Treatment of Traumatic Degloving Injury of the Foot Using a Biologic Dressing in a Pediatric Patient

Introduction. Degloving injuries of the foot involve the management of extensive soft tissue and osseous damage secondary to significant forced avulsion of soft tissue, which can present a major challenge for the surgeon. Surgical procedures on pediatric foot degloving involving split-thickness and/or full-thickness skin grafts and rotational flaps can result in negative consequences, such as donor site comorbidities and psychosocial implications when the pediatric patient returns to daily life. Case Report. The authors report the case of a 16-year-old girl with no past medical history who sustained an extensive degloving injury to her right foot involving severe subcutaneous and muscular soft tissue disruption and contamination. The initial treatment consisted of debridement, copious irrigation, primary wound closure at several sites, and application of an extracellular matrix (ECM) substitute graft. Shortly thereafter, secondary treatment consisted of application of primary musculoskeletal repair, negative pressure wound therapy (NPWT), and application of a dermal regeneration template. Over the 5-month course of treatment, an additional 3 trips to the operating room occurred, involving serial irrigation and debridement, NPWT application, and dermal/ECM substitute graft applications, leading to full epithelialization. Conclusions. To the best of the authors’ knowledge, this is the first reported case in which an instance of pediatric foot degloving is presented with serial debridement, NPWT, and biological dressings, resulting in no additional plastic surgical techniques needed to provide return to functional outcome.

In degloving injuries of the foot that involve osseous exposure, early coverage of the deficit must be a primary goal of treatment to prevent devastating complications such as osteomyelitis and severe soft tissue infection.¹ Contamination of the wound with debris, alongside severe edematous swelling, can make early definitive wound closure unfeasible and require a multistage approach in order to provide optimal functional outcome and return to previous activity.² In the pediatric patient, meticulous surgical techniques and return to functional outcome is of the utmost importance in order to allow the patient a quick return to their normal routine.

In the limited amount of literature available on pediatric foot degloving, surgical procedures all involved plastic surgery techniques such as split-thickness skin graft (STSG) or full-thickness skin graft (FTSG) and rotational flaps. Examples include the use of full-thickness skin to cover the dorsal aspect of the foot and posterior tibial artery flap to cover the plantar aspect of the foot in 7 children, as reported by Liu et al³ and a FTSG to treat a child’s foot that sustained laceration and degloving injury in a case reported by Cáp et al.⁴ However, these procedures have the potential to leave additional surgical scarring on the patient, provide donor site morbidities, and lead to severe physiological issues such as infection and necrosis.⁵ Furthermore, the psychological impact (eg, taunting from their peers) of an additional site of hypopigmentation and scarring are additional factors that must be considered in a pediatric patient population. 

There is growing evidence that negative pressure wound therapy (NPWT) is useful for quicker wound closure in foot and ankle surgery.⁶ Barendse-Hofmann et al⁷ reported a successful case of NPWT applied to a large lower extremity wound, involving both soft-tissue injury and femoral fractures for grafting, resulting in full healing and no complications. In particular, NPWT has been utilized on many wounds due to speculated mechanisms of action, such as angiogenesis, increased blood flow, and decreased interstitial fluid.⁸ Eginton et al⁹ observed significant wound depth and volume decrease compared with contemporary wound closures after 6 patients received NPWT. Negative pressure wound therapy is used widely, and, given the cost, there is a need for further trials on and evaluations of its benefits.¹⁰ In addition, the combined use of NPWT and a dermal regeneration template has shown both functional and aesthetic results in treating degloving injuries of the lower extremities.¹¹ The case presentation reported herein demonstrates meticulous serial debridement, NPWT, and dermal templates can leave satisfactory results without the potential physiological and psychosocial complications that can occur from plastic surgery techniques.

