Tag Archives: lower extremity

A case of recurrent hyperostotic macrodactyly

by Milad Motalebi Kashani DPM1*, Melinda A. Bowlby DPM2

The Foot and Ankle Online Journal 13 (4): 6

Macrodactyly and its variation hyperostotic macrodactyly are some of the rarest deformities encountered by foot and ankle specialists. Changing the natural aesthetic shape of the foot, limiting the functionality of the lower extremity, and causing pain are some ways that this condition can affect patients’ everyday life and mental health. This study presents a case of recurrent hyperostotic macrodactyly that was managed with surgical intervention in order to debulk the soft tissue and excise excess osseous elements with successful results.

Keywords: congenital deformity, forefoot, lower extremity, foot and ankle surgery

ISSN 1941-6806
doi: 10.3827/faoj.2020.1304.0006

1 – Swedish Medical Center- Cherry Hill Campus, Seattle, WA PGY-1
2 – Assistant Research Director, Swedish Medical Center-Cherry Hill Campus, Seattle, WA
* – Corresponding author- miladm14@vt.edu

Macrodactyly is a non-hereditary and congenital deformation pathology of the upper and lower extremities which can be bilateral or unilateral [1-5]. In this deformity both osseous and soft tissue components of the digit can be enlarged in size which can cause functional and esthetic problems for the patient. Two types of this condition that were described by Barsky are static, in which deformity is present at birth and increases in size proportionally to other digits, and progressive, in which a digit grows disproportionately to other digits and is most commonly encountered in the lower extremity [1].

Macrodactyly is believed to be originally described by Von Klein in 1824 in the upper extremity and later in 1925 by Feriz in the lower extremity [6-8]. This disorder is thought to be a rare condition and because of that there is no accurate estimate of the prevalence of this disorder. According to some estimates, macrodactyly accounts for 0.9% of all congenital deformities and it is more prevalent in males [9, 10]. The etiology of macrodactyly has been debated over the years, but no clear conclusion has emerged yet. Some cases of macrodactyly present in patients with other disorders such as Proteus syndrome, Neurofibromatosis type 1, Klippel–Trenaunay syndrome, lymphangioma and fibrous dysplasia [8,11,12]. However, in many of the case reports published regarding macrodactyly, this condition is observed as an isolated condition with no other associated disorders [2,3,9,13,14].

Throughout the years, different terms such as macrodystrophia lipomatosa progresia, macrodystrophia lipomatosa, megalodactyly, and localized gigantism have been used in the literature to describe macrodactyly or other variations of this deformity [7]. A unique and less discussed type of progressive macrodactyly is hyperostotic macrodactyly which usually has a later onset than typical macrodactyly and is associated with osteo-cartilaginous mass formation in peri-articular areas of the upper and lower extremity [15].

Figure 1 Preoperative medial oblique X-ray image (on the left) and clinical photo (on the right), prior to second surgery.

Figure 2 Postoperative medial oblique X-ray image, following the second surgery.

The rare presentation of hyperostotic macrodactyly and a lack of literature regarding this topic have provided practitioners with no clear guidelines regarding the management of this disorder. This case report presents a case of a mild recurrent hyperostotic macrodactyly in a patient with previous surgical interventions to address this deformity.

Case Report

A 53-year-old female with no past medical history other than asthma presented to the clinic with a painful recurrent mass on her left hallux. She related that she has had two prior surgeries. The patient reported that she was originally seen regarding this problem when she was 14 years old and was diagnosed with localized gigantism. She had a surgery at that time to fix her deformity which had satisfying results and resolved her problem for about 35 years.

The second surgery was performed four years ago when the patient was seen by another podiatrist regarding this problem. She had noticed an increase in size of her left hallux and denied any trauma to the area. She had pain both on the plantar and medial side of her left hallux and first metatarsal head with noticeable bony prominences. She changed her shoe gear, using slippers or open sandals to accommodate the prominences (Figure 1). In the second surgery, osteophytes from the left first metatarsophalangeal joint and hallux were excised and a soft tissue mass from the plantar aspect of the left hallux was removed as well (Figure 2). During the postoperative period, the patient stubbed her hallux on a heavy plastic bin which was very painful for her, however no fractures were noted, and the rest of her postoperative course was uneventful.

The patient presented to our clinic two years ago due to noticing the recurrence of her deformity after the second surgery. Physical exam revealed approximately a 4 cm x 3 cm firm soft tissue mass overlying the left first tarsometatarsal joint. There was also tenderness with palpation of a prominent exostosis along the medial aspect of the left hallux Interphalangeal joint. Joint motion at first metatarsophalangeal and tarsometatarsal joints were severely limited as well, but not painful (Figure 3). Magnetic resonance imaging report indicated an ovoid, subcutaneous lipoma measuring 5.2 x 2.8 x 1.1 cm. Mild to severe arthritis of the first tarsometatarsal and metatarsophalangeal joints with ossified bodies in addition to fatty infiltration of abductor and flexor hallucis muscles was also noted.

Figure 3 Preoperative clinical photos (in the left and the middle) and dorsoplantar X-ray image (on the right), prior to the third surgery.

After discussing the possible adverse effects, benefits and alternative therapies to the surgery with the patient, the patient wished to proceed with exostectomy and removal of the soft tissue mass. During the third surgery, osseous masses from the left hallux were removed and the soft tissue mass from the dorsal and medial aspect of first metatarsal of the left foot were excised and both specimens were submitted for pathology evaluation (Figure 4). The osseous masses were clinically equivalent with osteophytes measuring 0.8×0.6×0.5cm and 1.2×

Figure 4 Intraoperative image of the excised fibro-fatty mass, during the third surgery.

Figure 5 Postoperative clinical photo, following the third surgery.

The soft tissue mass revealed mature adipose tissue with features of a lipoma measuring 4.5×2.5×1.3cm. The patient was kept non-weight bearing in a splint for 2 weeks and then she was allowed to weight-bear as tolerated for 2 weeks in a surgical boot. Postoperative course was uneventful, and the patient made good progress, had no complaints, and was satisfied with the results more than 18 months after the third surgery (Figure 5).


Hyperostotic macrodactyly is a distinctive type of macrodactyly in which massive osteo cartilaginous deposits are observed around the joints [2,15]. Early in the formation process of these osteo-cartilaginous bodies around the joints, they are mostly cartilaginous and later they are substituted with osseous elements which leads to motion restriction across the affected joint [2]. As a progressive macrodactyly, it is not uncommon to observe fatty growths or lipomas and fatty infiltrations in this condition. In many reported cases this fatty hypertrophy and infiltration can be observed in both plantar and dorsal aspect of the foot [3,14]. The case presented in this article demonstrated both osseous and fatty enlargement across the first ray of the patient’s left foot.

The main goals of treatment for macrodactyly should be providing the patients with a pain free, functional foot that can fit into their shoes [4]. Unfortunately, there are very few reported cases of hyperostotic macrodactyly in the foot, however it appears that the removal and debulking of the excess fibro-fatty tissue and osseous bodies is the best method of management of this disorder which was the way the patient in this case was treated [2,9,13]. In a case report by Katz, the patient presented with lipomas across his right foot and ankle and osteo-cartilaginous growths across his fourth and fifth toes and metatarsals [9]. An surgery was performed on the patient in which the lipomas and osteo-cartilaginous bodies were excised and the fifth toe and half of the fifth metatarsal were resected. The patient had excellent results after the surgery. In another case by Matsuzaki, et al., the patient was suffering from painful and limiting osteo-cartilaginous masses around his left first metatarsal head and ankle [2]. Patient had a previous left second toe and hallux amputation surgery to address his macrodactyly. After removal of these osseous bodies from the patient’s left foot, his pain was relieved and the motion across his ankle joint increased and no recurrence was reported.

