Case Report
Hospital Middlemore Hospital, New Zealand
Secondary reconstruction of heal underwent treatment with NovoSorb ® BTM to form thicker layer of soft tissue overlying the calcaneus.
From a past traumatic wound, the patient had an unstable scar over the weight bearing surface of her left heel. Consideration was given for free muscle and regional flaps, but NovoSorb BTM was selected to reconstruct the dermis prior to definitive closure with a split thickness skin graft (STSG). At the 4 month post-operative check, the patient was able to weight bear on her heel and had an improved gait.
Figure 1: Pre-operative; break down of tissue over the calcaneus with an unstable scar.
Figure 2: Excision of left heel; thin layer of scar tissue exposed.
Figure 3: Application of NovoSorb BTM.
Figure 4: 4 weeks post NovoSorb BTM application; sealing membrane delaminated and neodermis lightly refreshed in preparation of skin graft.
Figure 5: 2 weeks post skin graft; patient started gentle weight bearing.
Figure 6: 4 months post skin graft; full weight bearing achieved with improved gait.
Background
Treatment
Outcome
39 year old female, with no significant comorbidities, sustained an injury from a motor vehicle accident 25 years prior, resulting in the loss of the heel pad of her left foot. At the time this was repaired with a STSG. Due to the thin layer of skin overlying the calcaneus, there was a breakdown in the layer when walked upon (Fig. 1). This led to the patient changing gait to avoid pressure on the area, causing discomfort and difficulty in performing her job that required standing for long periods of time.
Other reconstructive options considered were a free gracilis muscle flap and a STSG to provide a thicker layer of padding over the calcaneus. The patient refused this option due to the long and complex procedure and donor site morbidity. Regional options such as the medial plantar flap were not possible due to the previous injury and the reverse sural artery flap was also rejected due to donor site morbidity.
Under general anesthetic, the weight-bearing surface of the left heel was excised exposing a thin layer of scar tissue, soft tissue and periosteum over the calcaneus which was not exposed (Fig. 2). NovoSorb BTM was inserted into the wound margins and quilted with staples (Fig. 3). The outer dressing consisted of silver dressing and topical negative pressure wound therapy (NPWT) at 50mmHg.
The patient remained in hospital for 1 week until the first outer dressing change and NovoSorb BTM check were complete. Following discharge home, the patient attended the hospital once a week for dressing changes and review of NovoSorb BTM. The patient was advised not to weight bear during this period and was provided crutches to help with mobility.
4 weeks post NovoSorb BTM application, the wound appeared well vascularized and integrated. During the second stage procedure, NovoSorb BTM’s sealing membrane was delaminated and the neodermis was gently refreshed with an abrasive pad (Fig. 4). A meshed STSG was applied and secured with an absorbable suture. The outer dressing consisted of a soft paraffin dressing and NPWT.
At 5 days post grafting, 100% take was noted, allowing the patient to be discharged home. 2 weeks following the second stage procedure, gentle weight bearing was commenced (Fig. 5). When reviewed at 4 months in clinic, the patient was able to weight bear on the heel and had resumed a more normal gait. Upon clinical examination, the patient had a thicker layer of soft tissue overlying the calcaneus (close to 1cm in thickness), resulting in a more pliable surface where the underlying bone did not feel as prominent with applied pressure (Fig. 6).