Operative Technique in Plastic Surgery – Kevin C.Chung

Delayed
diagnosis
■ Delayed diagnosis can often be catastrophic and result in
functional losses, if not limb loss entirely.
Fascia
release
■ Often the fascia can be released through smaller subcutaneous
incisions by running scissors “blindly” along the fascia,
superficially. This, however, can often result in troublesome
bleeding from venous injury, or injury to the deep peroneal nerve.
Compartment
release
■ Inadequate compartment release can result in ongoing
compartment syndrome and disabling complications. Often,
extending the subcutaneous incisions to fully expose the fascia and
ensure adequate compartment release is the safest practice.
Nerve or
vessel injury
■ Iatrogenic nerve or vessel injury can lead to certain disabling
conditions similar to those in which the fasciotomy was initially
indicated to prevent. The common peroneal and superficial
peroneal nerve are the most commonly injured during lateral
compartment release. To prevent this, terminate the proximal
incision in the fascia 5 cm distal to the fibular head to prevent
injury to the common peroneal nerve, and distally direct the
incision towards the lateral malleolus to avoid injuring the
superficial peroneal nerve.
POSTOPERATIVE CARE
■ Patients require frequent neurovascular check every 1 to 2 hours for the initial
postoperative period.
■ Critical care monitoring and adequate IV fluid resuscitation are essential for
renal protection in the setting of myoglobin release.
■ Typically, fasciotomy wounds are initially dressed with wet to dry dressings
that are changed 2 to 3 times daily to allow frequent evaluation of the
underlying muscle.
■ After the initial 24- to 48-hour period following compartment release, a wound
vacuum dressing can be used to decrease the frequency of dressing changes
and promote healing.
■ Occasionally, if the limb is not too edematous, the fasciotomy incisions can be
closed several days after the procedure to heal by tertiary intention.
■ Frequently, skin grafting is required to ultimately heal the incision.
OUTCOMES
■ Functional outcomes following fasciotomy depend mainly on the underlying

injury, as well as time to procedure and adequacy of compartment release.
■ Appropriate timing of fasciotomy is essential for improved outcomes. For
fasciotomies delayed greater than 12 hours from the onset of compartment
syndrome, limb loss is as high as 50%, with only approximately 8%
maintaining normal limb function.
■ Fasciotomy wound closure can be attempted during the same hospitalization if
the swelling allows for tension-free closure of the skin. Occasionally, skin graft
closure is required.
REFERENCES
1. Ojike NI, Robers CS, Giannoudis P. Compartment syndrome of the thigh: a
systematic review. Injury. 2010;41(2):133-136.
2. Frink M, Hildebrand F, et al. Compartment syndrome of the lower leg and
foot. Clin Orthop Relat Res. 2010;468(4):940-950.
3. Sheridan GW, Matsen FA. Fasciotomy in the treatment of the acute
compartment syndrome. J Bone Joint Surg Am. 1976;58(1):112.

6
CHAPTER
Drainage of Abscesses of
Lower Leg and Foot
Michael Holland and Scott L. Hansen
DEFINITION
■ Infections of the foot, ankle, and lower leg range in severity from minor local
cellulitis to rapidly progressive necrotizing fasciitis.
■ Abscesses are a result of infection leading to inflammation and cell death,
whereby a cavity is created that is filled with a mixture of bacteria,
inflammatory cells, and necrotic tissue.
■ Painful areas of fluctuance can be identified on physical exam and are most
commonly surrounded by signs of inflammation (redness, warmth, pain, and
swelling) but may also be found in isolation.
■ Abscesses of the lower extremity and foot are frequently the result of trauma
creating a break in the skin’s natural barrier, allowing for colonizing or
environmental pathogens to proliferate in the skin and deeper subcutaneous
tissues.
ANATOMY
■ The lower leg, ankle, and foot are comprised of 28 bones.
■ Soft tissues include the overlying skin and subcutaneous tissue as well as
muscles that are divided into anatomically distinct compartments in both the
lower leg as well as the foot.
■ The four compartments of the lower leg include the anterior, lateral,
superficial posterior, and deep posterior divided by fascia.
■ The nine compartments of the foot include the calcaneal—communicating
with the deep posterior compartment of the leg, superficial, medial, lateral,
adductor, and four interosseous.
■ The primary neurovascular structures include the anterior tibial, peroneal, and

posterior tibial arteries and paired veins; superficial peroneal, deep peroneal
(fibular), tibial, saphenous, and sural nerves; and greater and lesser saphenous
veins in the superficial tissues (FIG 1).
FIG 1 • Cross section of lower leg demonstrating four
compartments separated by intramuscular septae,
neurovascular structures, and soft tissue. (From Pansky
B, Gest TR. Lower limbs. In: Lippincott’s Concise
Illustrated Anatomy: Back, Upper Limb, and Lower
Limb. Vol. 1. Baltimore, MD: Wolters Kluwer; 2012:198.)
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient’s initial complaint is typically of pain and swelling at the site of
infection. They may also notice changes in skin color and drainage of fluid.
There may be a history of antecedent trauma.
■ Systemic symptoms such as fevers, chills, malaise may not be present early in
the disease.
■ Past medical history of diabetes mellitus, vascular disease, immunodeficiency,
injection drug use prior fracture, and prior surgery may predispose to infection
and abscess formation.
■ Physical exam may reveal erythema, swelling, tenderness, warmth, fluctuance,

visible drainage, and eschar. Many times, erythema and tenderness will be the
only physical exam findings, so a high index of suspicion for underlying fluid
collection is necessary.
IMAGING
■ Despite its inability to well characterize fluid collections, standard multiple
view radiographs are the first initial test to identify any bony injury or
radiopaque foreign bodies as well as gas from anaerobic bacteria. Subtle soft
tissue changes may also be demonstrated but are harder to appreciate by the
untrained examiner.
■ Ultrasonography may show cobble stoning of the subcutaneous tissues, which
is indicative of edema. Discrete, hypoechoic fluid collections may also be
identified.
■ When multiple abscesses are suspected or ultrasound findings are equivocal,
CT with IV contrast of the lower extremity can be extremely valuable.
■ MRI is similar to CT in its ability to diagnose soft tissue infections; however,
its use is limited by cost and time required to obtain the study.
DIFFERENTIAL DIAGNOSIS
■ Cellulitis
■ Abscess
■ Septic arthritis
■ Necrotizing fasciitis
■ Plantar fasciitis
■ Seroma
■ Hematoma
■ Gout
■ Cyst
■ Tumor
NONOPERATIVE MANAGEMENT
■ Antibiotic therapy alone is often insufficient to manage abscesses, and
drainage is the primary treatment strategy.
SURGICAL MANAGEMENT
Preoperative Planning