One curious aspect of the case presented in this article that requires attention is the recurrence of osteo-cartilaginous bodies almost two years after their resection in the second operation. This seems to be too early for a recurrence to happen considering that it took almost 35 years after the first surgery for her to have problems with her left foot again. A possible explanation for this can be the traumatic event to the area in the postoperative course in which the patient stubbed her big toe straight into a heavy plastic bin. Some studies have suggested that trauma can be the trigger for the osteo-cartilaginous hypertrophy observed in hyperostotic macrodactyly deformity which would explain the recurrence in this case [2,15].

In conclusion, hyperostotic macrodactyly is a rare progressive form of macrodactyly in which massive and limiting periarticular osteo-cartilaginous bodies in addition to fatty tissue hypertrophy can form. Surgical intervention to remove these osseous and fatty masses in cases that they cause pain and functional disability due to blocking joints appears to be the best method to treat this condition. It is also very important to educate patients to avoid trauma to the areas affected by hyperostotic macrodactyly since trauma appears to be one of the causes of this disorder or its recurrence.


  1. Barsky AJ. Macrodactyly. The Journal of Bone & Joint Surgery. 1967 Oct;49(7):1255-66.
  2. Matsuzaki T, MD, Hitora T, MD, Akisue T, MD, Imaizumi Y, MD, Yamagami Y, MD, Yamamoto T, MD. Massive Heterotopic Ossification around the Ankle in a Patient with Macrodactyly of the Foot: A Case Report. Journal of Foot and Ankle Surgery, The. 2012;51(5):648-51.
  3. Zhang X, Liu Y, Xiao B, Li Y. Two cases of macrodactyly of the foot: relevance in pediatric orthopedics. Journal of Pediatric Orthopaedics B. 2016 Mar;25(2):142-7.
  4. Hop MJ, MD, van der Biezen, Jan Jaap, MD, PhD. Ray Reduction of the Foot in the Treatment of Macrodactyly and Review of the Literature. Journal of Foot and Ankle Surgery, The. 2011;50(4):434-8.
  5. Kalb JP, Suarez DA, Herrera AM. Bilateral Macrodactyly of the Halluces in an Adolescent Girl Corrected with Shortening Osteotomies of the First Metatarsal and the Phalangeal Bones: A Case Report. JBJS case connector. 2018 Jul;8(3):e58.
  6. Klein W, Germann G, Bosse A, Müller KM, Steinau HU. Clinical aspects, morphology and therapy of an unusual case of bilateral macrodactyly. Handchirurgie, Mikrochirurgie, plastische Chirurgie. 1993 Jan;25(1):12.
  7. Tatu RF, Anuşca DN, Dema ALC, Jiga LP, Hurmuz M, Tatu CS, et al. Surgical treatment in a case of giant macrodystrophia lipomatosa of the forefoot. Romanian journal of morphology and embryology. 2017;58(3):1115.
  8. Natividad D, Ellise, Patel D, Kinna. A Literature Review of Pedal Macrodactyly. Foot & ankle journal (Online). 2010 May.
  9. Katz JB. Progressive macrodactyly. The Journal of Foot and Ankle Surgery. 1999;38(2):143-6.
  10. Wang S, Han Z, Liu X. Hyperhidrotic Macrodactylism Caused by Osteoid Osteoma: A Case Report and Review of the Literature. The Journal of Foot and Ankle Surgery. 2019 May;58(3):586-90.
  11. Bulut M, Karakurt L, Belhan O, Serbest S. Ray amputation for the treatment of macrodactyly in the foot: report of three cases. Acta orthopaedica et traumatologica turcica. 2011;45(6):458- 62.
  12. Rampal V, Giuliano F. Forefoot malformations, deformities and other congenital defects in children. Orthopaedics & Traumatology: Surgery & Research. 2020 Feb;106(1):S115-23.
  13. Mullins AM. Multiple Lower Limb Osteophytosis with Macrodactyly: A Case Report. Foot & Ankle International. 1996 May;17(5):283-5.
  14. Yushan M, Alike Y, Keremu A, Abulaiti A, Ren P, Yusufu A. Precise Resection of Macrodactyly Under Assistance of Three-Dimensional Reconstruction Technology: A Case Report. The Journal of Foot and Ankle Surgery. 2020 Jan;59(1):125-7.
  15. Schuind F, Merle M, Bour C, Michon J. Hyperostotic macrodactyly. Journal of Hand Surgery. 1988 Jul;13(4):544-8.


Utilization of a peroneus brevis muscle flap for calcaneal fat pad atrophy secondary to radiation treatment: A case report and treatment course

by Amanda Kamery DPM1*, Byron Hutchinson DPM FACFAS2

It has been well-documented that peroneus brevis muscle flaps are an excellent option for coverage of small to medium sized soft tissue defects of the distal lateral lower extremity. They are widely used due to their reliable blood supply, minimal donor site morbidity and lower technical demand as compared to other lower extremity muscle flaps. To our knowledge, no study has evaluated the efficacy of the use of a peroneus brevis muscle flap for an intractable calcaneal scar tissue. We present a unique case in which the peroneus brevis muscle flap was used to assist with eliminating pain from an intractable calcaneal scar secondary to radiation treatment.

Keywords: Muscle flap, rear foot, lower extremity, reconstructive surgery

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0002

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Research Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author- akamery@kent.edu

Peroneus brevis muscle flaps are widely used for distal lateral lower extremity soft tissue defects due to their reliable blood supply, minimal donor site morbidity and lower technical demand as compared to other muscle flaps [1-3]. The efficacy and utility of this muscle flap has been well-documented in the literature. Since the first discussion of a distally based peroneus brevis flap in 1997, the indications for this flap have vastly expanded and the technique has since been simplified into 5 steps [4]. It has been documented that partial or full flap necrosis is a common complication, with an occurrence of up to 41% [4]. However, with advancements in postoperative dressings and wound care modalities, this complication can be well managed [3,4]. In this case report, we present a patient with a unique indication for a distally based peroneus brevis flap.

Case Report

The patient is a 40-year-old male who presented with a painful lateral calcaneal scar after removal of clear cell sarcoma and subsequent radiation treatment years ago (Figure 1). The patient complained of significant pain to the area with activity and irritation from shoe gear. He had undergone numerous conservative treatment options without relief of symptoms. He was unable to perform duties required of his job due to pain. His goal was for pain reduction to help return to normal activity levels at work. 

A staged procedure was planned. The index procedure included scar excision, a peroneus brevis muscle flap and application of an external fixator to allow for stability of the flap and to allow full flap incorporation (Figure 2). A secondary procedure, performed 7 weeks later, included external fixator removal and skin graft application (Figure 3).   

Figure 1 Pre-operative clinical picture.  

Figure 2 Intraoperative picture of muscle flap after placement.

Intra-operatively adequate bulk and length from the peroneus brevis muscle to cover the calcaneus and aid in scar revision (Figure 2). Slight distal tip necrosis was seen at 2 weeks post-index procedure, but was managed adequately with serial in-office debridements and local wound care. 

Following the secondary procedure, epithelialization was seen over the majority of the muscle flap. Complete muscle flap incorporation and donor site closure with 90% epithelialization was noted at 6 months post-index procedure. At 12 months post-index procedure, a small soft tissue defect with granular base remained on the plantar lateral aspect of the calcaneus (Figure 4). This small soft tissue defect closed at 16 months postoperatively. The patient reports significant improvements in pain scores, subjective ambulatory tolerance, ability to return to work at full capacity and improved quality of life. 

