From the Department of Hand Surgery and Microsurgery (H.N.), Institute of Trauma and Orthopedics, Central Hospital 108, Hanoi, Vietnam; ENT Department (H.N., R.S.), and Department of Plastic Surgery (H.N., C.H.), University Hospital “rechts der Isar,” Technical University of Munich, Germany.
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Because of the anatomic characteristics around the ankle joint, reconstructive procedures for obliterating a chronic infective cylindrical dead cavity following subtotal talectomy remains a significant surgical challenge. The use of direct bone grafting generally results in failure because of infection, whereas using local soft tissue flaps produces unfavorable results since flaps around the ankle are usually thin and sparse with minimal laxity for transposition. The eradication of this infective dead cavity using local muscle flaps such as the abductor digiti, minimi, or abductor hallucis is also impossible because the muscles are too small and have inadequate mass for cavity obliteration.1As a result of technological advances in operating microscopes and instruments, free tissue transfer using microsurgical techniques has become well established in reconstructive surgery.2 Although the effectiveness of using free muscle flaps in the treatment of osteomyelitis in lower extremities was well documented in the literature,3,4 the obliteration of a chronic infective dead cavity after subtotal talectomy using the free gracilis muscle and its final functional results has not been presented in the literature to date.Microsurgery is a new procedure in Vietnam. Because of lack of education, experience and adequate equipment, microsurgical applications in the clinical routine in Vietnam have only begun to develop in recent years. In this article we present a case of this type of injury, operated on in the Department of Trauma, Orthopaedics and Microsurgery at Central University Hospital 108, Hanoi, Vietnam, with subsequent evaluation of postoperative final functional outcomes.CASE REPORTA 41-year-old male manual laborer sustained a severely displaced open-fracture of the right talar body caused by a motorcycle crash. The talus was medially dislocated corresponding to the open laceration after trauma. Shortly after the injury, he was surgically treated in a small local hospital by simple wound suture and immobilization of the affected lower limb in a plaster cast. A high dose of a wide-spectrum antibiotic was also administered for 10 days postoperatively.This first approach was, however, unsuccessful with the development of a wound infection localized in the ankle joint corresponding to the initial injury. Six weeks after the initial surgery, the patient was transferred to another hospital with the diagnosis: “infected draining wound after severely displaced talar body open-fracture.” In this hospital, the second operation was performed including medial and lateral enlargement of the ankle joint for debridement of infected fistula and devitalized tissue, reduction of the os talus according to the anatomic form, and immobilization of the ankle joint using external fixation. Although the patient was prescribed a high dose of antibiotics for the next 4 weeks, the infected wound fistula did not heal.The patient presented in our department 4 months after the initial surgery with purulent fistulas on the medial and lateral side of the right ankle joint. The growth of the organism after bacterial culture in the chronic draining wound was identified as Staphylococcus aureus combined with E. coli. Preoperative roentgenograms showed obvious signs of severe talar osteomyelitis and sequestra (Fig. 1). The third operation was performed and showed that pus and infected tissue were dominant in the chronic infective draining wound. The posteriorly fractured half-talar body had become irrepairable because of severe infection and necrosis. The procedure continued with wound enlargement, radical debridement of infected tissues, removal of the devitalized half-talar body, opening of the wound fistulas, and immobilization of the ankle joint using a self-designed Vietnamese external fixation device (Fig. 2).