Complications relating to foot and ankle surgery in children and the medicolegal implications

There are several reasons why children may need to undergo foot and ankle surgery. Broken bones often necessitate surgical fixation and foot deformities, whether from trauma, degenerative processes or congenital diseases, may also require surgical intervention (1, 2). As a result, many procedures come under the umbrella of foot and ankle surgery. These include soft tissue procedures such as plantar fascia release as well as tendon lengthening and transfer. Bony procedures, such as osteotomies, are performed when a greater degree of correction is required. Fusion procedures are generally reserved for patients with the most severe degenerative joint changes and deformities (1).

Although in many patients, surgery and recovery proceed without issue, as with all surgical procedures, complications sometimes arise. While children generally tend to have a greater healing capacity than older patients, the growing skeleton can make recurrence unpredictable.  Furthermore, young patients may not fully appreciate the level of risk associated with their procedure or how an adverse outcome will impact them (3).

The incidence of complications after foot and ankle surgery is difficult to quantify, due to the variety of procedures available. However, most estimates lie within the range of 4% – 11% (4, 5). Some diseases or lifestyle factors may increase the risk of complications. In particular, factors that affect the peripheral circulation or nervous system, can increase the risk of infection and have potential to impact wound healing (6). Other factors include older age at surgery, obesity, degree of preoperative foot deformity (5, 7). In addition, some procedures (such as??) are associated with a higher risk of adverse outcomes (2).

Virtually all patients will experience a degree of pain after their procedure. Given that pre-existing pain is an important factor in the decision to undergo surgery in the first place, this can be disappointing if the pain is more severe than the patient was expecting or persists for a sustained period. Foot and ankle surgery can be associated with longer recovery times than surgery in other areas, and it is important that the patient and their carers are made aware of this (3). Although in most patients, pain resolves in a few weeks, some individuals go on to develop complex regional pain syndrome, in which their pain becomes chronic (4). This condition can be challenging to manage, and in some patients, it can result in a greater impact than the original complaint (3).

After pain, issues with wound healing are among the most commonly encountered complications following foot and ankle surgery. This is partly because reconstruction of this area is very difficult, due to the complexity of the anatomy and functional demands of the joint. Furthermore, the thick skin on the plantar surface of the foot is highly specialised and cannot easily be replaced by autologous tissue from other body sites, which does not share its tissue quality or functional capability. Conversely, the skin in the dorsal and ankle regions is thin and pliable and there is little subcutaneous fat. While this allows for an increased range of movement, it places the underlying tendons and bones at increased risk of damage following trauma or surgical intervention. Scar tissue from previous surgery poses additional challenges to successful wound closure (6).

Therefore, management of wounds and infection in the foot and ankle region presents certain problems to the surgeon. Wounds may be either superficial, involving only the skin or subcutaneous tissues, or deep, affecting the bones and tendons. In the latter, early coverage of exposed structures is critical to limb salvage and may require free tissue transfer from distant sites on the body. In some cases, hardware removal may be necessary if infection has taken hold. Cases of skin graft failure and chronic non-healing can result in amputation of the affected area (6).  

Fixation of ankle fractures is a common orthopaedic procedure, as surgical intervention is often required to restore the anatomy and function of the joint. Internal fixation of the bones is achieved with the use of screws, plates or similar implants. Although widely used, these are associated with various complications, including loosening and breakage. They also increase the risk of complications from infection and poor wound healing, both of which may necessitate their removal. However, repeat surgery for implant removal increases the likelihood that the patient will experience complications (8). Non- or malunion of the bones can also occur, leading to pain and loss of function. In this scenario, further orthopaedic surgery may be required (6), again placing the patient at risk of further complications.

Around 20% of patients with ankle fractures also sustain injuries to the syndesmosis, which is responsible for the stability of the ankle joint. Misdiagnosis or inadequate treatment of these injuries can result in persistent ankle pain, loss of function and post-traumatic arthritis. Therefore, correct diagnosis and treatment is vital. New techniques, such as the suture button procedure, bypass some of the problems associated with standard screw fixation for this type of injury and can be considered (8).

Occasionally, foot and ankle surgery is not successful in achieving the outcome expected by the patient and surgeon. Some patients are left with a residual deformity (2, 9), while in others, the issue recurs soon after surgery. The reasons for this are not always clear, but may include elastic recoil of the soft tissues, muscle imbalance or growth disturbance (2). The latter is particularly pertinent to younger patients whose bodies are still developing.

Some of the complications associated with foot and ankle surgery occur only rarely but are important to consider as their effects can be devastating. One example is acute compartment syndrome (ACS), an increase in pressure in a muscle which ultimately cuts off blood flow. In children, the condition is most commonly associated with elbow and forearm fractures. Thus, cases in the foot, which appear to be related to complexity of the surgical procedure, can often be missed due to a lack of suspicion or experience. Delayed or missed diagnosis may also be due to symptoms being masked by regional pain relief, trauma affecting multiple body areas, altered consciousness and peripheral nerve injury. Age is also a factor, as the condition is more difficult to diagnose in children than in adults. There is equipoise as to the best method of treatment for foot ACS however early recognition is essential (10).

Soft tissue tumours occur relatively frequently in the foot and ankle region and are usually surgically removed. The vast majority are benign, but differentiation between these and malignant lesions, such as soft tissue sarcoma, is difficult by clinical examination alone. Furthermore, malignant tumours are rare in this area of the body and the surgeon may not be expecting to find one. Excisions undertaken without sufficient preoperative evaluation often result in incomplete removal of the malignant tissue. This often requires re-resection, which tends to be more complicated than the original surgery. These patients also experience delays in diagnosis and correct treatment. All these factors can lead to residual disease and increase the risk of tumour recurrence (11).

Advances in reconstructive techniques have revolutionised the treatment of foot and ankle injuries and deformities. Previously unsalvageable limbs can often now be successfully treated. However, complications still arise. Careful patient selection and preoperative assessment must be undertaken, particularly with regard to skeletal and soft tissue anomalies that may dictate hardware placement and contribute to infection development or prolonged wound healing (6). Early identification of potential problems enables timely management and reduces the risk of complications and ensuing litigation.