Figure 3 Intraoperative picture of skin graft placement.

Figure 4 Twelve-month post-index procedure clinical picture.


The traditional applications for the peroneus brevis muscle flap are well-recognized and utilized. Painful calcaneal cicatrix is a less commonly seen pathology; however, when assessing these patients the peroneus brevis muscle flap should be considered as a viable option to eliminate intractable scar, relieve pain and improve patient function. Our case example demonstrates successful use of the peroneus brevis muscle flap for this novel indication.


  1. Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg. Plast Reconstr Surg. 2001;107(6):1443-8.
  2. Bach AD, Leffler M, Kneser U, Kopp J, Horch RE. The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg. 2007;58(4):397-404.
  3. Lorenzetti F, Agostini T, Pantaloni M, Lazzeri D. The versatility of the distally based peroneus brevis muscle flap. Plast Reconstr Surg. 2011;127(4):1751-2.
  4. Troisi L, Wright T, Khan U, Emam AT, Chapman TWL. The Distally Based Peroneus Brevis Flap: The 5-Step Technique. Ann Plast Surg. 2018;80(3):272-276.

Staged correction of equinovarus in a diabetic patient: A case report

by Amanda Kamery DPM1*, Byron Hutchinson DPM FACFAS2

The Foot and Ankle Online Journal 12 (2): 1

A rigid equinovarus deformity in the diabetic patient is a challenge for many surgeons. The utilization of a single stage, acute correction of the deformity can lead to soft tissue compromise and neurovascular complications. Using gradual correction by means of external fixation, with subsequent internal fixation for arthrodesis, provides a viable option for limb salvage in this difficult patient cohort.

Keywords: Reconstructive surgery, diabetes, external fixation, lower extremity 

ISSN 1941-6806
doi: 10.3827/faoj.2018.1202.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Research Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author- akamery@kent.edu

The diabetic patient with a rigid equinovarus deformity subsequent to soft tissue contracture is a unique and challenging patient [1]. Limb salvage options for this patient population are limited and complex. The utilization of gradual correction with external fixation proves to be an adequate treatment option that has less complications and leads to a stable and functional foot in this at risk group [1]. Single stage acute correction is another viable option, however, this can lead to limb length discrepancy due to significant bone resection or neurovascular compromise [2,3]. Longstanding soft tissue contracture of the medial ankle can lead to a rigid equinovarus deformity, in this setting acute correction is not a viable option due to the risk of neurovascular compromise and the delicate soft tissue envelope [4].

Case Report

A 59 year-old female presented to the clinic with a rigid equinovarus deformity secondary to multiple medial malleolar wound debridement. The patient developed this deformity over several months of wound care, which resulted in soft tissue contracture to the medial ankle. She presented to our service non-ambulatory and unbraceable due to progression of the deformity (Figure 1). She subsequently developed a wound on the lateral malleolus. 

Staged surgical correction was planned due to severe contracture and questionable medial neurovascular and soft tissue compromise. It was felt that a single stage correction would not be ideal in this particular patient. A dynamic circular frame was placed for gradual correction (Figure 2). Five days post initial procedure, the patient was educated on how to perform distraction with a total of 2 degrees of angular correction daily. The patient was non-weight bearing during the correction process. 

After 42 days, approximately 84 degrees of correction was obtained (Figure 3). At this point, a clinical decision was made to proceed with a Tibio-talo-calcaneal (TCC) fusion. 

Figure 1 Pre-operative AP foot radiograph showing severe equinovarus deformity.

Figure 2 Intra-operative clinical picture.  

Figure 3 Clinical picture after 42 days of correction.

It was determined that enough correction had occurred to relax the medial soft tissue envelope. The patient was returned to the operating room for the secondary procedure. This included external fixator removal and TCC arthrodesis with an intramedullary nail.  The patient remained non-weight bearing for 6 weeks until bony consolidation was seen on x-ray (Figure 4). 

The patient was then transitioned to protected weight bearing for 2 weeks in a controlled ankle motion (CAM) boot. The patient eventually successfully transitioned into a Charcot restraint orthotic walker (CROW) (Figure 5). The patient has remained ambulatory in a CROW for 6 months.

Figure 4 Six-week post secondary procedure. 

Figure 5 Clinical picture six weeks post secondary procedure.


The diabetic patient with a severe lower extremity deformity and soft tissue compromise presents a challenging case for foot and ankle surgeons. Staged correction of these deformities utilizing gradual correction by external fixation and subsequent internal fixation with arthrodesis proves to be a viable option to help with limb preservation in these patients. Our case presentation demonstrates the efficacy of staged correction in these challenging patients and that limb salvage and return to ambulation in a CROW can be obtained and maintained. 


  1. Cuttica DJ, Decarbo WT, Philbin TM. Correction of rigid equinovarus deformity using a multiplanar external fixator. Foot Ankle Int. 2011;32(5):S533-9.
  2. Mirzayan R, Early SD, Matthys GA, Thordarson DB. Single-stage talectomy and tibiocalcaneal arthrodesis as a salvage of severe, rigid equinovarus deformity. Foot Ankle Int. 2001;22(3):209-13.
  3. Paley, D., Herzenberg, JE. Ankle and Foot Considerations In: Principles of Deformity Correction. 2002. 571-646.
  4. Bellamy JL, Holland CA, Hsiao M, Hsu JR. Staged correction of an equinovarus deformity due to pyoderma gangrenosum using a Taylor spatial frame and tibiotalar calcaneal fusion with an intramedullary device. Strategies Trauma Limb Reconstr. 2011;6(3):173-6.

Staged treatment of plantar midfoot ulceration with use of a Hemisoleus Muscle Flap, application of external fixation and split-thickness skin graft

by Stephanie Oexeman, DPM1*; Mallory J. Schweitzer, DPM, MHA2; Craig E. Clifford  DPM, MHA, FACFAS, FACFAOM3

The Foot and Ankle Online Journal 11 (4): 2

Muscle flaps are a versatile option for limb salvage that can provide coverage for chronic ankle and foot defects that fail to heal from other conservative and surgical treatments. We discuss the use of a medial hemisoleus muscle flap for treatment of a chronic foot ulcer following dehiscence of an intrinsic pedicled muscle flap. Hemisoleus muscle flaps are utilized for soft tissue defects of the distal third of the lower extremity but are not commonly utilized for coverage of defects on the plantar foot.

Keywords: wound care, muscle flap, lower extremity, hemisoleus muscle flap, medial hemisoleus muscle flap

ISSN 1941-6806
doi: 10.3827/faoj.2018.1104.0002

1 – Resident Physician, PGY-1, Franciscan Foot & Ankle Institute, Federal Way, WA,
2 – Resident Physician, PGY-2, Franciscan Foot & Ankle Institute, Federal Way, WA,
3 – Residency Director, Franciscan Foot & Ankle Institute, Federal Way, WA
* – Corresponding author: s.oexeman@gmail.com

We discuss the use of a medial hemisoleus (MHS) flap for treatment of a chronic foot ulcer following dehiscence of an intrinsic pedicled muscle flap. This case study presents our treatment of a chronic wound that failed to heal despite local wound care and several attempts at primary closure. We present our surgical technique for mobilizing the MHS flap and recommend concomitant use of external fixation to decrease motion of the flap on the wound bed, allowing for neovascularization and full incorporation.

