Severely damaged lower limb salvage in a critically ill burned patient. Lessons learned

Abstract

Lower limb salvage in severely injured burned patients with bone or tendon exposure may be a reconstructive challenge. In this cases, local or regional flaps and other more conservative therapies such as dermal substitutes and negative-pressure wound therapy are usually not available or are not good enough to solve the problem. In such situations, microsurgical reconstruction with distant flaps seems to be the best option, even though the particularities of the severe burn patient may decrease free flaps' success rate. We report the case of a patient with severe electrical injuries affecting 70% of the total body surface area who had full-thickness burns to the lower extremity with wide bone exposure and extensively drug-resistant Pseudomonas aeruginosa infection. We achieved limb salvation using rectus femoris muscle free flap plus lateral and medial gastrocnemius muscle flaps and soleus muscle flap, after two failed microsurgical coverture attempts and a long not useful periplus with conservative therapies such us negative-pressure wound therapy and dermal substitutes. After 3 years of follow-up, the patient can walk without aid, and he has recovered his social and employment situation prior to the accident.

Keywords: Burn; electrical injury; flaps; free flap; lower limb reconstruction; microsurgery.

Figure 1

Large initial defect exposing the tibia and anterior compartment tendons.

Figure 2

Wound size reduction using regional flaps: medial gastrocnemius muscle flap and hemisoleus muscle flap.

Figure 3

Muscle rectus femoris free flap for covering the wound resulting after the partial coverage with regional flaps.

Figure 4

Final result. Two months after the last surgery.

Figure 5

Decision algorithm for the reconstruction of wide defects with bone exposure in the lower limb in a burned patient. LD: Latissimus Dorsi; ALT: Antero Lateral Tight; NPWT: Negative Pressure Wound Therapy.