Complete avulsion of the heel pad with talar and calcaneal fracture: salvage with multiple K-wire anchorage, internal fixation and free ALT flap

Abstract

Background: Degloving of the sole of the foot is a rare and serious injury because the heel pad cannot be replaced by similar tissue. The management is challenging and only a few cases have been reported with different treatment regimens.

Methods: Here, we report on a 46-year-old female patient with complex foot trauma consisting of complete avulsion of the heel pad at the hindfoot and a soft tissue defect at the posterior aspect of the heel accompanied by rupture of the anterior tibial tendon and fractures of the talus, calcaneus and midfoot. The sole of the foot was fixed to the calcaneus with multiple temporary Kirschner wires and moist wound dressings. The anterior tibial tendon was sutured. The soft tissue defect at the posterior heel was treated with a free anterolateral thigh flap. The fractures were fixed in staged procedures.

Results: At 2-year follow-up, the patient had a durable soft tissue cover over the heel with full sensation over the sole and a pliable flap over the posterior aspect of the heel. The patient was able to fully bear weight and was pain free during her daily activities in comfortable, custom shoes. All fractures had healed, the talar neck fracture after one revision and bone grafting. The foot was plantigrade and stable with preserved painless but limited range of motion at the ankle, subtalar and mid-tarsal joints.

Conclusion: The unique tissue at the sole of the foot can be salvaged even in cases of full degloving at the hindfoot with the simple method of anchorage with multiple temporary K-wires. Traumatic defects of the vulnerable skin at the posterior aspect of the heel requires durable coverage with free flap coverage. With staged treatment of all bone and soft tissue injuries, a favorable result can be obtained even in case of a complex foot trauma.

Keywords: Degloving; Free flap; Hindfoot; K-wires; Planta; Reconstruction; Sole.

Fig. 1

a Clinical findings of the complete degloving of the heel pad. b The initial CT scan obtained in the emergency department revealed a displaced intra-articular fracture of the calcaneus, displaced fractures of the talar neck and lateral talar process, non-displaced fractures of the navicular, first cuneiform and first metatarsal base and a subluxation at the mid-tarsal joint

Fig. 2

a Anchoring of the avulsed heel pad to the tuberosity of the calcaneus using multiple K-wires. b Fracture reduction was achieved via a small lateral approach over the sinus tarsi under direct vision using K-wires. The unstable talonavicular joint was reduced and transfixed with a K-wire

Fig. 3

a Repeated debridements were carried out as well as the application of a negative pressure wound therapy to promote healing. b After complete resection of all necrotic tissue, a full thickness soft tissue defect above the Achilles tendon insertion and malleoli of 26 × 7 cm resulted

Fig. 4

a The remaining soft tissue defect necessitating flap coverage. b An anterolateral thigh (ALT) flap was raised at the left thigh, positioned on the soft tissue defect and the pedicle connected to the posterior tibial artery and veins by an end-to-end anastomosis using microsurgical techniques. c Postoperative findings after the successful ALT flap transfer

Fig. 5

a Lateral view of the non-union of the talar neck postoperatively treated with debridement, cancellous bone grafting from the iliac crest, and medial plate fixation. b Dorsoplantar view postoperatively

Fig. 6

a Dorsal view of the heel pad, the patient was fully weight bearing in normal shoewear. b The soft tissues completely healed, the plantar heel pad was stable and solidly attached to the calcaneus. c The single leg stance is safe and not painful. d Dorsiflexion and plantarflexion of the foot were 10° and 20°. e Frontal view with the patient fully weight bearing