Case Study

A case is presented of a fifty-seven-year-old male who underwent a plantar fasciotomy with a subsequent postoperative soft tissue infection. This resulted in a chronic, painful wound to the plantar medial left foot after the infection resolved. Non-invasive vascular studies and clinical vascular examination were normal. He failed conservative therapy including local wound care and offloading and elected to undergo primary closure eight months after the plantar fasciotomy. A fissure developed along the incision six weeks postoperatively and persisted for nine months despite continued wound care. A second attempt at primary closure was made and approximately three weeks later the incision partially dehisced. Progressive healing was achieved for three months, but the patient fell at this time which resulted in the wound reopening. An MRI was obtained and ruled out osteomyelitis or presence of a foreign body. The patient then elected to undergo scar excision with the placement of an abductor hallucis muscle flap. The patient had an uneventful postoperative course and was transitioned to heel weight bearing at twelve weeks postoperatively. At four months postoperatively, the incision partially dehisced and became a chronic ulcer (Figure 1).

Figure 1 Preoperative (A) Chronic ulceration to plantar medial left foot (B) Ellipsoid excision of the ulcer.

At this time, the patient was given the option of a  below-knee amputation and he declined. After five months of additional conservative therapy with no improvement  in appearance of the wound, another attempt at closure was made by performing a medial hemisoleus flap. The decision was made to utilize an  external fixator to minimize motion of the flap within the wound bed. Three weeks later a split-thickness skin graft (STSG) was applied and the external fixator was removed at this time. The incisions healed and the graft and flap had completely incorporated at ten weeks postoperatively (Figure 4). The patient is ambulatory in accommodative shoe gear and has not had a recurrence of the soft tissue defect after twenty-three months of follow-up.

Surgical Technique

The patient was brought to the operating room and placed on the operating room table in the supine position. A tourniquet was not utilized during the procedure. An elliptical incision was made to encompass the wound (Figure 1). Due to previous surgeries, a significant amount of scar tissue was encountered that extended to the level of the plantar musculature. Attention was directed to the tarsal tunnel and dissection was carried through the flexor retinaculum. The wound was irrigated with copious amounts of normal saline and all nonviable soft tissue was excised; leaving a large soft tissue defect (Figure 2).

Figure 2 Intraoperative (A) Excision of Chronic Wound (B) Incision and dissection of medial soleus (C) Closure with application of External Fixation for ankle motion and flap protection.

The decision was made to transpose a medial hemisoleus muscle flap for coverage of the defect. Continuing the incision from the tarsal tunnel, a longitudinal incision was made over the medial aspect of the calf. The incision was carried down to the crural fascia. The fascia was incised longitudinally allowing exposure to the gastroc-soleus muscle complex. The soleus muscle belly was identified and the medial portion of the muscle was transected proximally and freed from lateral muscle belly along the central raphe down to the level of the tarsal tunnel.  An intraoperative doppler was utilized during this dissection to identify perforators of the muscle. With sharp dissection, the epimysium was excised. The muscle was transposed through the tarsal tunnel and placed within the plantar soft tissue defect. 3-0 nylon was used to secure the flap in the proper position, with no tension on the flap. The medial incision was closed in layers and the skin was closed with staples. Vessel loops in a zig-zag pattern were used to reduce tension to the edges of the incision.

Figure 3 Intraoperative (A) status post 3 weeks from muscle flap (B) Fenestrated STSG applied to debrided muscle flap.

An external fixator consisting of a tibial block with two full rings and a distal block with a full ring was used to encompass the forefoot. Opposing olive wires were inserted using standard techniques.

Three weeks following the frame application, the patient was brought back to the operating room for debridement of the muscle flap and application of a split-thickness skin graft (STSG). The external fixator was removed and extremity was prepped and draped in a sterile manner. The muscle flap was debrided of eschar tissue, leaving a mixture of bleeding granular and muscular tissue (Figure 3). The muscle flap measured 3cm x 9cm. The site was covered with an intermediate STSG harvested from the proximal left thigh with use of a dermatome. The skin graft was meshed and sutured in place using 3-0 Monocryl. The skin graft was covered with a sterile dressing and a wound VAC was applied. The STSG was fully incorporated after 10 weeks of local wound care (Figure 4).


MHS flap reliability has been questioned due to variability in vascularity, but successful coverage of distal lower extremity defects have been reported. Our use of a MHS flap for plantar foot defects is a novel application.

The performing surgeon should have an in-depth knowledge not only of the muscular but also of the vascular anatomy. There are many classifications within the literature discussing mapping the vasculature of the lower leg.

Figure 4 Clinical images (A) healing STSG five weeks postoperatively and (B)  fully incorporated split thickness skin 10 weeks graft.

Angiosomes should always be acknowledged throughout the surgical planning and intervention. Angiosomes are a unit consisting of the skin, subcutaneous tissue, fascia, muscle, and bone being supplied by a source artery. The human body has forty angiosomes, with six being located in the foot and four located within the lower leg [1,2]. Mathes and Nahai’s classification divides muscle flaps accordingly to their blood supply. The soleal muscle flap is a type II flap, meaning it has one major pedicle and several minor pedicles [2,3]. Its dominant  pedicle is the posterior tibial artery and the perforating branches of this artery are the secondary pedicles [2,4-7].  The vascular supply of the medial soleus muscle body is mainly from the posterior tibial artery (PTA) via multiple minor pedicles [4,5,8]. The medial soleus has perforators from the PTA extending the length of the muscle [9,10].  

Ward, et al. state that perforators can be found on the posterior border of the tibia roughly 5 cm, 10 cm, and 15 cm proximal to the ankle joint [11].  Similarly, Raveendran, et al. report the distal perforating arteries of the PTA averaged 6.5 cm, 11.6 cm, and 16.8 cm from the medial malleolus [12].

When planning for coverage, the entire soleal muscle can cover defects approximately 26 cm2 [2]. However, the MHS has an extended arc of rotation compared to a full soleal flap which allows a greater percentage of coverage [6,7,13,14]. The medial soleus belly averages 25.4 cm in length, 6.9 cm in width, and has a mean surface area of 87.5 cm2 [15]. Techniques, such as excising the epimysium, can also increase the flap’s range by 20% [4].

Prior to incision, perforators should be marked appropriately along the posterior border of the tibia [9,11]. For the surgical approach, we prefer a medial incision overlying the posterior compartment. Preserving the saphenous neurovascular bundles can be achieved and blunt dissection can be utilized to separate the gastrocnemius from the soleus [2,11]. It is highly encouraged to use intraoperative doppler examination throughout the surgery to confirm the major pedicle is viable and only minor perforators are being ligated [2]. The medial body of the soleus should be dissected from the lateral portion at the “C-point”, or the perforator located approximately 15 cm from the ankle joint [11].  Bourdais-Sallot et al. reported the pivot point for MHS is 14.5 cm from the top of the medial malleolus or 32.5% of the tibial length [15].  The lateral soleal muscle body is left intact to help maintain plantar-flexion at the ankle [9,2].


To our knowledge, the use of a MHS flap for coverage of a plantar foot soft tissue defect has not been previously described. MHS flaps have been used to cover defects in the proximal and distal lower extremity [7,10]. Techniques can be used to extend the range of coverage of the medial soleus in order to reach the plantar foot.  With careful and proper planning, the MHS flap is an option for coverage of soft tissue defects of the plantar foot.

The goal of our staged procedure was to heal the chronic ulceration and provide a functional lower extremity for ambulation. Within ten weeks of MHS flap with external fixator and STSG, the patient was able to ambulate with a well adhered and fully incorporated graft. No dehiscence has occurred in twenty-three months.


