Case 16 (2023): Single-stage treatment of chronic osteomyelitis reconstructed with a free muscle flap
Josefine Slater, PhD-student, Birgitte Kiil, Alex Ramsden, FRCS (Plast)
Abstract
A 53-year-old female was referred to the Nuffield Orthopaedic Centre, Bone Infection Unit, Oxford University Hospital, for treatment of a chronic osteomyelitis defect on the left tibia. The patient had a limb laceration leading to a contiguous osteomyelitis of her left tibia that developed at the age of 3 years.
BeforeAfterA 53-year-old female was referred to the Nuffield Orthopaedic Centre, Bone Infection Unit, Oxford University Hospital, for treatment of a chronic osteomyelitis defect on the left tibia. The patient had a limb laceration leading to a contiguous osteomyelitis of her left tibia that developed at the age of 3 years.
She had previously been treated with a debridement as a child that was left to heal by secondary intention. The chronic wound broke down 2-3 times a year and discharged malodorous pus, but since 2021 it has remained unhealed. The patient is hypothyroid, has a BMI of 35, complete heart block and has a pacemaker since 2014. Antibiotics had been stopped two weeks prior to surgery according to protocol.
Pre-operative MRI.
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Pre-operative MRI.
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Limited exposure to allow for microbiological and histopathological samples.
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Taking multiple samples for microbiology and histopathology, added to separate tubes and using clean instruments which are changed between each sample to minimise cross contamination. Care is taken to avoid touching the skin or wound with instrument tips, fingers or suction until sampling is complete.
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Debridement and excision of sinus tracts, scar and dead bone continuing until healthy, bleeding bone and soft tissues is reached.
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Washout with 0.05% aqueous chlorhexidine solution.
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Obturation of dead space within bone with antibiotic-loaded biocomposite (Cerament, Bone Support, Lund, Sweden).
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Through a longitudinal incision medially on the thigh.
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Dissection of vessels and preparation for microsurgical anastomosis.
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Recipient vessel dissection (a. tibialis post) and preparation. This is often a challenge in the case of chronic infections due to chronically inflamed and fibrotic tissues. Anatomical planes may be disrupted because of previous trauma or surgery.
“The zone of inflammation” may extend far up the limb in the neurovascular plane, why anastomosis often is performed in the scarred area and the vessels are spastic.
The gracilis flap. Ischemia time was noted. As of Mathes and Nahai classification of pattern of circulation: a type II with dominant pedicle(s) and a minor pedicle (seen with clips). In this patient two minor pedicles and one dominant pedicle was present.
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End-to-side
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End-to-end with a 2 mm venous flow coupler.
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Flap inset. Tension-free closure with muscle tucked under the edges of the skin defect as it important to ensure a good inset. A drain with weak suction is applied to secure flap to bone surface creating optimal contact, and prevention of fluid collection.
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The muscle is resurfaced with a split-thickness skin graft without creation of mesh, but hand fenestrated for a better cosmetic result.
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Surgical dressing.
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Follow-up (5 days) – Flap a bit swollen, but healing as expected.
20– Cast was put on for early post-operative immobilisation.
– Surgical dressing left on constantly for the first five days.
– Create a window to peak for early post-operative monitoring. In this patient, monitoring muscle flap color may be intricate due to the skin pigmentation.
– Flap viability is monitored post-operatively by venous flow doppler. Every 30 minutes until midnight the day of the operation; then hourly for 24 hours; then every other hour for 72 hours; then once per nursing shift until discharge.
– The flow doppler is constantly running, so the patient can alarm the staff if anything changes. – After five post-operative days compress bandaging will be applied reducing edema and improving flap contour. Usually this is worn until no pitting edema, approx. for 2-3 months.
– The patient will then start walking for short periods of time.
– The venous doppler is pulled out at 7-10 days, and the patient was discharged on post-operative day 10.
– The patient will continue oral antibiotic therapy guided by culture results for approx. weeks.
How to cite this article
Josefine Slater, PhD-student, Birgitte Kiil, Alex Ramsden, FRCS (Plast). Case 16 (2023): Single-stage treatment of chronic osteomyelitis reconstructed with a free muscle flap. Journal of Plastic, Breast & Reconstructive Surgery. 2023.
Open access. © 2023 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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