Free-Muscle-Flap Coverage of Exposed Knee Joints Following Fulminant Meningococcemia: Twenty Year Follow up of Limb Salvage

Purpose

            Fulminant meningococcemia caused by Neisseria Meningitidis occurs in less than 5 cases per 100,000 people. It can present with thrombosis of the microvasculature leading to ischemia and limb loss.¹ In 1995, we published a novel procedure utilizing free muscle flaps to cover widely exposed knee joints resulting from fulminant meningococcemia to prevent limb loss.² This study aims to show long term results twenty years after the original surgeries were performed.

Methods

At the original operation, a left free latissimus dorsi flap was transferred to the right knee. A right free latissimus dorsi flap was transferred to the left knee but failed. A gastrocnemius muscle flap was then used to cover the medial, anterior, and posterior left knee. A free rectus muscle flap was used to cover the lateral left knee. The patient underwent skin grafting and physical rehabilitation regaining ambulatory status.

Following IRB approval, the patient was evaluated to assess range of motion, strength, and sensation twenty years later.

Experience

One patient underwent free muscle flap coverage of exposed knee joints due to fulminant meningococcemia.

Summary

There was complete flap viability of the free latissimus muscle flap used to cover the right knee.  Capillary refill was less than two seconds. The patient had 5/5 strength of the right lower extremity. Goniometry showed active and passive flexion to 130 degrees and active and passive extension to 20 degrees. There was perception to light and deep touch over the flap.  The patient ultimately underwent amputation through the left knee joint after Ilizarov lengthening failed several years after the flap healed.  However, the flap used to cover the exposed knee joint was used to cover the amputation site and allow for the use of a prosthesis.

Conclusions

The utilization of local flap coverage in fulminant meningococcemia is often limited to due severe surrounding tissue necrosis and defect size. This case demonstrates that free muscle flaps can be utilized to promote limb salvage in the setting of extensive tissue loss following meningococcal septicemia.