  1. Brodmann, Marianne. “The Angiosome Concept in Clinical Practice.” Endovascular Today, May 2013.
  2. Dockery, G. and Crawford, ME. Lower Extremity Soft Tissue & Cutaneous Plastic Surgery. Saunders Elsevier, 2012, pp. 269–288.
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Use of an external vibratory device as a pain management adjunct for injections to the foot and ankle

by Joseph D. Rundell, BS1, Joshua A. Sebag, BA1, Carl A. Kihm, DPM, FACFAS2, Robert W. Herpen DPM3, Tracey C. Vlahovic DPM3*pdflrg

The Foot and Ankle Online Journal 9 (4): 6

Objectives:  Pain modulation through the combined effect of vibratory stimulation of Aβ mechanoreceptors and cold thermal stimuli has been demonstrated to reduce the pain associated with injections and IV cannulation.  Although past reports have focused on its use on the upper extremity, there are no current studies to evaluate the efficacy of these combined modalities for lower extremity injections.    The authors propose the combined use of vibratory stimulation with cold thermal stimulation will yield lower reported pain values associated with injection compared to cold thermal stimulation alone.  
Methods:  In this multicenter, randomized, prospective clinical trial, 108 patients necessitated a lower extremity injection for the treatment of their presenting condition and was randomized into a treatment (vibration and cold spray) or control (cold spray only) groups.  The primary outcome was pain, subjectively measured on a 10-point numerical pain rating scale (NPRS) by the patient.  Pain was also ranked by an observing physician via the Wong-Baker Pain Faces Ranking Scale (WBPFRS).
Results:  Forty treatment subjects and 68 control subjects were included in this study.  Pain scores were significantly lower in the treatment group receiving the vibratory device and the cold spray compared to the cold spray alone (NPRS mean values:  Treatment: 3.39, Control: 4.46; p=0.022.  WBPFRS mean values: Treatment: 2.29, Control: 4.05; p=0.030).  
Discussion:  Utilizing a combination of cold spray with vibratory stimulation produced a statistically significant decrease in pain associated with lower extremity injections.  Due to the relatively small size of our study, further investigation is needed to assess effect on specific injection site.  

Keywords:  injection, vibratory stimulation, foot and ankle, lower extremity, buzzy

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0006

1 – Fourth year student, Temple University School of Podiatric Medicine, 148 N 8th Street, Philadelphia, PA 19107
2 – Private practice, University Foot & Ankle, 3 Audubon Plaza Dr Ste 510, Louisville, KY 40217
3 – Faculty, Temple University School of Podiatric Medicine, Philadelphia, PA, 19107
* – Corresponding author: traceyv@temple.edu

Injection therapy has been a mainstay intervention for addressing musculoskeletal pain for over 50 years [1]. Foot and ankle physicians commonly perform office procedures which are made tolerable by first injecting local anesthetics. Unfortunately, injections to the foot and ankle often elicit exquisite pain due to a greater density of sensory nerve endings in that area of the body [2] and the depth of some of the injections. The pain and anxiety from needle injections can have deeper consequences such as impaired patient compliance[3], deferral due to needle phobia [4] or lack of follow-up due to fear of future injections [5]. There can be value in utilizing interventions to reduce the pain associated with injections. Therapeutic outcomes could possibly improve by increasing patient compliance and reducing fear avoidance if injections are perceived as less painful. Increased patient satisfaction and the overall patient experience could be maximized.

Although there are distinct benefits from decreasing the pain associated with needle injections, there remains a dogma that injection pain reduction modalities are deficient [6].  There are options available that deserve consideration utilizing various mechanisms.  Pharmacological intervention via topical or injectable anesthetics, are commonly used.  While this intervention has been shown to alleviate pain associated with injections [3,7,8], it is not without drawbacks.  The use of topical anesthetics can cost $20 or more [9].  Additionally, these can prolong time in the office and procedure times, since it takes time for the induction of effective analgesia [7]. The drug cost can present concerns regarding the stewardship of already strained healthcare resources.  In addition to pharmacological interventions, there exist other modalities which utilize the gate theory of pain control.  Cold therapy [10] and activation of Aβ sensory fibers through vibratory stimulation [11] of mechanoreceptors are believed to cause presynaptic inhibition of the dorsal horn.  This therefore “closes the gate” and reduces the transmission of nociceptor signals.  Cold therapy has demonstrated efficacy in reducing injection pain in both adult [12] and pediatric [7, 13] groups.  Cold therapy sprays are commonly used in an office setting for immediate but temporary analgesia for the time of injection.  In addition, vibratory stimulation to manage pain from injections has yielded positive results in adult [9,14] and pediatric [15-17] populations.  

Reusable devices that produce a combination of cold and vibratory stimulation to manage injection pain have been developed; one such device is called “Buzzy®” (MMJ Labs Atlanta, GA).  There have been a number of studies which have demonstrated its efficacy in reducing injection pain, but these studies have focused particularly on pediatric IV access [9,16,18,19].  This device has the advantage of being reusable, easy to use and does not require much additional time.  The clinician uses a built-in Velcro strap to apply the device proximal to the injection site.  While there is evidence this device can reduce injection pain related to venipuncture access, no studies have investigated the efficacy of this device for pain management of injections to the foot and ankle.  It was the goal of this study to determine whether pain associated with injections to the foot and ankle is decreased when using the Buzzy® (or vibratory) device.   

Materials and Methods

Our study was a multicenter, prospective clinical trial using 108 patients needing an injection to the foot or ankle.  The study was explained to every patient and consent to participate was obtained.  This study was performed at the Temple University School of Podiatric Medicine’s Foot and Ankle Institute (FAI) clinic (n=42) and in a separate private practice podiatry clinic (n=66).  Participants were excluded if they had: skin compromise over the vibratory device application site, history of peripheral neuropathy, fibromyalgia, complex regional pain syndrome, cognitive or verbal impairment, patients who were blind or not fluent in English, and those impaired via narcotics/analgesics within 4 hours prior to the office visit.

Data Collection and Outcomes

The primary outcome variable was pain, which was measured utilizing an 11-point Numerical Pain Rating Scale (NPRS).  The patient reported their pain on a scale of 0-10 where 0 is no pain and 10 is the worst pain imaginable.  As a secondary variable outcome, pain was assessed via the Wong-Baker Pain Faces Rating Scale (WBPFRS).  It should be noted WBPFRS was only collected on the FAI patients by an observing physician.   The patients were not made aware of the WBPFRS measurement to minimize chances of altering their facial expressions in front of the physicians.   


After informed consent was obtained, patients were randomly assigned into the treatment or control group.  The treatment population was treated with external vibratory stimulation delivered through the vibratory device and cold spray prior to injection.  The control population was treated solely with cold spray prior to injection.  Determination of randomization was performed immediately before injection.  At the FAI, randomization was performed via drawing an opaque envelope whereby the instructions inside would assign the group.  At the private practice clinic, randomization was achieved by randomly assigning subject numbers with control or treatment groups.  As patients presented for an injection, the patients were assigned the next consecutive subject number.


Demographic information consisting of age, gender, and whether they have had an injection to the foot or ankle previously was recorded on the questionnaire.  The attending physician instructed the patient on using the NPRS.  In order to maintain consistency of the pain data, the patient was instructed to rank the pain associated with the initial needle stick, but to not watch the injection being performed.  The injection site was first prepped with alcohol or betadine.  If the patient was assigned to the treatment group, then the vibratory device unit was applied 5-10cm proximal to the injection site over the anatomical location of the appropriate sensory nerve(s).  The vibratory device was turned on for approximately 1 minute prior to and maintained during the injection.  

