A 26-year-old Indian shipyard worker with a history of poorly controlled diabetes mellitus (preoperative hemoglobin A1c of 11%) was admitted to the hospital with a 2-week history of left foot abscess without any prior history of trauma to the left foot. On physical examination, erythema and edema were noted over the plantar and dorsal aspect of the left foot. There was also a small abscess collection at the left fourth interspace foot region subcutaneously. The patient's hemoglobin level was 14 g/dL and his albumin level was 38 g/L. Dorsalis pedis and posterior tibial pulses were strongly palpable; however, Doppler ultrasound studies of the foot revealed suspicion of stenosis in the distal anterior tibial and dorsalis pedis arteries. Left foot plain radiographs did not show any signs of osteomyelitis and broad-spectrum intravenous antibiotics were started immediately. Non-invasive vascular studies including arterial ankle-brachial index (ABI) and toe-brachial index (TBI) for the dorsalis pedis and posterior tibial arteries were within normal limits.
The patient underwent multiple surgical debridements with a subsequent partial fifth ray (toe and metatarsal) amputation due to abscess extension circumferentially around the fifth metatarsophalangeal joint (MTPJ). Further extensive debridements were performed due to the unhealthy tissue along the fourth toe extensor tendon and paratenon of the fourth metatarsophalangeal capsule. It was noted that the fourth MTPJ capsule postdebridement was exposed. The wound was subsequently left to heal by negative pressure wound therapy application (Fig. 1). Tissue cultures grew penicillin-sensitive Streptococcus agalactiae and antibiotics were tailored according to the culture results. The total duration of antibiotics was 2 weeks prior to definitive closure. A lateral lesser toe fillet flap reconstruction was then performed and after repeated tissue cultures was negative prior to closure.
The surgical procedure was performed under regional anesthesia and a tourniquet was used for hemostasis. A sandbag was placed under the ipsilateral gluteal region to allow for better positioning in surgery via internal rotation of the leg. A direct lateral incision was made over the lateral aspect of the fourth toe from the tip of the distal toe to the metatarsal wound, exposing the phalanges of the fourth toe (Fig. 2). The phalanges, tendons, and joint capsule were filleted out from the skin, carefully preserving neurovascular bundles to ensure flap survival. The filleted skin flap was then approximated laterally to the wound using a non-absorbable 4-0 Prolene suture, covering the exposed fourth metatarsal head (Fig. 3a and b).
Once the exposed structures were covered, a split-thickness skin graft (STSG) was harvested from the ipsilateral thigh and applied onto the remaining wound bed defect. The STSG was then secured to the wound edges using staples (Fig. 4). A bolster dressing which consisted of a tie-over with flavin cotton wool was placed on STSG for 5 days to ensure maximal graft adherence to wound. The patient was kept non-weight bearing on the left foot for 2 weeks. Oral analgesia was prescribed with non-steroidal anti-inflammatories and paracetamol. Intravenous antibiotics were provided for 1 week due to previous infections and immunocompromised state due to poorly controlled diabetes mellitus. The wound was inspected postoperative on day 5, 10, and 14 for any wound dehiscence, flap necrosis, or infection. Sutures and staples were removed at 2 weeks postoperatively. Dressing changes over the STSG donor site were performed twice weekly thereafter until the STSG was completely incorporated.