A 16-year-old girl presented to the Hahnemann University Hospital Emergency Department (Philadelphia, PA) with a severe Gustilo Anderson IIIA degloving injury to her medial right foot secondary to a motor vehicle accident in which her bare right foot was stuck under the passenger seat of the car (Figure 1). The podiatric surgery department was consulted within 30 minutes of her presentation to the emergency room. Upon physical examination, there was significant debris contaminating the soft tissue, open and exposed first ray and navicular, and significant exposure of musculoskeletal tissue. Within the hour, the patient was brought to the operating room (OR), where the wound was copiously irrigated and debrided to remove all debris and nonviable tissue. The patient’s first ray was then closed primarily and OASIS Wound Matrix (Smith & Nephew, Fort Worth, TX) was applied to the wound. Next, the patient underwent a 72-hour course of cefazolin (Figure 2A, 2B). Three days later, after adequate wound drainage had occurred, NPWT (V.A.C.ULTA; KCI, an Acelity Company, San Antonio, TX) was initiated at the bedside at 125 mm Hg continuous pressure. 

One week following initial presentation, the patient was taken to the OR a second time for further debridement, primary repair of muscle (abductor hallucis and extensor digitorum brevis), application of Integra Dermal Regeneration Template (Integra LifeSciences Corporation, Plainsboro, NJ), re-application of NPWT, and bone biopsy of the navicular (Figure 2C) to rule out osteomyelitis. Intraoperatively, the soft tissue was noted to be hypergranular with minimal remaining debris.

A third serial debridement was performed during the patient’s initial hospital stay 2 weeks following initial presentation. During this procedure, additional debridement was performed, and all remaining necrotic skin was removed. The combination of acute application of dermal templates over large deficits, combined with meticulous soft tissue debridement, provided a granular, healthy wound bed with all osseous structures fully covered. After discussion with the patient and her family, it was decided at this point not to utilize STSG or FTSG during additional procedures due to potential psychological concerns and donor site complications. After this third debridement and a lengthy 3-week hospital course, the patient was discharged from Hahnemann University Hospital, accompanied with home nursing and NPWT changes every 3 days. The patient was given a controlled ankle movement walker with customized offloading felt built in and was allowed to weight bear as tolerated in her boot. 

Over the next 5 months, the patient followed up on an outpatient basis with the podiatric surgery department. Due to pain levels and the patient declining in-office peripheral nerve blocks, she was taken back to the OR 2 additional times for further irrigation and debridement with biological dressing application. Following her final operative debridement at 4 months post initial presentation (Figure 3A), NPWT was discontinued, and the patient was switched to collagen (Endoform [Aroa Biosurgery Limited, Auckland, New Zealand] and Hydrofera Blue [Aroa Biosurgery Limited]) dressing changes every other day. Five months after initial presentation, the patient had obtained full epithelialization. After 7 months, the patient had been completely discharged from the clinic with total return to normal day-to-day activities and life (Figure 3B).

Degloving injuries, which often present as grossly contaminated wounds with extensive soft tissue defects, require a multistage approach, often followed by a plastic surgical procedure to fully close.¹ This multistage approach primarily consists of an application of an autogenous skin graft, followed by conventional dressings.¹² Examples include a report by Yan et al,¹³ in which 21 patients with foot degloving injuries were treated, and a case by Zagrocki et al¹⁴ of similar treatment for a forklift injury resulting in extensive degloving injury to the foot, ankle, and lower leg. However, plastic surgical procedures often present themselves with the complications of donor site morbidity, infection, and seroma and hematoma formation,² as well as cosmetic complications, such as hyperpigmentation and hypertrophic scarring and keloids. To illustrate potential complications, in a case series of 21 patients, Kudsk et al¹⁵ noted direct closure of avulsed tissue in combination with STSGs resulted in more than 50% necrosis of the graft, with infection complications requiring additional debridement and skin grafts. Complications such as these must be significantly considered in the pediatric patient, whom can have severe psychological ramifications from both the cosmetic and physiologic complications of plastic surgery techniques. 