In both groups, Gebauer’s Ethyl Chloride® (Cleveland, OH) was applied to the injection site, and then a 25 gauge needle was inserted.  The injection was performed under the supervision of an attending physician (TV or RH).  At the private practice clinic, all injections were performed by 1 attending physician (CK).  During the injection, the attending physician at the FAI assessed pain utilizing the WBPFRS.  In the private practice setting, the attending was visually focused on the injection and not the face; therefore WBPFRS was not recorded.  After the injection, the patient was asked to rank their pain on the NPRS, and if the injection was better or worse than anticipated.  It should be noted, the vibratory device does come with reusable ice-packs to provide the cryothermal stimulation; however, cold spray was utilized in its place in order to minimize deviation from the clinic’s standard of care.  

Statistical Evaluation

The outcome variable was pain.  This was ranked primarily via the NPRS between the treatment and control groups.  Pain ranked by WBPFRS was utilized as a secondary outcome variable.  The unpaired t-test was used to evaluate the statistical significance of the NPRS and WBPFRS values between the treatment and intervention groups.  The criteria for significance between the values was a p value <0.05.   Statistical calculation was performed utilizing GraphPad® statistical software.


One hundred and eight consenting patients were recruited to participate in this study.  Based on our parameters, no patients required exclusion from the study.  The treatment group (n=40) was composed of 18 (45.0%) males and 22 (55.0%) females with a mean age of 39.2 ± 20.9 years (range 12-79 years).  The control group (n=68) was composed of 32 (47.0%) males and 36 (53.0%) females with a mean age of 43.5 ± 23.2 years (11-92 years).  There was no statistically significant difference in age or gender between the groups (Table 1).   The material injected was as follows:  for the intervention group 14 received a steroid cocktail (acetate and phosphate-based steroid, diluted in local anesthetic) and 54 were injected with only local anesthetic (1% lidocaine or 0.5% marcaine plain).   


Table 1 Demographic and Injection Data.


Table 2 Pain Measurements using both scales.


Table 3 Pain Rating Mean Values.

For the treatment group, the mean NPRS value was 3.39 ± 2.67 (0-10) and the mean WBPFRS was 2.29 ±1.59 (0-6).  Seventeen patients reported the injection was “better” than expected while 6 reported it was “same” and 1 “worse” than expected.

With regards to the control group, the mean NPRS value was 4.64 ± 2.72 (0-10) and the mean WBPRFS was 4.05 ± 3.13 (0-10) (Table 2).  Twenty six reported the injection was “better” than expected while 8 reported it was “same or worse” than expected.  

In terms of anatomical location of the injection, an injection into an intermetatarsal space the addition of vibratory stimulation to cold spray provided the largest percent difference in NPRS scores, whereas hallux block showed the least reduction in pain (Table 3).


It is recognized that control of pain contributes to improved clinical outcomes and patient satisfaction.  This right unfortunately comes with added costs monetarily (i.e. cost of of topical lidocaine) and in time (delay for topical anesthesia induction)[20, 21].  These can provide added cost and personnel burdens to an already resource-strained healthcare system.  These barriers, combined with attitudes that injections will cause pain, hamper the use of interventions to reduce injection pain.  It has been reported that only 6% of pediatricians utilize available interventions to reduce the pain associated with injection therapy [21].

In our study, we investigated the use of eliciting the pain gating theory to activate descending noxious stimuli inhibition to manage pain associated with injections to the foot and ankle.  The pain gating phenomenon was first described in 1965 where Aδ pain fibers shared a final common pathway with thermal and Aβ, and stimulation of thermal and Aβ would effectively “close the gate” to noxious stimuli from Aδ nociceptors [10].  By combining the use of vibratory stimulation and cold spray it may be possible to maximize pain reduction.  The hope of our study is to demonstrate if this is possible in our clinics (Table 3).

Through the combined use of the vibratory device with cold spray, we demonstrated an appreciable decrease in pain associated with injections to the foot and ankle.  Our primary outcome was pain reported by the patient utilizing the NPRS.  We report a mean drop in NPRS scores from 4.64 to 3.39; this represents a 31.3% decrease in pain associated with injections between the treatment and control group.  Our secondary outcome was an observer physician-recorded pain utilizing the WBPFRS; mean scores dropped from 4.0 to 2.29 representing a 54.4% decrease in mean pain recorded through this scale.  Both of these outcomes were statistically significant with p values of 0.022 and 0.03 respectively.

While a statistically significant decrease in pain through this or any intervention might seem like a definitive success, it is still imperative to consider whether this significance translates into a clinically relevant context versus a purely numerical context.  There exists a number of studies that address this matter.  Todd et al [22] determined a decrease of 13mm on the 100mm VAS yielded a clinically relevant decrease in pain.  There are other arguments that relative decrease in pain is more clinically relevant than the decrease in the absolute value of the pain.   Campbell et al [23] within the setting of a dental surgery practice, determined a decrease in VAS score by “between 31% and 48%, depending on its initial intensity” is requisite to be considered clinically relevant.  In a study by Farrar et al [24] 10 clinical control trials for chronic pain interventions were reviewed, and it was concluded a 30% decrease in pain scores indicated a significant decrease; furthermore, this 30% decrease was determined to correspond to a 2-point decrease on the NPRS.  Comparing our data to that of the studies mentioned here, utilizing the vibratory stimulation in addition to cold spray did produce a clinically significant reduction in pain.   

Comparing patients’ expectations (better or worse than expected) between treatment and control groups was performed by Fisher’s Exact Test which yielded a p value of 0.76, thus no statistical significant outcome can be drawn from this.  In terms of patient’s tolerance of the vibratory stimulation, it was tolerated well as only one commented that, “It felt annoying.”  With regards to ease of use, no one in either clinic reported any difficulty in using the vibratory device.    

This study is not without limitations.   The first of which is pain scores were only from one patient encounter.  Pain is well noted to be an extremely subjective sensation in terms of perception and tolerance with wide variation between people. Additionally, it is well known that pain has multidimensional contributing factors, such as anxiety or recent pain sensations [25].   As such, measuring the pain of a heel injection between various people can elicit widely different values, even if no intervention is used.  Another limitation of this study was for the injections performed at the FAI.  There may be differences in injection technique, ability, and apparent confidence between attending physicians.  Finally, this study included injections to any anatomical location to the foot and ankle.  It is likely an injection to certain parts of the foot or ankle will naturally just elicit more pain than other areas would.  This is expected due to the possible sources of sensory nerve distribution and the vibratory device’s ability to effectively target more than one sensory nerve simultaneously.  In the future, the device may be better contoured for the ankle so as to prevent slippage and simultaneously affect numerous nerves. Injection techniques were not standardized as well.  For instance, one of the clinicians prefers a medial glabrous skin junction approach for painful heel injections while the other prefers a plantar approach.  Also, there may be inherent differences based on the composition of local anesthetic and injectable corticosteroid, which varied greatly in makeup proportion and delivered amount.  Temperature of injectable, pH of injectable, needle gauge and quantity injected are possible covariables which were not studied.

The investigators did find that it was harder to apply the vibratory device to some parts of the foot versus others due to anatomical contouring of the unit. This may have affected the ability of the device to work optimally and target the desired areas.  As seen in Table 3, there is marked variation between pain scores and location of the injection.  Lastly, although it was attempted to not influence a known effect of the vibratory unit, it is possible that natural bias was placed on the patient to downplay perceived pain.  This could have been avoided with a double-blind study protocol.

