A 65-year-old man with a painful, swollen left great toe walked into a clinic carrying far more than an ordinary foot complaint. Pus was draining from the joint, the overlying skin had begun to die, and radiographs showed degeneration of both the distal and proximal phalanges of the first toe, findings that pointed squarely at osteomyelitis, an infection of bone that most often develops when a soft-tissue infection spreads downward into the skeleton. He lived in poor sanitary conditions, every toenail was ingrown, and he carried a 30-pack-year smoking history alongside hypertension and, as later testing revealed, prediabetes with a hemoglobin A1c of 5.9 percent. Each of these factors quietly stacked the odds against him. A new case report published in BMC Plastic and Reconstructive Surgery by Hee Gyun Yang and Sehwan Lee now documents in unusual detail how his toe amputation spiraled into a stubborn stump wound, and how a classic geometric reconstruction technique combined with months of persistent dressing changes ultimately restored the tissue barrier.
Osteomyelitis of the foot is a familiar adversary in medicine, particularly among patients with diabetes and peripheral neuropathy, where loss of protective sensation allows small wounds to deepen unnoticed until bacteria reach bone. The standard playbook combines targeted antibiotics with surgical removal of infected bone, an approach widely accepted as effective for most cases of diabetic foot osteomyelitis. But the operation itself is only the opening act. Wound care after amputation remains one of the most deceptively difficult phases of treatment, because the surgeon is working with tissue that is already infected, poorly perfused, and dependent on a patient’s long-term cooperation. In this case, the toe was amputated at a secondary hospital, yet the story took a turn that clinicians see all too often: after seven days of hospitalization, dissatisfied with the service and the wound dressing care he was receiving, the patient discharged himself against medical advice.
Several days later he arrived at an outpatient clinic with an oozing wound at the amputation stump. Examination revealed loss of the cutaneous layer, with swollen subcutaneous tissue exposed to the air. Encouragingly, his white blood cell count and C-reactive protein levels were within normal limits, no microbial growth was identified in cultures, and no peripheral necrosis or vascular disease was detected. The wound was not systemically infected. But it refused to dry. The volume of exudate did not decrease, and a transparent yellow discharge, suspicious for synovial fluid leaking from the disrupted joint, persisted day after day. That detail mattered enormously. A dehisced stump with no protective skin barrier, sitting over a joint capsule that might be leaking synovial fluid, is an open invitation for bacteria to colonize the wound and seed the deeper structures. The treating team concluded that flap reconstruction was indispensable, not merely to close a hole but to rebuild the biological wall separating the outside world from the joint.
The operation they chose was the Limberg flap, also known as a rhomboid flap, a workhorse of reconstructive surgery first described decades ago and still prized for its elegant geometry. The technique recruits a diamond-shaped segment of adjacent healthy skin and subcutaneous tissue, transposes it across a pivot point, and uses the laxity of surrounding skin to fill the defect while distributing mechanical tension along the closure lines. Here, the surgeons first performed a rhomboid-shaped debridement, excising necrotic and swollen tissue to leave a clean 3.5 by 3.5 centimeter defect, then raised the Limberg flap with its pivot point at the medial side of the proximal phalanx stump. The geometry was constrained by the previous surgery and the scarcity of healthy adjacent tissue, meaning that mechanical tension on the flap was unavoidable, a compromise the team accepted because no better local option existed.
Perioperative care was built to protect the fragile reconstruction. The patient received a prophylactic first-generation cephalosporin to guard against infection, a prostaglandin E1 analogue to promote vasodilation, and antiplatelet therapy to enhance blood supply to the flap, a rational combination given that microvascular perfusion determines whether transferred skin lives or dies. In the immediate aftermath, the strategy appeared to work. Exudate dropped markedly, and the suspicious synovial fluid leakage stopped entirely, confirming that the flap had successfully sealed the joint. One week after surgery, however, mild edematous changes appeared in the flap, and the tissue eventually became necrotic. The reconstruction had partially failed, a consequence of the tension under which it was placed and the compromised local conditions.