The common treatment for degloving injuries has been extensive irrigation and debridement to remove debris, followed by simple reattachment of the avulsed skin and musculoskeletal tissue, immediate closure of osseous deficit, application of NPWT, use of supplemental biological dressings, and, finally, the utilization of STSG or FTSG.² Factors to success through this treatment include the appropriate selection of the donor site, good vascular anastomosis, and active postoperative rehabilitation.¹

As an adjunct to extensive irrigation debridement and repair of musculoskeletal structures, NPWT has demonstrated significant advantages in avulsion injuries. It has been shown to improve bacterial clearance, increase local blood flow, and promote granulation tissue formation.¹⁶ In addition, evidence shows NPWT is beneficial in the management of many patients with heavily contaminated soft tissue injuries.¹⁷ Promising results were reported by Liu et al¹⁸ in a study of 179 patients who sustained severe open tibial and fibular fractures and massive soft tissue injuries during an earthquake and were treated with external fixation and NPWT. In the present case, the authors noted NPWT promoted a consistently healthy bed of granulation tissue, which helped lead to eventual full epithelialization. 

Current evidence suggests NPWT is surmised to be as or more effective compared with contemporary wound treatments. When correctly administered under appropriate circumstances, NPWT is more probable to be safe rather than harmful.¹⁹ Also, NPWT can lead to elevated proportions of healed wounds, quicker time to wound closure, faster and more vigorous granulation tissue response, and possibly less re-amputations compared with standard care.²⁰ Further studies are warranted, in particular to soft tissue trauma, open fracture, and flap reconstruction, to advocate NPWT.²¹

In cases in which tendon or bone are exposed in addition to defatted and degloved tissue, use of biological dressings (acellular dermal matrices and dermal regeneration templates) can aid in wound healing. Dermal substitutes can be used in complex soft tissue loss often seen in degloving injuries, which require supplementation of the wound bed over exposed joint, tendon, or bone. These dermal matrices prepare the wound bed for healthy granular healing and yield better long-term coverage, along with superior aesthetic results compared with prolonged granulation followed by grafting.^22,23 In the present case study, the dermal regeneration template and acellular dermal matrix were used due to on-shelf availability in the treating facility.

As previously stated, the patient had complete return to function at 7-month follow-up, with no complications or impairment of daily activities or motor function. The patient and her family were very pleased with the result of her treatment, and she has been able to resume her daily adolescent lifestyle without limitations. 

This study is the first reported in which plastic surgery techniques were not used as an adjunct to meticulous debridement, NPWT, and biological dressings. Due to the excellent results obtained with maintaining a healthy granular base and overall patient compliance, additional plastic surgical procedures such as flaps and STSG or FTSG were not required to obtain adequate epithelialization. This approach resulted in a favorable outcome, providing the patient with a return to full function of her foot. This case study demonstrates that in a healthy, young, and compliant patient, additional plastic surgery techniques, which present with potential physiological and psychological complications, such as infection, graft failure, and poor cosmesis, may not always be necessary to provide adequate healing and epithelialization. 

Authors: Richard Kaufman, DPM, AACFAS, CWSP¹; Joshua Nguyen, BS²; Brett Williams, DPM³; Sunny Patel, DPM⁴; Ramon Lopez, DPM⁵; and Steven F. Boc, DPM, FACFAS, FACFAOM⁵

Affiliations: ¹Ankle and Foot Centers of Georgia, Roswell, GA and Piedmont Atlanta Hospital, Atlanta, GA; ²Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL; ³Foot and Ankle Center of Philadelphia, Philadelphia, PA; ⁴Achilles Foot and Ankle Center, Henrico, VA; ⁵Hahnemann University Hospital/DUCOM, Philadelphia, PA

Correspondence: Richard D. Kaufman, DPM, AACFAS, CWSP, Ankle and Foot Centers of Georgia, 865 Holcomb Bridge, Roswell GA, 30076; kaufmandpm@ankleandfootcenters.com

Disclosure: The authors disclose no financial or other conflicts of interest.