■ In patients who are hemodynamically unstable, antibiotic therapy should not
be withheld while awaiting cultures.
■ In patients who are otherwise stable, consider deferring antibiotics until
cultures have been obtained.
■ If hardware is present, consider need for removal with orthopedic surgery
consultation, as well as need for bony debridement.
■ Ensure medical comorbidities are addressed.
■ Ensure appropriate laboratory investigations are obtained including complete
blood count, basic metabolic panel, C-reactive protein, sedimentation rate, and
blood cultures.
■ Antibiotic selection should cover gram-positive organisms with methicillin-
resistant Staphylococcus aureus (MRSA) coverage, and due to prevalence of
gram-negative organisms in foot infections, gram-negative coverage should
also be provided while awaiting culture results.
Positioning
■ Supine position is sufficient for exposure.
Approach
■ The goal is to completely drain the abscess cavity, remove any debris or dead
tissue, thoroughly irrigate, and allow wound to heal by secondary intention.
T E C H N I Q U E S
■ Abscess Drainage
■ Identify abscess cavity by palpation of fluctuance and correlate to previous
imaging (TECH FIG 1A).
■ A linear incision is designed over the most fluctuant area, attempting to
avoid making the incision over weight-bearing area or known neurovascular
structures or tendons.
■ An incision is made through the skin with a no. 15 scalpel. If the incision
was designed immediately over the cavity, abscess fluid will be released
immediately.
■ Ensure the incision is opened up sufficiently in a proximal and distal

direction (TECH FIG 1B).
■ Obtain microbiology cultures, including bacterial cultures (aerobic,
anaerobic) as they are most common. If there is clinical suspicion of other
rare pathogens, send those as indicated such as fungal, yeast, mycobacteria,
etc.
■ Using a curved hemostat or Kelly clamp, spread gently throughout the
abscess cavity for complete drainage.
■ Gently probe the extent of the cavity in all directions to ensure that the
cavity has been completely opened through the incision and that there are no
residual fluid collections or loculations.
■ Visualize cavity to ensure no necrotic tissues remaining. Adequately debride
all necrotic tissues (TECH FIG 1C,D).
■ If necrotic tissue, especially muscle, is encountered beyond the extent of
abscess cavity, consider diagnosis of necrotizing soft tissue infection or
necrotizing fasciitis, need for wide excision of all necrotic tissue, and
addition of protein synthesis inhibiting antibiotics (eg, clindamycin).
■ Irrigate the cavity with at least 3 L of saline.
■ Pack the cavity with surgical packing, ensuring to apply enough packing to
prevent the wound from closing prematurely.

TECH FIG 1 • A. Necrotic right lateral foot wound with
underlying abscess. B. Sharp debridement and
drainage of wound and abscess. C. Wound after
debridement and drainage of abscess with continued
necrotic tissue. D. Granulating wound prior to split-
thickness skin grafting.
PEARLS AND PITFALLS
Preoperative
workup
■ Failure to get bacterial cultures
Technique
■ Incomplete drainage: ensure that entirety of abscess cavity is
explored and septations are taken down
■ Ensure incision is large enough
■ Use copious (generally at least 3 L of irrigation)
Postoperative
care
■ Failure to ensure glycemic control
Dressings
■ Applying an occlusive dressing can result in reaccumulation of
abscess and inability to monitor wound. Do not apply negative
pressure wound therapy on grossly infected wound
■ Ensure enough packing is used to prevent wound from closing
prematurely
Wound
hazards
■ Do not probe wound with digit, as you may injure yourself with
potential foreign body
POSTOPERATIVE CARE
■ Surgical management with drainage alone has been recommended for small
(less than 5 cm abscesses) without associated cellulitis or systemic signs of
infection.
■ However, a recent randomized control trial (RCT) has demonstrated superior
cure rates for patients who received post drainage antibiotics for 7 to 14 days,

even in uncomplicated cases.1
■ Patients require at least twice daily dressing changes until wound heals by
secondary intention.
■ Negative pressure wound therapy e.g. Wound VAC may be considered for
abscesses that result in large open wounds, however, should not be placed at
time of initial debridement and should be placed only after wound appears
healthy and without signs of residual infection.
■ Blood sugar control
■ Smoking cessation
■ Early range of motion should be encouraged to prevent stiffness and
contracture.
COMPLICATIONS
■ Persistent infection
■ Missed diagnosis of necrotizing infection
■ Injury to neurovascular structures
■ Hematoma
REFERENCE
1. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-
sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J
Med. 2016;374(9):823-832.

7
CHAPTER
Excision of Soft Tissue
Tumors of the Foot and
Ankle
Raffi S. Avedian, Robert J. Steffner, and Subhro K. Sen
DEFINITION
■ Soft tissue tumors of the ankle may be benign or malignant (soft tissue
sarcoma) and exhibit a variable natural history ranging from latency to rapid
growth.
■ Tumors located entirely above the muscle, fascia, or tendon are considered
superficial, whereas tumors involving the fascia or located deep to it are
considered deep.
ANATOMY
■ The ankle is a synovial joint involving the tibia, talus, and fibula. Tendons of
the leg muscles travel around the ankle in discrete groups each contained in a
retinaculum (FIG 1).
■ The anterior tibial artery and deep peroneal nerve travel anterior to the ankle
joint just lateral to the anterior tibialis tendon.
■ The posterior tibial artery and tibial nerve travel along the medial aspect of the
lower leg, in the fascial plane between the deep and superficial compartments.
At the ankle, they course posterior to the posterior tibial tendon along the
medial malleolus.
■ The tendons of the peroneus muscles travel along the posterior aspect of the
lateral malleolus to their attachments in the foot.
PATHOGENESIS
■ The mechanism for soft tissue tumor formation is not known.
■ Risk factors for sarcoma development include radiation exposure,

radiotherapy, pesticide exposure, and hereditary conditions including Li-
Fraumeni syndrome and retinoblastoma gene mutation.
NATURAL HISTORY
■ All soft tissue sarcomas have the potential for local recurrence and metastasis.
■ Soft tissue sarcomas exhibit a spectrum of natural history from slow-growing
low-grade tumors with low risk of metastasis to high-grade sarcoma that may
grow rapidly and pose a high risk of metastasis.
■ Lungs are the most common site of metastasis. Lymph node involvement is
rare.
■ Angiosarcoma, clear cell sarcoma, epithelioid sarcoma, rhabdomyosarcoma,
myxofibrosarcoma, and synovial sarcoma are associated with increased risk of
lymph node spread compared to other sarcomas.
■ Benign tumors by definition do not have metastatic potential but can grow to
large sizes and cause symptoms.

Superficial peroneal nerves Dorsalis pedis artery Extensor digitorum longus Deep peroneal nerve Extensor hallucis longus Tibialis anterior tendon Extensor retinaculum Saphenous nerve Peroneus brevis and longus Peroneal retinaculm Sural nerve Small saphenous vein Tibial nerve Posterior tibial artery Flexor hallucis longus Achilles tendon A

FIG 1 • A. Cross-sectional anatomy of the ankle. Notice
that the tendons are contained within a retinacular layer.
B. Oblique view of the ankle anatomy.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Conducting a thorough history and examination is important to assess duration
of symptoms, comorbidities, physical dysfunction, organ involvement, overall
health, and patient expectations in order to best tailor treatment strategy for the
individual patient.
■ Many sarcomas may be asymptomatic with the only patient complaint being
the presence of a mass.
■ Neurovascular examination is mandatory for any extremity tumor.
IMAGING
■ Magnetic resonance imaging is the principal imaging modality used to

