Are there 2 or 3 toes missing ? The wound looks infected (biofilm !) and has to be cleaned first ; do bacterial sensitivity tests and use a local antibiotic (for example open a cefalotin vial) and strew the power into the wound every day for a week. Then, I would use a horizontal "random pattern" flap of 6 cm by 2.5 cm  from the non-weight-bearing skin of the sole and turn it 90 degree into the defect. Close the donor defect with a split- or better full- thickness skin graft from the groin. Good luck ! 

Hydrogel and foam over exposed area. 

Hydrogel will ensure the area is clean and the tendon doesn't not dry out before the SSG applied.

In my experience, once the tissue is free of infection, you can work with a local rotational flap (if possible) otherwise, a free flap, although the irradiated tissue is compromised. Usually, a skin graft is risky and doesn't take over tendons because there is not enough circulation. If you need more information on flaps, I can get more information from a worldwide known plastic surgeon who is a specialist in flaps, he had been doing extensive research on the subject. Let me know.

First you need to clean the bed. Debridement either physical or chemical.  You may need some sharp debridement to remove the "picture frame" of fibrotic/keratotic skin around the wound. NB this should produce no bleeding as you are only removing dead tissue. Then you need to change the local mileu ("fertilize the soil");  the use of amniotic membrane is good for this as it does promote neo-vasculalrization. Then you have a number of reconstructive options. Daily gardening can support closure from wound contraction; the use of Integra (dermal regeneration template) can permit revascularization over exposed tendons and then a subsequent graft. There are many flap options but it does depend on how extensive the radiotherapy has been and the total dose. I have seen healthy flaps floating in a sea of spreading necrosis if inset into unhealthy skin. General provisoes include stoping primary and secondary smoking etc

This seems like an irradiated wound on the plantar weight bearing surface of the foot with partial resection of the medial plantar area.  Need to debride to healthy tissue. I would recommend also obtaining  a biopsy to establish a diagnosis and rule out recurrence of tumor and infection, especially in light of radiation. Is there bony involvement ? Osteomyelitis vs tumor extension vs osteoradionecrosis ? and treat the patient accordingly, keeping the wound moist with dressings. This patient might need an amputation.

Once the infection and the tumor has been taken care of the wound needs to covered with WELL VASCULARIZED tissue. Skin grafts, integra etc on an irradiated weight bearing surface is not recommended. Local flaps are limited in this setting and also of questionable vascularity. A free  flap with a long pedicle with anastomoses outside of the  zone of injury is required.

Abdul Shararah, MD, FRCSC, FEBOPRAS

Division of Plastic and Reconstructive Surgery

Thank you so much. I appreciate the responses

cultivation of patient injury was performed. Bacterial growth of Proteus vulgaris sensitive to third generation cephalosporin was observed. It is currently under intravenous and topical antimicrobial treatment.

Soon I publish a photographic progress of the injury.

This is the image after surgical cleaning

In my opinion looking at the picture, I don not think that there is tendon tissue exposed. Depending on the condition of the patient I would go for conservative wound management, since there is a lot of scar tissue in the surrounding area precluding any local flap.

Carlos, if you show us a photo of  the whole foot sole, we may be able to recommend a local rotation  flap from the non-baring part of the sole into the defect. Thanks ! 

This is the result after several cures and treatment with antimicrobials. What do you suggest at this time?

Cover skin with flap or healing by second intention

Professor Lemperle

This is a picture.

One could try with NPWT, but I think a dressing would suffice, as long as hyperkeratosis is regularly removed and offloading assured; one should use a dressing that doesn't promote biofilm growth.

My recommendation:

Clean lesion only with saline,put AquacelAg, soak it with saline ,as wound looks dry, and cover with a thin layer of sterile gauze. Redressing every 3-4 days . When you remove the AquacelAg do not soak it. According to my experience the wound could be closed for 3 weeks.

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Microvascular free flap coverage will work, and is the gold standard for irradiated tissue.  The anastomoses, ideally, will be located outside of the irradiated zone.

Dear Steve. Thanks by your answer.

Carlos, thgt´s what I meant with a random-pattern rotation flap ! If you take it correctly, i.e. look at your hand when elevating a flap; beneath the tip 5 mm subcut. fat, at the base 10 mm than this is a 100 % safe flap. I used many 50 years ago as step-in-flap or cross-leg-flap for the coverage of the other foot´s heel-sole. Of course, a free flap is the gold standard today - but you may have no access to it ?

Good luck ! Gottfried

Dear professor Lemperle

I really appreciate your help. The design is very interesting. In my hospital, we do not perform reconstructions with free flaps because we do not have the instruments for it. I think the flap of rotation he proposes is applicable. We already control the local infection and prepare to rebuild. Thank you so much. I'll send you pictures of the case.