The authors believe further studies are needed to better understand and quantify potential benefit of such devices.  Future modifications of such units may optimize use and benefit also.  This pilot study suggests that the combination of vibratory stimulation and cold sensation does reduce the pain associated with injections to the foot and ankle.  Further control of cofactors is necessary to conclude how effective and specifically which injections (injectable and location) and patient demographics are most affected.  


The combination of external vibratory stimulation in addition to cold spray produced an appreciable reduction in the pain in comparison to cold spray alone for our patients undergoing foot and ankle injections.  Further investigation is warranted for injections of the lower extremity.   


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Bad ink: A case of a chronic ulceration of the lower extremity secondary to tattooing

by Larissa Rolim DPM, MS1; Christopher Blanco DPM, FACFAS1; Sara Lewis DPM1pdflrg

The Foot and Ankle Online Journal 9 (1): 7

Introduction:  Tattoos are a vastly popular form of body modification. However, there are no government regulations in regards to tattoo ink compositions. In this paper we report a case of chronic ulceration secondary to tattoo.
Case presentation: A 42-year-old female presented with a history of a non healing ulcer on her leg over a recent tattoo. Surgical excision of ulcerated area as well as negative pressure vacuum therapy and weekly wound care visits were performed and patient was fully healed by her 16 week follow up.
Conclusion:  The composition of commonly used Tattoo ink can cause ulcerative lesions.

Key words: tattoo, ulceration, wounds, lower extremity

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0007

1 – South Miami Hospital, South Miami, FL
* Correspondence: Larissa_rolim@hotmail.com

Since the word tattoo was introduced to the Western Hemisphere by explorer James Cook, it has gained widespread popularity through all social classes including the likes of Winston Churchill himself. However, increases in popularity also come with increases in documented complications such as allergic, granulomatous and lichenoid reactions [1]. We present a rare case of a non-healing ulceration and allergic reaction caused by a tattoo.

Case Report

A 42 year-old female presented to our wound care center with complaints of a six-month history of a non-healing ulceration to her lateral left ankle. The patient stated that one-year prior she received a tattoo to her left ankle while vacationing in Cuba. The tattoo initially healed with no issues. At 6 months after the initial tattoo application the patient noticed a raised area where red ink had been placed, which eventually ulcerated.

The patient attempted to treat the area with topical over-the-counter cortisone creams and triple antibiotic ointment, with no improvement. The patient complained of mild discomfort and pruritus to the area but there was no noteworthy pain.  The patient had no significant past medical history and no known drug allergies. The patient was not currently taking any medications at home.

Physical examination revealed full thickness ulceration to the lateral aspect of the ankle. The ulceration measured 0.6cm x 0.6cm x 0.3 cm. The wound base was a mixture of fifty percent granular and fifty percent fibrotic tissue. The periwound area had a raised verrucous appearance in a 2cm diameter with xerosis and erythema. There was no noted drainage or purulence (Figure 1).  Patient had strong pedal pulses bilaterally. Varicose veins were noted as well as corona phlebectatica. A punch biopsy was performed at the initial visit. The pathology report revealed acanthotic and parakeratotic epidermis with surface suppurative inflammation and superficial dermal mixed acute and chronic inflammation, hypocellular and partially necrotic dermal collagen and pigment in the dermis.


Figure 1 Initial wound presentation.

The patient underwent wide excision of the ulceration with 2mm margins surrounding. The tissue was sent for pathology and cultures. The area was debrided of any non-viable tissue and a bovine collagen graft (Integra) was applied and secured with staples. Negative pressure therapy (KCI wound VAC) was initiated at that time

Post excision pathology report showed skin ulceration with acute and chronic inflammation, focal abscess formation and collections of histiocytes. There were no organisms found on AFB or PAS stains. Surgical cultures revealed heavy growth of Methicillin-Resistant Staphylococcus Aureus. An infectious disease consultation was obtained and the patient was treated with IV vancomycin while inpatient and oral trimethoprim/Sulfa at discharge for ten days [2].

We continued use of negative pressure wound VAC therapy (KCI wound VAC) and weekly sharp debridement. Wound VAC therapy was discontinued at 7 weeks. Weekly debridement of any fibrotic tissue and the use of multi-layer compressive dressings were continued. The patient was completely healed at their 16-week follow up and was discharged from our care at that time (Figure 2).


Figure 2 Final appearance of healed wound.


The growing popularity of tattoos has lead to an increase in the rate of complications associated with tattoo application. A review of the literature depicts complications of tattooing as early as 1952 where Lubek et al documented four separate pathologic consequences of tattooing, namely Boeck’s sarcoid, secondary syphilis, discoid lupus and a mercury sensitivity reaction.  Currently, the FDA has no approved tattoo inks and do not regulate their composition [3]. In April of 2014 the FDA launched a “think before you ink” campaign warning consumers of substantial risks including infection, allergies, scarring, granulomas and MRI complications [4]. Tattoo inks include different pigments ranging from inorganic metallic salts, organic molecules and organic dyes. Kluger et al reported known allergenic metals, nickel, cobalt, chromium and mercury, found in tattoo inks. While there are documented complications from all tattoo pigments, hypersensitivity reactions to red pigments are the most common [3,5]. Particularly reactions to red pigments containing cinnabar, which is composed of mercuric sulfide. Reactions to red pigment have been associated with allergic contact dermatitis, lichenoid dermatitis, pseudolymphomatous and sarcoid reactions [5].

Hypersensitivity reactions and complications are not isolated to the lower extremity. There have been a number of documented cases of adverse reactions to tattoos involving all areas of the body [4]. Tattooing has the potential to spread infectious diseases, namely hepatitis, chanchroid, MRSA and atypical mycobacterial diseases, among others and lowers the ability to fight infections in the tattooed area [2,6]. The process of tattooing in itself induces a chronic inflammatory response that can be seen years later [6]. Currently there are no set standards in the treatment of tattoo related reactions. Tattoo related reactions have variable presentation and the treatment and management of these dermatologic inflammatory reactions are based on the presenting pathology with the use of biopsy and cultures [7,8]. Tattoo related ulceration appears to be uncommon with only a few cases documented in the literature [4,7,8]. Our case presents the rare occurrence of tattoo-associated ulceration while also highlighting a novel method of management that ultimately led to wound healing.

Moving forward it is critical to stress the importance of patient awareness of the risks associated with tattooing. Though these risks may appear minimal, they can be disfiguring and lead to the introduction of deadly infectious agents. Tattooing has been around for centuries and its popularity is unlikely to decrease, so timely recognition of adverse reactions to tattooing such as allergic reaction, granulomatous and ulcerating reactions should be reported and managed promptly to ensure optimal patient outcomes.