characterize tumors, formulate differential diagnosis, define local tissue
infiltration, and devise a surgical plan.
■ Plain radiographs are used if there is concern for bone involvement or to
demonstrate mineralization within a tumor such as vascular malformations.
■ Staging for soft tissue sarcomas consists primarily of lung imaging.
DIFFERENTIAL DIAGNOSIS
■ The differential diagnosis for a soft tissue tumor includes benign tumors,
sarcomas, lymphoma, infection, and inflammatory lesions (eg, rheumatoid
nodules).
■ There are over 50 sarcoma subtypes. Common histologies include
pleomorphic undifferentiated sarcoma, synovial sarcoma, leiomyosarcoma,
malignant peripheral nerve sheath tumor, and liposarcoma.
SURGICAL MANAGEMENT
■ The appropriate treatment for any musculoskeletal tumor is based on its
diagnosis and natural history.
■ Biopsy incisions are considered contaminated and must be resected at the time
of definitive surgery. Care should be taken to place the biopsy in a location that
does not interfere with the final surgical plan.
■ Simple marginal excision is appropriate for most benign tumors, whereas wide
resection with a clean margin is performed for soft tissue sarcomas.
■ Given the relatively low volume of tissue in the lower leg and ankle, soft
tissue reconstruction with local or free flaps is often needed.
Preoperative Planning
■ A patient is considered ready for surgery after completion of staging and
multidisciplinary review of pertinent imaging, pathology, and treatment
strategy.
■ The retinacula and tendon sheaths around the ankle are robust tissues that act
as barriers to tumor penetration. Careful assessment of preoperative imaging is
needed; however, these tissues often can be used as a margin around the tumor
(see FIG 1).
■ When tumor abuts, but does not encase blood vessels or nerves, they can be
dissected free by leaving adventitia and epineurium on the tumor as the margin.
■ The surgical plan is created by thorough study of the preoperative MRI scan.
Fluid-sensitive sequences and fat-suppressed contrast images show the extent

of disease that must be accounted for in the excision. T1 fat-sensitive images
show the normal anatomy best including fat planes between tumor and critical
structures such as nerves and vessels (FIG 2).
Positioning
■ Patient positioning is based on the surgeon’s assessment of the critical
anatomy of the surgery and how best to visualize it during surgery. Supine and
lateral positions are most common.
■ If a flap is to be used, the harvest must be performed using a separate back
table and instruments and the surgical sites completely isolated to avoid
contamination.
Approach
■ The surgical approach varies based on location of the tumor.
■ Previous biopsy and surgical scars are considered contaminated and must be
excised en bloc with the tumor.
FIG 2 • A. Axial T1 MRI of a 57-year-old man with a
myxofibrosarcoma on the lateral aspect of the ankle.
Note that the tumor sits on the joint capsule and
anterior talofibular ligament. B. Coronal MRI
highlighting the tumor and its relationship to the
surrounding anatomy. Notice that the joint capsule and

retinaculum around the peroneal tendons act as a
barrier to tumor penetration.
T E C H N I Q U E S
■ Excision of Soft Tissue Tumor of the Ankle
■ Tourniquet is used at discretion of surgeon using gravity exsanguination
rather than Esmarch to avoid tumor compression.
■ A margin of normal skin is marked around previous biopsy incisions and
incorporated into the surgical approach (TECH FIG 1A).
■ The dissection is beveled away from the sarcoma through the subcutaneous
tissue to the deep fascia or retinacular layer at a point that is clear away
(ideally 1–2 cm if possible) from palpable tumor or tumor visualized on
preoperative MRI.
■ The deep fascia and retinacula are cut and used as the deep margin.
Occasionally, the joint capsule may have to be included in the deep margin.
■ Cutaneous nerves often are involved in the tumor. They should be cut away
from the tumor and buried in the deep layers to minimize risk of symptomatic
neuroma formation.
■ If the tumor partially encases the tendons, the retinaculum or tendon sheath
may be incised on the uninvolved side of the tendon and lifted off as the
margin on the tumor preserving the tendon (TECH FIG 1B).
■ An assessment of joint stability is performed, and ligament reconstruction or
augmentation is performed if indicated.
■ Free tissue transfer is performed to reconstruct soft tissue defects.

TECH FIG 1 • A. Photograph showing planned
incision that includes wide excision of previous biopsy
incision. Because the tumor is superficial, which is
often the case for ankle tumors, a large paddle of skin
is removed as the margin on top of the tumor. B.
Photograph illustrating the deep dissection. The tumor
was abutting the joint and partially encasing the
peroneal tendons. The retinacular tissues around the
tendons were opened and peeled off the tendons
allowing the tumor to be removed safely while
preserving the tendons. Similarly, the joint capsule,
retinaculum of the extensor digitorum longus, and
periosteum of the fibula serve as deep margin for the
more anterior portion of the tumor.
PEARLS AND PITFALLS
Wound
breakdown
■ Soft tissue reconstruction should be without tension.
■ Patients should be counseled about the importance of leg
elevation and activity modification.
Positive
margins
(sarcoma
excision)
■ Appropriate preoperative planning is important to minimize risk
of unplanned positive margins.
■ Inability to primarily close a wound should not interfere with
the decision to remove a tumor with a clean margin. Plan on soft

tissue reconstruction.
■ Planned positive margins around critical structures such as
nerves and vessels may be appropriate in certain settings.
POSTOPERATIVE CARE
■ The ankle is splinted ideally in the neutral extended position.
■ Weight bearing may begin once soft tissues including flaps and ligament
reconstructions, if performed, have healed sufficiently, typically 6 weeks after
surgery.
■ Extremity elevation is recommended while patient is in bed.
■ Antibiotics may be administered while drains are in place.
OUTCOMES (FIG 3)
■ Oncological outcomes include local recurrence and metastasis. Surveillance
for recurrence should be managed by a multidisciplinary sarcoma team. Local
recurrence is higher when margins are positive.
■ Functional outcomes depend on the extent of tissue resection and patient
overall health status. Most patients will experience some form of disability that
is proportional to the volume of soft tissue resection. Estrella et al. reported on
a small series of six patients who underwent resection of foot and ankle
sarcoma followed by free flap coverage. The average Revised Musculoskeletal
Tumor Society (Enneking) functional score was 92.8% at average 49-month
follow-up.1
FIG 3 • A. Photograph immediately after completion of
free anterolateral thigh flap. B. 5 years after surgery.
COMPLICATIONS

■ Local recurrence occurs in a minority of patients with sarcoma and is more
common in patients with positive margins.
■ Deep infection can occur at any time after surgery and requires aggressive
therapy including surgical debridement and antibiotic therapy to achieve limb
salvage.
■ Wound breakdown
REFERENCE
1. Estrella EP, Wang EHM, Caro LDD, Castillo VG. Functional outcomes of
reconstruction for soft tissue sarcomas of the foot and ankle. Foot Ankle Online
J. 2001;2(3):2.

8
CHAPTER
Ankle and Foot Bone
Tumors
Robert J. Steffner, Raffi S. Avedian, and Sahitya K.
Denduluri
DEFINITION
■ Bone tumors of the foot and ankle are usually primary tumors. Metastatic bone
cancer to sites below the knee is rare but not impossible.
■ Primary bone tumors can be benign, low-grade malignant, or high-grade
malignant.
■ Surgery is considered for benign tumors with progressive growth or those
producing symptoms. Malignant bone tumors are generally operative in both a
curative and palliative setting.
ANATOMY
■ There is minimal soft tissue coverage in the ankle and foot. Surgical resections
requiring skin excision and/or placement of bulk cortical allograft should
consider the need for soft tissue coverage to minimize the risk of infection and
nonunion.
■ When functional deficit and donor site morbidity for free tissue transfer are
anticipated, consideration should be given to below-knee amputation. Patients
may recover faster and have better long-term function with a prosthesis.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ It is important to ask patients about prior trauma and infections at the site of
concern.
■ A clinical history focusing on the duration of symptoms, presence of night
pain, and systemic symptoms can help delineate benign from malignant
etiologies.
■ Physical exam focuses on the presence of prior incisions, skin mobility over

