We present the case of a 24 y/o man without significant medical history who was involved in a MVA presenting with a left open Gustillo IIIB forearm fracture. He was first treated with debridement, ulnar ORIF and Radius stabilization with an external fixator elsewhere. At our institution he was scheduled for a composite reconstruction with an osteo-cutaneous fibula flap and a sural graft to the ulnar nerve for a composite defect including a five cm segmental radial defect, ulnar arteriovenous bundle defect and a 15 by 10 cm skin defect in the anterior aspect of the forearm communicating with the radial fracture site.
Surgical procedure was realized under tourniquet at 300 mm Hg for 75 min, after flap raising, muscles of the lateral and deep posterior compartment were approximated and closed over a drain. The cutaneous defect was closed with a STSG from the ipsilateral thigh. A below-knee cast was applied with the ankle at 90°. Flap was anastomosed to the sectioned proximal ulnar artery and cephalic vein and fixed with a plate. Skin island was partially sutured and the remaining defect was left open for coverage in a second operation. Additionally, a 5 cm cable sural graft was used to reconstruct an ulnar nerve defect. Patient was transferred to the ICU for flap monitoring. In the postoperative period, the patient complained of severe pain in the leg. Dressings were removed, and surgical wound inspected looking for hematomas or extrinsic compression. Initially, no significant edema or augmented tension were seen, but at the second postoperative day the wound was reevaluated, and severe edema with signs of skin suffering, graft dehiscence and muscle ischemia were noted. An angioscan showed no signs of venous thrombosis but a generalized myositis with involvement of all the leg compartments was seen. Patient was taken to the OR and an extensive debridement including all the muscles from the lateral and posterior compartments was required. Tissue cultures were positive for a multidrug resistant enterobacteria. A multidisciplinary treatment was started including systemic antibiotics, physical therapy, NWPT and serial debridements with infection resolution and granulation of residual defect that was later reconstructed by a STSG. During the healing phase, a complete involvement of the posterior tibial nerve and ankle rigidity were demonstrated. After four months patient persists with an anesthetic plant, but he is ambulatory with the aid of a walking stick and an Ankle foot orthosis. The reconstructed upper limb had no complications and it is completely healed.
Osteocutaneous fibula flap can be raised safely in most patients but surgeons have to be suspicious of early OCS due to extensive leg trauma or isquemia, even in the absence of closed space.