A 93-year-old woman with a rigid rearfoot and severe pes planovalgus presented to our office with a small Grade 1 ulceration on her plantar medial hallux that extended through subcutaneous tissue. There were no signs of infection and drainage. The patient had poorly palpable pulses and the vascular team determined that she was not a good candidate for revascularization. I discussed at length the challenges of this case with the patient and her daughter. We made the decision to proceed with a dermal graft in the surrounding subcutaneous layer of tissue.
The goals of this procedure were twofold. First, I wanted to facilitate shock absorption by offloading the base of support so the graft could take the brunt of the load and relieve peak pressure forces on the plantar medial hallux. By decreasing these forces, the skin will have an opportunity to heal. Essentially, the injected dermal graft filler provides an internal pad instead of an external offloading pad. The second benefit is stimulation of collagen growth to the surrounding tissues in an effort to establish thickened tissue and increase the overall subcutaneous thickness in the region.
With mild peripheral arterial disease, there is a concern for an increase in the size of the ulceration and infection. Graft filler injection into the wound deficit can be a non-invasive attempt to allow healing. One performs the injection with 0.8 cc of a dermal graft into the plantar medial hallux through a medial approach with a 23-gauge, one-inch needle. In this case, the patient tolerated the procedure well with just a local ethyl chloride spray anesthesia and sterile skin preparation.
I applied an external offloading foot pad to the great toe and advised the patient to minimize activity for one week. She returned in one week with the ulceration completely healed.
I noted epithelialized skin in the area of concern along with a decrease in peak pressure as analyzed by gait plates. The patient understood that the graft is not a permanent solution and that touch-ups are required.
In my experience, this is one of many case presentations in which fat grafting, dermal graphing, adipose matrix and dermal fillers may help heal ulcerations and prevent recurrence.
Dr. Schoenhaus is a Diplomate of the American Board of Foot and Ankle Surgery. She is in private practice in Boca Raton and Boynton Beach, Fla. One can follow Dr. Schoenhaus online at @jsfootdoc and www.bocaratonfootcare.com.