the tumor, and neurovascular status distal to the site of tumor involvement.
IMAGING
■ Obtain plain radiographs of the involved site.
■ Perform an MRI scan with and without contrast to assess the extent of tumor
and involvement of critical structures such as tendons, nerves, and vessels.
Also perform a whole bone MRI to demonstrate the extent of intramedullary
involvement of tumor and look for skip lesions.
■ Make every effort to obtain any prior imaging for comparison.
■ Quality of imaging and the interpretation of imaging are vital for surgical
planning.
■ Upon diagnosis of a primary bone malignancy, staging studies are performed
to assess for regional or distant metastatic disease. This generally requires a
chest CT and whole body bone scan.
DIFFERENTIAL DIAGNOSIS
■ Benign and malignant bone tumors can be found in the foot and ankle.
Distinguishing between benign and malignant guides the extent of surgical
management.
■ Benign tumors include simple cyst, intraosseous ganglion, and enchondroma.
■ Benign but active tumors include aneurysmal bone cyst (primary or
secondary), giant cell tumor, osteoid osteoma, and, in pediatric patients,
chondroblastoma.
■ Malignant bone tumors include osteosarcoma, chondrosarcoma, Ewing
sarcoma, primary lymphoma of bone, and metastatic carcinoma.
NONOPERATIVE MANAGEMENT
■ Benign-appearing lesions that are not causing symptoms can be followed with
serial imaging. Stable appearance on serial imaging studies supports
nonsurgical management.
SURGICAL MANAGEMENT
■ Symptomatic benign bone tumors and benign but active bone tumors are most
often treated with intralesional curettage or marginal excision.
■ Malignant bone tumors may require multidisciplinary management with the
possible need for chemotherapy and/or radiation in addition to surgery.
■ In nonmetastatic or oligometastatic primary bone cancer, the goal of surgery is

resection with negative margins.
Preoperative Planning
■ If needed, size-matched fresh-frozen allografts should be coordinated from an
appropriate vendor well ahead of time. The surgeon should assure that the graft
has been delivered to the hospital. It is wise to have a back-up allograft
available.
■ Bone cuts are planned off T1-sequences from the first MRI scan. It is
important to appreciate any soft tissue extensions and to look for fat planes
around neurovascular structures to make sure they are free from tumor.
Determination of appropriate margins is based on the specific diagnosis and the
type of tissue at the level of resection.
Positioning
■ Positioning depends on tumor location. Please see the “Techniques” section
below.
Approach
■ An oncologic approach allows for a limited tissue biopsy while maintaining
the possibility of wide resection in the setting of a malignant diagnosis. If
oncologic principles are followed, the majority of patients will be eligible for
limb salvage.2
T E C H N I Q U E S
■ Benign Bone Tumor of the Talus (TECH FIG 1A,B)
■ Patient positioned supine with an ipsilateral hip bump on a radiolucent table
■ Tourniquet used after gravity exsanguination
■ Localize tumor with intraoperative fluoroscopy
■ To access talar body, an oblique osteotomy of the medial malleolus or distal
fibula is often required. The surgeon may predrill bone in a lag-by-technique
fashion before the osteotomy. This facilitates repair at the end of the surgery.
■ A cortical window or cartilage flap is created with a curette or high-speed
bur to access the bone tumor (TECH FIG 1C).

■ Tissue is removed and sent for frozen section. If the pathology report is
consistent with a benign tumor and matches the patient’s clinical history and
imaging, the surgery proceeds.
■ The cortical window is expanded to adequately visualize and remove the
tumor through intralesional curettage.
■ Tumor margins are extended with use of a high-speed bur to smooth out the
internal cavity of the cyst. Adjuvant treatments such as cryosurgery (liquid
nitrogen) and argon beam coagulation can penetrate bone and further the
zone of tumor kill. These measures lower the risk of local tumor recurrence.3
■ Care should be taken near cartilage and growth plates to avoid damage to
these structures. It is appropriate to accept a higher risk of local tumor
recurrence in order to avoid injury to these structures.
■ The resultant bone defect is filled with a substance of the surgeon’s choice.
In general, we use allograft in young patients; artificial bone void filler in
young adults (mixture of calcium phosphate and calcium sulfate) and cement
in older individuals.
■ Supplementary internal fixation may be needed in weight-bearing locations
and large defects (TECH FIG 1D).
TECH FIG 1 • A. Lateral radiograph of a secondary
Aneurysmal Bone Cyst of the talar body (arrow). B.
Axial Fat-suppressed T2 MRI image demonstrating
fluid-fluid levels. C. Photo after oblique osteotomy of
the distal fibula to access the talar body. A cartilage
flap is made to access the bone tumor. D.
Fluoroscopic image demonstrating cancellous allograft
filler in the talar body and internal fixation of the distal

fibular osteotomy (arrow).
■ Malignant Bone Tumors of the Foot and Ankle
General Principles
■ Use separate instruments for tumor resection and bone defect reconstruction.
■ Obtain a thorough preoperative neurovascular exam.
■ Consider an epidural catheter that can be test-dosed before surgery and used
once a postoperative nerve exam is obtained.
■ Use a thigh tourniquet and gravity to exsanguinate the leg.
■ Hold paralytic medications if a nerve dissection is needed.
■ Ellipse biopsy tract and keep in continuity with the resected tumor.
■ Generally work from normal anatomy to abnormal anatomy.
■ Clip or tie any arteries or veins that could be used for microvascular
anastomosis.
■ Measure bone cuts several times before cutting.
■ After the bone cut, send a marrow margin for frozen section from the
nonresection side.
■ Orient resected specimens before sending to pathology.
■ Fresh-frozen allografts are opened when frozen sections are negative. The
allograft should be cultured and then placed in warm water bath with
antibiotics for thirty minutes before use.
Distal Fibula Resection
■ Lateral position on a beanbag. Straight lateral incision (TECH FIG 2A).
■ Anteriorly, assess relationship of tumor with extensor digitorium longus and
peroneus tertius.
■ Posteriorly, assess relationship of tumor with peroneus longus and brevis and
flexor hallucis longus (FHL).
■ At the ankle joint, release the tibiofibular ligaments, talofibular ligaments,
and calcaneofibular ligament.
■ Make proximal bone cut early and roll fibula to expose the intraosseous
membrane (TECH FIG 2B,C).
■ Deep to FHL is the peroneal artery and vein; the latter may need to be
ligated.

■ Remove the tumor and send a marrow margin for frozen section.
■ No bony reconstruction is necessary.
■ Use a medium suture anchor to create a soft tissue sleeve for the peroneal
tendons. This maintains length-tension relationships and avoids tendon
subluxation (TECH FIG 2D).
■ If possible, use absorbable suture to approximate the extensor digitorium
longus muscle belly to the peroneus brevis.
■ Immobilize for 6 weeks in a short leg splint with a mold in dorsiflexion and
eversion.
■ Obtain recovery room radiograph to check for any tibiotalar tilt. If present,
the splint will need to be changed.
■ Partial progressive weight-bearing begins at 6 weeks. Long-term, the patient
may need a custom ankle brace.
TECH FIG 2 • A. Illustration of the straight lateral
approach for a distal fibula bone tumor. B. Anterior
and posterior dissection with ellipse of biopsy tract.
Notice the margin of normal tissue left with the
malignant bone tumor. C. External rotation of the distal
fibula after proximal bone cut (arrow). This exposes