  1. Pesapane F, Nazzaro G, Gianotti R, Coggi A. A short history of tattoo. JAMA Dermatol. 2014;150(2):145. (Link)
  2. Lubeck G, Epstein E. Complications of tattooing. Calif Med. 1952;76(2):83-5. (Link)
  3. Kluger N, Koljonen V. Tattoos, inks, and cancer. Lancet Oncol. 2012;13(4):e161-8. (PubMed)
  4. Wollina U. Severe adverse events related to tattooing: an retrospective analysis of 11 years. Indian J Dermatol. 2012;57(6):439-43. (PubMed)
  5. Cruz FA, Lage D, Frigério RM, Zaniboni MC, Arruda LH. Reactions to the different pigments in tattoos: a report of two cases. An Bras Dermatol. 2010;85(5):708-11. (Link)
  6. Bittencourt Mde J, Miranda MF, Parijós AM, Mesquita LB, Fonseca DM, Jambo DA. Dermatofibroma in a black tattoo: report of a case. An Bras Dermatol. 2013;88(4):614-6. (PubMed)
  7. Tammaro A, Cortesi G, Narcisi A, et al. An interesting case of oedema and ulceration in red areas of tattoo. Int Wound J. 2014 (Link)
  8. Vasilakis V, Knight B, Lidder S, Frankton S. Severe type IV hypersensitivity to ‘black henna’ tattoo. BMJ Case Rep. 2010. (PubMed)


Compartment syndrome in a patient on warfarin with a ruptured Baker’s cyst

by Megan Wilder, DPM1; Kenneth Hegewald, DPM2; Thomas Landino, DPM3pdflrg

The Foot and Ankle Online Journal 7 (1): 4

Compartment syndrome of the lower leg is typically viewed as a surgical emergency. Elevated pressure within a closed myofascial space impairs perfusion pressure below a level necessary for muscle viability. It is caused by bleeding or edema in a closed, non-elastic muscle compartment surrounded by fascia and bone. We report the case of a 66-year-old patient on warfarin with acute compartment syndrome caused by hemorrhaging from a ruptured Baker’s cyst. The patient responded well to an emergent fasciotomy. The present case highlights the need for an awareness of acute compartment syndrome in patients on warfarin therapy and clinical symptoms consistent with compartment syndrome.

Key words: Baker’s cyst, compartment syndrome, lower extremity, warfarin

ISSN 1941-6806
doi: 10.3827/faoj.2014.0701.0004

Address correspondence to:Megan Wilder, DPM; Franciscan Foot and Ankle Institute, Federal Way, WA, Email: MeganWilder@fhshealth.org

1 Podiatric Medicine and Surgery Resident (Postgraduate Year I), Franciscan Foot and Ankle Institute, Federal Way, WA
2 Podiatric Medicine and Surgery Resident (Postgraduate Year 2), Franciscan Foot and Ankle Institute, Federal Way, WA
3 Attending Staff, Department of Orthopedics and Sports Medicine, Virginia Mason Medical Center, Federal Way, WA

Compartment syndrome of the lower leg is a surgical emergency in which elevated pressure within a closed myofascial space reduces circulation below a level necessary for muscle viability. It is caused by bleeding or edema in a closed, non-elastic muscle compartment surrounded by fascia and bone [1]. The long-term consequences were described by Volkmann in the 19th century following the application of casts [2]. Acute compartment syndrome is typically associated with fractures, closed soft tissue injuries, revascularization procedures, and crush injuries [3]. Anticoagulation has been suggested as risk factor in the development of acute compartment syndromes [4-6].

Extravasation of a ruptured Baker’s cyst and its damage on surrounding tissue has been linked to development of compartment syndrome [7,8]. However, we did not discover any cases where a Baker’s cyst with concomitant anticoagulation leading to compartment syndrome have been discussed.

Patient and Methods

A 66 year-old female presented to the Emergency department with two days of left lower extremity edema and pain that began suddenly and had continued to progress. Past medical history included: psoriatic arthritis, Baker’s cyst left lower extremity, left venous stripping, hypertension, GERD, and pulmonary embolism. The patient had a hardware removal from the right foot two weeks prior, but denied any other trauma or injury.

Examination revealed non-erythematous left calf measuring 40 cm in diameter (right calf measuring 33cm) with pain rated severe. Overlying skin was tense and unyielding compared to the contralateral limb. Sensation and pulses were normal. The patient had pain out of proportion with passive dorsiflexion and plantar flexion of the left ankle. Radiographs of the left lower extremity were negative for fracture revealing only arthritic changes.


Figure 1 MRI T2 Sagittal. The mass is centered in the proximal half of the left calf an extends 20.1 cm in length x7.7 cm transverse x4.4 cm AP and compresses the medial head of the gastrocnemius muscle with myositis evident in the proximal fibers of the muscle. Edematous changes are present over the posterior fascial plane at the interface of the fascial plane and subcutaneous fat.

Venous and arterial ultrasounds were performed and returned negative for deep venous thrombosis. Further ultrasound exam findings revealed an area of approximately 10 cm at the posterior left knee which was read as possible hematoma versus Baker cyst (Figures 1 and 2). With high clinical suspicion of compartment syndrome a wick catheter was used to measure intracompartmental pressures. The patient’s blood pressure was 139/70 mmHg Initial compartment pressures were read at: Anterior-12mmHg, Lateral-10mmHg, Deep Posterior-45 mmHg, Superficial Posterior-12mmHg. The deep posterior and superficial posterior compartment pressures were repeated and with consistent readings at 30mmHg and 12mmHg respectively.


Figure 2 MRI T2 Axial. The heterogeneity signal and characteristics of the mass as well fluid level are suspicious for an active hematoma adjacent to semimembranosus/popliteal cysts within the gastrocnemius bursa.

Given the unique presentation, a STAT MRI of the left lower extremity was completed. MRI findings revealed a complex large mass to the posteromedial proximal half of the calf with accompanying gastrocnemius muscle edema, suggestive of a complex hematoma with active bleeding (Figure 2). The characteristic enhancement suggested the possibility of a chronic popliteal cyst with intracystic hemorrhage. The mass appeared to be superficial to the muscle and compressed the muscle component. Also of note, the patient was on warfarin for a pulmonary embolism that had occurred 6 months previously. Patient’s laboratory values were: Prothrombin time 26.3, INR 2.4, partial thromboplastin time 41. The patient was taken to the operating room for emergent open fasciotomy of the compartments of the left lower extremity.


Figure 3 Intraoperative hemorrhaging and herniation of muscle belly upon release of the fascial compartments.

Through a standard anterolateral extensile approach all four-muscle compartments of the lower extremity were decompressed and hematoma was evacuated (Figure 3). The incision site was approximated using staples (Figure 4). Patient was placed in a modified Jones compression posterior splint. 1500 mL of blood loss occurred during the operation, requiring type and cross match blood transfusion of two units of packed red blood cells.


Figure 4 Incision re-approximated utilizing staples.


Post-operatively the patient was transferred to the ICU where pain was improved immediately post-operatively. After a 6-day hospital stay the patient was deemed medically stable and released for outpatient treatment. The patient was taken off of warfarin and an IVC filter was placed. The patient had wound dehiscence of the distal aspect of the incision requiring local wound care of a 4-month duration.


Few cases relating an acute onset of compartment syndrome to a Baker’s cyst or as a spontaneous occurrence with anticoagulation have been described [4-8]. Petros et al, reported the incidence of a ruptured Baker’s cyst misdiagnosed as a deep venous thrombosis, which was then treated with anticoagulation creating hemorrhaging and hematoma into the lower extremity compartment [7].

The risk of developing a compartment syndrome after a ruptured Baker’s cyst especially when associated with coagulopathy should be considered. An acute compartment syndrome is a medical emergency. Irreversible changes are known to occur after 8-12 hours of increased compartment pressure. Immediate evaluation should include compartment pressure measurements, and if elevated, surgical decompression. A fasciotomy should be performed when the difference between compartment pressure and diastolic blood pressure is less than 30 mmHg or when clinical symptoms are obvious [9].

In summary, we present a patient with a ruptured Baker’s cyst on long-term anticoagulation therapy with an INR in the therapeutic range complicated by the development of a posterior compartment syndrome.

Acknowledgements: Craig Clifford, DPM; Research Chair, Franciscan Foot and Ankle Institute.


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