What happened next is arguably the most instructive part of the case. Rather than rushing back to the operating room for another flap or a skin graft, the team pivoted to conservative management: daily dressing changes with intermittent debridement of the necrotic material. Although the skin flap did not fully survive, it continued to serve as a physical barrier and provided structural support to the adjacent tissue, promoting recovery and the formation of healthy granulation tissue beneath it. Over the following two months, healthy tissue gradually covered the lesion, and the wound healed by secondary intention. The authors point out that this outcome echoes a concept recognized in the literature, in which even a failed flap can function as a biological dressing, reducing contamination and inflammation and facilitating the development of healthy tissue before any subsequent grafting. In other words, a partially necrotic flap is not always a wasted operation; sometimes it is scaffolding.
The case also shines a light on how often amputation wounds go wrong in broader populations. Stump-related complications are dominated by wound infection and poor healing, which account for roughly 70 percent of problems, followed by poorly fashioned stumps at 20 percent and phantom pain at 10 percent. Research has linked smoking to both immediate and late complications, preoperative infection to immediate and intermediate complications, and amputations performed for peripheral vascular disease or trauma to late complications. One study of 739 patients who underwent lower-limb amputation found that 8.3 percent were readmitted within 30 days because of stump-related complications, and 61 percent of those complications required surgical intervention, with readmission rates of 35.9 percent after above-knee amputation and 68.7 percent after below-knee amputation. In the present patient, the authors suggest that both his smoking history and the underlying osteomyelitis likely contributed to the wound breakdown, and they note that pre-emptive vascular examinations to identify peripheral vascular disorders would have aided wound care planning from the start.
The report also engages with a genuine technical controversy in modern wound care: the use of topical negative pressure therapy, or TNP, in which vacuum sealing drainage systems actively draw fluid from a wound to promote granulation. While TNP has advanced the management of soft-tissue defects and amputation wounds, its application over open joints remains contested, with variable reported outcomes. In this case, the authors argue that applying negative pressure directly to the wound could have caused excessive drainage of synovial fluid and potential joint disruption. Their proposed sequence for similar situations is therefore deliberate: flap reconstruction first, to close the joint and reestablish the skin barrier, followed by TNP dressing only afterward, once the joint is protected. This ordering, they suggest, captures the benefits of vacuum therapy without exposing a leaking joint to its risks.
Perhaps the most sobering threads running through the case are the ones that have nothing to do with surgical technique. The patient’s poor sanitary conditions, his ingrown toenails, his self-discharge against medical advice, and his refusal to return to the hospital where the amputation was performed all shaped the clinical course as powerfully as any incision. The authors emphasize that understanding patient needs and providing clear explanations of wound status at every visit are essential for building trust, and that consistent wound care until complete recovery is non-negotiable, yet the high cost of treatment often limits access to appropriate care. This patient was a type I medical aid recipient in South Korea, with his basic wound care almost fully covered by government support, a fact the authors credit with making the prolonged dressing regimen feasible. They call for greater coordination among healthcare systems, insurance providers, and government assistance programs to reduce the burden of medical poverty, arguing that patient compliance, trust in clinicians, and financial support together determine whether complicated wounds heal. The case, prepared in accordance with the SCARE reporting criteria, ultimately delivers a double lesson: a well-executed Limberg flap can rescue a failing amputation stump even when the flap itself partially dies, but surgery is only one pillar of recovery, and the quieter work of daily dressings, repeated debridement, and sustained patient engagement is what carries the wound across the finish line.
Subject of Research: Management of a complicated post-amputation stump wound using Limberg flap reconstruction and persistent wound care following toe osteomyelitis
Article Title: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report
Article References: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report. (n.d.). https://doi.org/10.1186/s44452-026-00028-6
Image Credits: AI Generated
DOI: 10.1186/s44452-026-00028-6
Keywords: osteomyelitis, amputation, Limberg flap, wound care, flap reconstruction, debridement, stump complications, topical negative pressure, patient compliance, diabetic foot, reconstructive surgery, synovial fluid leakage
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Tags: amputationdebridementdiabetic footflap reconstructionLimberg flaposteomyelitispatient compliancereconstructive surgerystump complicationssynovial fluid leakagetopical negative pressurewound care