the intraosseous membrane and posterior
ligamentous structures. D. Use of remaining soft
tissues to create a sling for gliding of the peroneal
tendons. This also prevents tendon subluxation.
First Metatarsal (TECH FIG 3A,B).
■ Supine position with a small contralateral hip bump.
■ Dorsal incision that is just medial to the extensor hallucis longus (EHL)
tendon. The tarsometatarsal (TMT) joint serves as the proximal extent of the
incision (TECH FIG 3C).
■ Ellipse circumferentially around the base of the great toe. If away from
tumor, the skin around the great toe can be used for soft tissue coverage.
■ Proximally, release the EHL tendon.
■ Medially, dissect over the fascia of the abductor hallucis, leaving the muscle
with tumor.
■ Laterally, transect the extensor hallucis brevis.
■ Come through the TMT joint proximally. The lateral aspect of the joint is
close to the deep peroneal nerve and the deep plantar branch of the dorsalis
pedis artery. Disarticulate and lift. Release the anterior tibialis tendon from
the base of the first metatarsal and tag with suture.
■ From plantar direction release the adductor hallucis and flexor hallucis
brevis off the sesamoids. Transect the FHL tendon.
■ Try to preserve the medial plantar artery and nerve.
■ Release the intermetatarsal ligament and remove the resected specimen
(TECH FIG 3D).
■ Frozen section should be sent if there are any areas concerning for a positive
margin.
■ Scuff the medial cuneiform and attach the anterior tibialis tendon to this area
with a suture anchor (TECH FIG 3E).
■ Place a short leg splint for 2 weeks then allow heel weight bearing for the
next 4 weeks.
■ Once swelling is reduced, the patient is fit for a custom insert to go inside
the shoe.
■ Monitor postoperatively for lesser toe ulcers, flat foot deformity, and
imbalance.

TECH FIG 3 • A. AP foot radiograph demonstrating an
aggressive bone tumor of the first metatarsal. B. T1
coronal MRI showing Ewing sarcoma of the first
metatarsal. C. Illustration of the dorsal incision with

circular ellipse around the great toe used for first
metatarsal resection. D. Resected specimen after
oncologic amputation of the first metatarsal. E. AP foot
radiograph after surgery demonstrating suture anchor
repair of the anterior tibialis tendon into the medial
cuneiform.
Calcaneus
■ Patient is positioned lateral on a beanbag. Blankets are used to create a
platform for the top leg. Make sure the down leg will not obscure
intraoperative fluoroscopic images.
■ If there is concern for a postoperative equinus contracture, a gastrocnemius
recession can be done before tumor resection.
■ A lateral approach is made (TECH FIG 4A). Identify the peroneal tendons
and sural nerve (TECH FIG 4B). Tumor extent will dictate the ability to
salvage these structures. As able, try to preserve the tenosynovium over the
peroneal tendons.
■ A geometric tumor resection can utilize CT-guidance. To use this technology,
a preoperative CT scan with fiducials or an intraoperative scan with an O-arm
machine is needed. In the operating room, an array is placed close to the
surgical site and points are cross-referenced between the CT scan and the
patient’s intraoperative position (TECH FIG 4C). This allows simultaneous
localization in the axial, coronal, and sagittal planes.
■ The angle of Gissane and posterior facet provide orientation.
■ Using measurements from the preoperative MRI scans, use a sterile marker
to draw the geometric cuts. If available, use CT guidance to confirm that the
proposed geometric cuts are free from tumor.
■ Use a microsaw to cut bone up to the opposite cortex. Use an osteotome to
complete the resection. This will minimize risk to the medial plantar artery.
Roll the resected bone and release the remaining soft tissue attachments
(TECH FIG 4D).
■ Perform frozen sections from the cut margins of the remaining bone as
needed. Once frozen sections are negative, establish a new clean field and
open reconstruction equipment.
■ Use wax paper from surgical gloves to draw the bone defect.

■ A fresh frozen femoral head allograft is opened and prepared as noted in
“General Principles.”
■ Fashion the allograft with a microsaw to fit the wax paper template.
Maintain the subchondral bone of the femoral head for the plantar surface of
the allograft (TECH FIG 4E).
■ Place cancellous allograft at the femoral head allograft-host bone junction.
■ Temporarily stabilize with k-wires.
■ Using fluoroscopic views of the lateral foot and Harris axial, navigate
percutaneous screws from the heel into the anterior process of the Calcaneus.
Try to minimize the number of drill holes through the allograft (TECH FIG
4F).
■ Soft tissue closure may be primary or require flap reconstruction.
■ In general, a short leg splint is applied for 6 weeks. Front foot weight
bearing is then allowed until 3 months postoperatively. Partial progressive
weight bearing is then initiated.
TECH FIG 4 • A. Illustration of the lateral approach to
the calcaneus used for tumor resection. B. Ellipse of

the biopsy tract with identification of the peroneal
tendons, which were amenable to preservation. C.
Placement of the array into the fifth metatarsal. The
array is used to couple the patient’s intraoperative
anatomy to a CT scan to facilitate localization during
the geometric resection of tumor. D. The tumor is
gently rolled out, and soft tissue attachments from the
medial side are released to remove the tumor. E.
Placement of the fashioned fresh-frozen allograft
femoral head into the calcaneal defect. The
subchondral surface is used on the plantar aspect of
the foot. F. Follow-up lateral radiograph of the femoral
head allograft stabilized with two percutaneous 2.7-
mm screws. The host-allograft junctions appear
healed. This patient required free tissue transfer for
soft tissue coverage.
Distal Tibia
■ Supine position without a hip bump.
■ Incision is along the anteromedial tibia (TECH FIG 5A).
■ Save the saphenous vein and nerve if possible.
■ Release the posterior compartment fascia, identify and protect the tibial
nerve and posterior tibial artery, which is found between the flexor digitorum
longus and FHL muscles.
■ Release the anterior compartment fascia, identify and protect the deep
peroneal nerve and anterior tibial artery, which is found between the tibialis
anterior and EHL muscles.
■ The neurovascular bundle at the anterior ankle goes from medial to lateral
relative to the EHL tendon.
■ Measure resection lengths off the medial malleolus.
■ Mark rotation on the nontumor side both proximal and distal to the bone
cuts.
■ Use retractors to protect the soft tissues around the tibia. Use the microsaw
to cut bone while irrigating to prevent bone necrosis from heat.

■ Roll the resected segment and release the intraosseous membrane.
■ Check marrow margins from the intramedullary canal of the remaining bone
at the proximal and distal ends (TECH FIG 5B).
■ Measure the length of the resected specimen (TECH FIG 5C).
■ Prepare the fresh-frozen allograft as described in the “General Principles”
section. Start by making the allograft longer than the resected specimen.
■ Make small cuts and recheck fit of the allograft.
■ Check plain radiographs of the entire tibia in the operating room to assure
proper fit of the allograft and confirm that a deformity is not being created.
■ Select a plate that spans the intercalary defect and gets multiple points of
fixation on both sides.
■ Try to avoid open growth plates. If possible, consider compression plating
across the host-allograft junctions. Be careful, too much compression and
placement of cortical screws through a poorly contoured plate can lead to a
fractured allograft.
■ Hybrid fixation with locking screws is beneficial in short segments. Locking
screws are also preferred on the allograft side as it minimizes risk of fracture
(TECH FIG 5D).
■ Only use enough screws on the allograft side to eliminate gross motion at the
host-allograft junction. Too many screws can weaken the allograft.4
■ A small second plate can be used to improve rotational strength if that is a
concern.
■ Closure is often primary. If there is notable skin loss, free tissue transfer may
be needed.
■ Patients are placed in a short leg splint. They are usually nonweight bearing
for approximately six months. Partial progressive weight bearing is then
started.

