  2000; 5: 417– 42. Google Scholar PubMed  7. Bennett GB, Helm P, Pundure GF, Hurt JL Serial casting a method treating burn contractures. J Burn Care Rehabil  1989; 10: 543– 5. Google Scholar CrossRef Search ADS PubMed  8. Johnson J, Silverberg R Serial casting of the lower extremity to correct contractures during the acute phase of burn care. Phys Ther  1995; 75: 262– 6. Google Scholar CrossRef Search ADS PubMed  9. Mani MM, Chhatre M Reconstruction of the burned lower extremity. Clin Plast Surg  1992: 19; 693– 703. Google Scholar PubMed  10. Achauer BM Lower extremity. In: Burn Reconstruction.  New York: Thieme Medical Publishers, 1991. 11. Manoli A 2nd, Smith DG, Hansen ST Scarred muscle excision for the treatment of established ischemic contracture of the lower extremity. Clin Orthop  1993: 292; 309– 14. 12. Erdoğan B, Gorgu M, Girgin O, Akoz T, Deren O Application of external fixators in major foot contractures. J Foot Ankle Surg  1996; 35: 218– 21. Google Scholar CrossRef Search ADS PubMed  13. Kanda T, Sakai H, Kaseki K, Tamai K, Takeyama N, Saotome K Anterior dislocation of the subtalar joint. A case report. Foot Ankle Int  2001; 22: 609– 11. Google Scholar CrossRef Search ADS PubMed  14. Yowler CJ, Mozingo DW, Ryan JB, Pruitt BA Jr Factors contributing to delayed extremity amputation in burn patients. J Trauma  1998; 45: 522– 6. Google Scholar CrossRef Search ADS PubMed  15. Ward RS, Hayes-Lundy C, Schnecbly WA, Reddy R, Saftle VR Rehabilitation of burn patients with conco minant limb amputation: case reports. Burns  1990; 16: 390– 2. Google Scholar CrossRef Search ADS PubMed  16. Naresh B, Parameswaran S Reconstruction of lower leg defects using a medial island fasciocutaneous flap. Med J Malaysia  1998; 53: 77– 82. Google Scholar PubMed  17. Haymans O, Verhelle N, Peters S, Nelissen Y, Oelbrandt B Use of the medial adipofascial flap of the leg for coverage of full-thickness burns exposing the tibial crest. Burns  2002; 28; 674– 8. Google Scholar CrossRef Search ADS PubMed  18. D'sousa H, Aroojis A, Yagnik MG Rotation fasciocutaneous flap for neglected clubfoot a new technique. J Pediatr Orthop  1998; 18: 319– 22. Google Scholar PubMed  19. Bosse MJ, Mackenzie EJ, Kellan JF, Burgess AR, et al.   An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med  2002; 347: 1924– 31. Google Scholar CrossRef Search ADS PubMed  20. Muir DC, Amendola A, Saltzman CI Long-term outcome of ankle arthrodesis. Foot-Ankle Clin  2002; 7: 703– 8. Google Scholar CrossRef Search ADS PubMed  Copyright © 2004 by the American Burn Association
TI - Postburn Subtalar Dislocation in a Major Foot Contracture
JO - Journal of Burn Care & Research
DO - 10.1097/01.BCR.0000124787.27614.87
DA - 2004-05-01
UR - https://www.deepdyve.com/lp/oxford-university-press/postburn-subtalar-dislocation-in-a-major-foot-contracture-7GBQhcty1b
SP - 319
EP - 323
VL - 25
IS - 3
DP - DeepDyve
ER -