TECH FIG 5 • A. Illustration of the anteromedial
incision for intercalary resection of the distal tibial
diaphysis. B. Bone defect after resection of the distal
tibia bone tumor. C. Length measurement of the
resected segment of distal tibia. D. Spanning plate
with hybrid internal fixation across the fresh-frozen
intercalary allograft used to reconstruct the bone
defect after tumor resection.
PEARLS AND PITFALLS
Imaging
■ MRI scans are performed with and without contrast and done as a
“tumor protocol.” Tumor protocol at our institution represents T1
axial, T2 fat-suppressed, and T1 fat-suppressed pre- and postcontrast

images.
Localization
■ There are many small bones and joints in the foot and ankle. It is
helpful to use intraoperative fluoroscopy to assure incisions are
appropriately placed.
Biopsy
■ The oncologic approach to biopsy should be in-line with the incision
necessary to perform a wide resection of the tumor.
Frozen
section
■ Bone is too hard for frozen section processing. If sending a bone
sample for frozen section, ask the pathologist to do a “touch prep” to
examine cells inside the bone sample.
Implant
selection
■ Future imaging will be needed to assess healing and look for
recurrent tumor. Use of titanium implants can limit artifact on future
MRI and CT scans. This benefit should be weighed against the need
for a durable implant. New carbon implants may provide both
strength and limited artifact on imaging.
Healing
■ Healing at the host-allograft junction can be augmented by step-cuts
that increase the surface contact area between the two sides. Using
microsurgery, vascularized bone, most commonly the fibula, can be
set at the junction to aid healing and improve bone strength.
POSTOPERATIVE CARE
■ Please see individual sections under “Techniques.”
■ In all cases, patients are initially placed in a short leg splint and instructed to
elevate the lower extremity at or above heart level for soft tissue rest.
■ Structural fresh-frozen allograft used to fill defects in the lower extremity
generally needs 6 months of nonweight bearing followed by partial progressive
weight bearing to achieve full weight bearing over 4 to 6 weeks.
■ Radiographs are done at 6 weeks and 3 months after surgery and then every 3
months for the first 2 years.
■ Any mention of acutely worsened pain should trigger an assessment for
infection and fracture.
OUTCOMES
■ Very few studies have looked at outcomes of tumors about the foot and ankle,
likely due to their rare incidence.
■ Benign bone tumors of the foot and ankle are 3 to 4 times more frequently
encountered than malignant bone tumors.5,6
■ In patients with malignant bone tumors of the foot, one center reported that

half were treated with some form of amputation.5
■ A single-institution study found that the overall and disease-free survival rate
at 9 years was 65% and 40%, respectively, for both benign and malignant bone
and soft tissue tumors of the foot and ankle.6
COMPLICATIONS
■ Leg length discrepancy: May develop from early physeal arrest. Two
centimeters or less is well tolerated with a shoe lift. Anticipating this problem
allows the surgeon to shut down the contralateral physis.
■ Fracture: Fresh-frozen cortical allograft does not fully vascularize. The
implant spanning the allograft will be needed for load-sharing forever and
should not be removed. It is wise to restrict cutting and pivoting sports and
activities.
■ Nonunion: Allograft-host bone junctions can be slow to heal, especially at
diaphyseal-diaphyseal junctions. Additional surgery to place cancellous
autograft at the junction may be needed.
■ Infection: Poor soft tissue coverage and lack of blood supply to bulk cortical
allografts puts the surgical site at risk of infection. Generally, patients are
maintained on oral antibiotics for three months after surgery. Infected allograft
needs to be removed to clear the infection.
■ Local recurrence: The surgeon should follow the patient for 5 years for high-
grade and 10 years for low-grade malignancies to assess for local recurrence.
MRI is generally the imaging modality of choice. The first postoperative scan
is performed 3 months after surgery and serves as a baseline for future
comparison.
REFERENCES
1. Pinzur MS, et al. Controversies in lower-extremity amputation. J Bone Joint
Surg Am. 2007;89(5):1118-1127.
2. Hogendoorn PC, et al. Bone sarcomas: ESMO Clinical Practice Guidelines for
diagnosis, treatment and follow-up. Ann Oncol. 2010;21(suppl 5):v204-v213.
3. Giacomo GD, et al. Local adjuvants in surgical management of bone lesions. J
Cancer Ther. 2015;6(6):9.
4. Kuchinad RA, et al. The use of structural allograft in primary and revision
knee arthroplasty with bone loss. Adv Orthop. 2011;2011:578952.
5. Ruggieri P, et al. Review of foot tumors seen in a university tumor institute. J
Foot Ankle Surg. 2014;53(3):282-285.

6. Azevedo CP, et al. Tumors of the foot and ankle: a single-institution
experience. J Foot Ankle Surg. 2013;52(2):147-152.

9
CHAPTER
Debridement of Soft Tissue
Infections of the Foot and
Ankle
Hunter S. Oliver-Allen, Michael Holland, and Scott L. Hansen
DEFINITION
■ Soft tissue infections of the lower leg and foot include a spectrum of severity
from superficial cellulitis to rapidly progressive necrotizing fasciitis.
■ Soft tissue infections of the foot and ankle can involve skin, subcutaneous
tissue, fascia, muscle, ligaments, tendons, joints, and around the nails.
■ Secondary infections can be due to peripheral vascular disease (PVD),
diabetes, metabolic conditions, and immunocompromised patients.
■ Infections of the foot and ankle are often categorized into three groups: soft
tissue infections, bone infections, and diabetic infections.
■ Infections can be further characterized into nonpurulent (cellulitis and
erysipelas), purulent (abscess), necrotizing soft tissue infections (NSTI)
(including necrotizing cellulitis, myositis, and fasciitis) as well as tendonitis
and septic arthritis.
■ Immediate goal is to treat and control the infection.
■ Long-term goal is for limb salvage, preserve limb function, and decrease risk
for amputation.
■ Infections are most commonly caused by bacteria, however can also be due to
viral, fungal, or mycobacteria.
■ Some may respond to treatment with topical, oral, or intravenous antibiotics
alone, while others will require surgical debridement of devitalized tissue.
■ Typically present as painful lesions with skin changes invariably present, with
or without involvement of deeper tissues.
ANATOMY

■ The lower leg, ankle, and foot comprise 28 bones.
■ Soft tissues include muscles that are divided into anatomically distinct
compartments in both the lower leg and the foot (FIG 1).
■ The four compartments of the lower leg include the anterior, lateral,
superficial posterior, and deep posterior divided by fascia.
■ The nine compartments of the foot include the calcaneal—communicating
with the deep posterior compartment of the leg, superficial, medial, lateral,
adductor, and four interosseous.
■ The primary neurovascular structures include the anterior tibial, peroneal, and
posterior tibial arteries and paired veins; superficial peroneal, deep peroneal,
tibial, saphenous, and sural nerves; and greater and lesser saphenous veins in
the superficial tissues.
■ Plantar surface is composed of thick glabrous epidermis and dermis, and a
subcutaneous layer with vertical fibrous septae, densely adhering it to the
plantar fascia and periosteum.
FIG 1 • Cross section of the leg showing the
compartments. (From Pansky B, Gest TR. Lower limbs.
In: Lippincott’s Concise Illustrated Anatomy: Back,
Upper Limb, and Lower Limb. Vol. 1. Baltimore, MD:
Wolters Kluwer; 2012:198.)

PATHOGENESIS
■ Infections result from breakdown of natural defenses in skin such as with
trauma or open wound and invasion of resident skin flora or environmental
pathogens.1
■ Patients with neuropathy and vascular disease and are immunocompromised
have increased risk of infection.1
■ Group A beta-hemolytic streptococcus is the most common and second most
common is Staphylococcus aureus.
■ Infections are also commonly polymicrobial, especially in diabetic patients.
■ NSTI result from bacterial invasion and subsequent angiothrombosis
decreasing blood supply causing tissue necrosis They are classified into two
groups:2
■ Type I is a polymicrobial infection consisting of anaerobic bacteria and
aerobic bacteria.
■ Type II is monomicrobial infections typically of group A streptococcus or
other beta-hemolytic streptococcus alone or with other pathogens.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient’s initial complaint is typically of pain and swelling at site of
infection. They may also notice changes in skin color and drainage of fluid.
There may be a history of antecedent trauma.
■ Systemic symptoms such as fevers, chills, malaise may not be present early in
the disease but indicate an immune response to the infection.
■ Past medical history of diabetes mellitus, vascular disease, immunodeficiency,
heart failure, cirrhosis, or prior surgery may predispose to infection.
■ Physical exam may reveal erythema, swelling, tenderness, warmth, fluctuance,
visible drainage, and eschar.
■ Open wounds may be present with exposed subcutaneous fat, muscle, fascia,
or bone.
■ Pain out of proportion to physical exam findings or crepitus are concerning
physical exam findings for necrotizing fasciitis.
IMAGING
■ Despite its inability to well characterize fluid collections, standard multiple
view radiographs are the first initial test to identify any bony injury or
radiopaque foreign bodies as well as gas from anaerobic bacteria. Subtle soft

tissue changes may also be demonstrated but are harder to appreciate by the
untrained examiner.
■ Ultrasonography may show cobble stoning of the subcutaneous tissues, which
is indicative of edema. Discrete, hypoechoic fluid collections may also be
identified. For patients with isolated abscesses, please see the chapter on
drainage of abscesses of foot and ankle.
■ Cross-sectional imaging with CT or MRI may better evaluate the extremity to
determine the extent of infection.1
DIFFERENTIAL DIAGNOSIS
■ Cellulitis
■ Abscess
■ Necrotizing fasciitis
■ Plantar fasciitis
■ Gout
■ Skin cancer
■ Venous stasis ulcer or dermatitis
■ Impetigo
■ Erysipelas
NONOPERATIVE MANAGEMENT
■ Simple infections such as folliculitis or impetigo may improve with topical
antibiotics alone.
■ Cellulitis and more superficial infections require oral or intravenous
antibiotics.
■ Infected open wounds without burden of necrotic tissue may be treated with
local wound care and antibiotics with careful monitoring for clinical worsening
in poor surgical candidates.
SURGICAL MANAGEMENT
■ The goal of surgery is to identify and debride all nonviable tissue, and a
planned second look operation may be considered in severe infections where
debridement is limited by critical structures.
Preoperative Planning
■ In patients who are hemodynamically unstable or with suspected necrotizing
infection, empiric antibiotic therapy should be ordered while drawing blood

cultures and should not be delayed for wound cultures.
■ In patients who are otherwise stable, consider deferring antibiotics until wound
cultures have been obtained.
■ If hardware is present, consider need for removal with orthopedic surgery
consultation, as well as need for bony debridement.
■ Ensure medical comorbidities are addressed. Patients with infected wounds
due to vascular ulcers may require preoperative revascularization. Diabetics
should have tight glycemic control.
■ Ensure appropriate laboratory investigations are obtained including complete
blood count, basic metabolic panel, C-reactive protein, sedimentation rate, and
blood cultures.
■ Antibiotic selection should cover gram-positive organisms with MRSA
coverage, and due to prevalence of gram-negative organisms in foot infections,
gram-negative coverage should also be provided while awaiting culture results.
Positioning
■ Supine position is usually sufficient for exposure.
T E C H N I Q U E S
■ Debridement of Soft Tissue Infections
■ Identify the affected area of the leg or foot and prep well beyond the border
with healthy tissue (TECH FIG 1A).
■ Identify necrotic or nonviable tissue and sharply debride without the use of
cautery.
■ Avoiding cautery will allow using the presence of bleeding to guide when
sufficient debridement has been performed.
■ Necrotic tissue is picked up with forceps and trimmed with curved mayo
scissors, Metzenbaum scissors for finer tissue, or scalpel.
■ Tissue may be sent to pathology and microbiology for culture and Gram
stain.
■ Presence of tunneling or disruption of fascial planes should be examined to
identify necrotizing fasciitis.
■ Probe the wound for any areas of tunneling. Areas of tunneling with fascial

disruption and/or presence of “dishwater-” appearing fluid raises concern for
presence of necrotizing fasciitis.
■ If tunneling found, most overlying tissue should be opened to explore extent
of infection, debride overlying tissue that is nonviable.
■ Irrigate the cavity with at least 3 L of saline, which is easily done with cysto
tubing (TECH FIG 1B).
■ Obtain hemostasis with electrocautery.
■ Pack the open wound with surgical packing.
■ Consider ultimate reconstructive goal, including healing by secondary
intention with wound care, wound Vacuum-assisted closure (VAC), skin
grafting, local flap, or free flap (TECH FIG 1C).
TECH FIG 1 • A. Infected lateral malleolar wound after
trauma. B. Debridement with high-pressure water. C.
Healed wound with split-thickness skin graft.
PEARLS AND PITFALLS
Preoperative
workup
■ Failure to obtain blood cultures
■ Failure to identify patients needing revascularization before
making larger wound
■ Delaying antibiotic therapy in severe infections
■ Nutritional optimization
Technique
■ Incomplete debridement resulting in need for additional surgery
■ Incompletely exploring extent of wound/tunneling
■ Use copious irrigation
Postoperative
■ Placing wound VAC on infected wound

care
■ Neglecting medical comorbidities or nutritional status
POSTOPERATIVE CARE
■ Continue broad spectrum antibiotics while awaiting culture speciation
■ Continue local wound care with at least twice daily dressing changes until
wound is confirmed to be clear of infection, afterward specialty dressings or
wound VAC may be applied which may be changed less frequently.
■ Silver sulfadiazine or other silver impregnated dressings controls both
bacterial growth and facilitates wound healing.
■ Continue to optimize medical comorbidities and smoking cessation.
■ Allow for at least passive range of motion exercises if weight-bearing surface
is affected.
■ Elevation of the extremity and pressure off-loading.
COMPLICATIONS
■ Persistent infection
■ Missed diagnosis of necrotizing infection
■ Injury to neurovascular structures
■ Hematoma
REFERENCES
1. Anakwenze OA, Milby AH, Gans I, et al. Foot and ankle infections: diagnosis
and management. J Am Acad Orthop Surg. 2012;20(11):684-693.
2. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med.
2017;377(23):2253-2265.

10
CHAPTER
Debridement of Infected
Bone of the Foot and Ankle
Michael Holland and Scott L. Hansen
DEFINITION
■ Osteomyelitis of the foot and ankle is defined by bacterial or less commonly
fungal infection of bones of the lower third of the leg and foot.
■ Spectrum of severity can range from chronic, indolent infections to acute,
suppurative infections resulting in sepsis.
■ Often resulting from existing soft tissue wound extending deep to underlying
bone; however, seeding (eg, from bacteremia), direct inoculation (eg, trauma,
puncture wounds), or healing of prior soft tissue defects can result in isolated
osteomyelitis in the absence of soft tissue signs or symptoms.
■ Frequently associated with hardware and prior fractures necessitating removal
or replacement of hardware.
■ The management of acute osteomyelitis is primarily medical, whereas the
management of chronic osteomyelitis is mainly surgical in combination with
antibiotic therapy.1
ANATOMY
■ The ankle is formed by the distal aspect of the tibia (medial) and fibula
(lateral) articulating with the talus of the foot.
■ The foot is composed of 26 bones functionally homologous to bones of the
hand and wrist.
■ The hindfoot is composed of the talus, which is seated on the calcaneus.
■ The midfoot articulates with the bones of the hindfoot and is composed of the
cuboid navicular and three cuneiform bones (medial, intermediate, and lateral).
■ The forefoot is composed of the 5 metatarsal bones and 14 phalanges.
■ Two sesamoid bones underlying the first toe metatarsal phalangeal joint also

are present in adults, with infrequently found accessory sesamoid bones at
other joints.2
PATHOGENESIS
■ Infection most often arises from soft tissue wounds, open fractures,
complications from orthopedic reduction of closed fractures, hematogenous
seeding from bacteremia or endocarditis, or inoculation from trauma
PATIENT HISTORY AND PHYSICAL FINDINGS
■ History of diabetes mellitus, vascular insufficiency, venous hypertension,
peripheral neuropathy, immunodeficiency, prior fracture, presence of hardware,
prior surgery, and prior podiatric procedures are important to identify
preoperatively in order to determine whether or not adjuvant therapy may be
beneficial to precede operative intervention.
■ Diminished sensation, paresthesias, and claudication are symptoms that may
indicate the presence of these above comorbidities.
■ Presence of open wounds with or without visible bone, erythema, fluctuance,
and bony tenderness can indicate active infection.
■ Decreased Semmes-Weinstein monofilament test, prior scars, palpable
hardware, and venous ulceration are physical exam findings that may indicate
higher-risk populations for developing osteomyelitis.
IMAGING
■ Three-view plain radiographs of the foot and ankle are the first test to order,
and will help give clear definition of bony anatomy, presence of hardware or
radiopaque foreign bodies, and can detect subtle changes of osteomyelitis as
early as 10 to 14 days but typically requires 3 weeks of active infection before
changes will be found.3
■ Periosteal reaction (FIG 1A), lytic lesions, endosteal scalloping, loss of bone
density, or trabecular architecture are findings indicative of osteomyelitis.4
■ CT scan is useful for demonstrating extent of osteomyelitis and may detect
radiologic changes earlier than plain radiographs; however, sensitivity is
limited at around 67%5 and may have findings obscured by hardware artifact.
Utility may be found in ability to evaluate extent of disease and to create three-
dimensional reformats for reconstructive planning.
■ MRI is the most sensitive and specific modality for diagnosis of osteomyelitis,
as early as 3 to 5 days (FIG 1B).6,7

FIG 1 • A. Radiograph of the right foot demonstrating
periosteal reaction of the calcaneus indicating
osteomyelitis. B. Corresponding MRI of the right foot
demonstrating the extent of calcaneus osteomyelitis.
DIFFERENTIAL DIAGNOSIS
■ Gout
■ Cellulitis
■ Plantar fasciitis
■ Sickle cell anemia
■ Neoplasm (primary or metastasis)
NONOPERATIVE MANAGEMENT
■ Acute osteomyelitis without abscess or necrotic component can frequently be
treated with isolated intravenous antibiotic therapy for a duration of at least 6
weeks. However, if nonoperative management fails, operative management is
indicated.
SURGICAL MANAGEMENT
■ Surgical debridement should always be considered and is mandatory for
osteomyelitis with any necrotic component and, in combination with antibiotic
therapy, is the mainstay of treatment for chronic osteomyelitis.
Preoperative Planning
■ Identify need for glucose control, preoperative revascularization, smoking
cessation, nutrition optimization, initiation of antiretroviral therapy, address
patients ultimate reconstructive goal (eg, flap vs amputation).

■ Coordinate with orthopedic surgeon if hardware is in place in order to
determine plan for replacement with antibiotic spacer or removal.
■ Consider orthopedic surgery consult if large amount of debridement is
expected with possible destabilization of ankle joint or foot requiring spanning
ex-fix or other temporary stabilization.
■ Obtain infectious disease consultation for antibiotic selection and duration.
■ A second look procedure should be anticipated and discussed with patient.
■ Laboratory studies including complete blood count, sedimentation rate, C-
reactive protein, metabolic profile, and blood cultures should be obtained and
trended throughout therapy.
Positioning
■ Place patient in supine position.
■ Prep affected extremity from toes to groin with Betadine.
■ Apply either lower extremity drape or split sheet to create sterile field.
Approach
■ Principles of therapy include wide debridement, stabilization of remaining
bony architecture, culture-guided antimicrobial therapy, and reconstruction of
resultant bony defects.8
T E C H N I Q U E S
■ Wide Debridement of Bone Infection
■ If a wound is present with exposed bone (TECH FIG 1A), the wound edges
are debrided sharply until healthy, bleeding tissue is reached (TECH FIG
1B).
■ The underlying bone is inspected for viability.
■ Any soft or necrotic bone must be removed with rongeur, curette, or
osteotome, until healthy, viable bone is reached (TECH FIG 1C,D).
■ If hardware is present, it must also be removed at this time.
■ Removed bone is sent to pathology and microbiology for culture and Gram
stain.
■ The resultant defect is examined for viability. Any remaining nonviable

tissue must be removed to prevent reinfecting compromised bone.
■ The wound is irrigated copiously with at least 3 L of saline.
■ Any dead space must be obliterated with antibiotic beads, cement, or soft
tissue to prevent fluid accumulation.
■ Bony stabilization can be further provided with plating, screws, or external
fixation.
■ A sterile, temporary dressing may be applied if second look is anticipated.
■ After final debridement, soft tissue coverage must be applied by primary
closure, local flap, or free flap.
TECH FIG 1 • A. Medial malleolar chronic wound with
underlying bone involvement. B. After wound care,
there is no significant change. C. Wound after soft
tissue debridement. D. Wound after debridement of
infected bone.
PEARLS AND PITFALLS
Preoperative
planning
■ Lack of patient optimization resulting in poor wound healing.
■ Lack of plan with orthopedic surgeon for need for removal of
hardware, stabilization.
■ Not considering patient preferences for early amputation and
reconstructive goals.
■ 6-week antibiotics.
■ Premature, early weight bearing and subsequent fracture.
Technique
■ Not performing wide enough debridement to reach healthy
margins.
■ Not taking intraoperative cultures for culture-guided therapy.

■ Not taking a second look.
Postoperative
■ Inadequate antibiotic duration, failure to follow culture-directed
therapy.
POSTOPERATIVE CARE
■ The patient is continued on antibiotics that may be narrowed when culture data
return.
■ Laboratory values are checked every few days to monitor for response to
treatment.
■ Postoperative radiographs are obtained to document degree of bony resection.
■ Infectious disease consultation is considered if not already obtained.
■ The patient is allowed to work with physical therapy but is kept nonweight
bearing until final orthopedic reconstruction is completed or stability
determined to be sufficient. If soft tissue reconstruction performed, positioning
restrictions may vary depending on appearance of flaps.
OUTCOMES
■ Patients frequently require multiple surgeries for adequate debridement to
viable tissue.
■ With adequate debridement, need for subsequent amputation has been reported
to be around 18%, minor 11.7% and major 6.3%.9
■ Long-term limb salvage (avoiding need for major amputation) with surgical
management is around 82%.9
■ Persistent infection can be as high as 36% after debridement, underscoring
need for adequate debridement of all nonviable tissue.10
■ Overall perioperative mortality has been reported to be 1.6%11
COMPLICATIONS
■ Persistent infection
■ Fracture
■ Minor amputation
■ Major amputation
REFERENCES
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