The Journal of Foot & Ankle Surgery 53 (2014) 344–349

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Reverse Sural Flap with Bifocal Ilizarov Technique for Tibial Osteomyelitis with Bone and Soft Tissue Defects Christopher Bibbo, DO, DPM, FACFAS Chief, Foot and Ankle and Limb Preservation Service, Department of Orthopaedics, Marshfield Clinic, Marshfield, WI; Department of Surgery, Division of Plastic and Reconstructive Surgery, Hospital of The University of Pennsylvania, Philadelphia, PA

a r t i c l e i n f o

a b s t r a c t

Level of Clinical Evidence: 4

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk patients. We describe a case of methicillin-resistant Staphylococcus aureus tibial osteomyelitis with intercalary bone loss successfully managed with bifocal Ilizarov compression osteogenesis at the bone resection site and proximal distraction osteogenesis, accompanied by a reverse sural fasciocutaneous flap performed with a delayed technique. When free tissue transfer is not a reconstructive option owing to medical comorbidities or patient refusal, the reverse sural flap combined with bifocal Ilizarov compression and distraction osteogenesis can provide a reconstructive option to achieve limb salvage for these challenging cases. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.

Keywords: distraction osteogenesis external fixation flap intercalary tibial defect length inequity limb salvage tibia

Osteomyelitis, especially of the tibia, is a complex disease that is a tremendous challenge to treat. The effective management of tibial osteomyelitis hinges on both appropriate medical management and surgical reconstructive techniques. Quite often, the efficacy of 1 arm of the management plan will be mutually dependant on the other for a clinically successful outcome to result. Still, despite advances in our knowledge and treatment of osteomyelitis, certain anatomic locations have continued to pose a tremendous challenge. Chronic posttraumatic tibial osteomyelitis can be an exceptionally difficult clinical problem, especially when associated with bone loss and a hostile soft tissue envelope in a medically compromised host. In such a clinical setting, the management plan can be truly categorized as an attempt at “limb salvage.” Adequate debridement of the devitalized bone and associated soft tissues remains a cornerstone in the management tibial osteomyelitis. A number of surgical techniques have been described to assist in the overall surgical management plan for tibial osteomyelitis, including the Papineau technique, Ilizarov techniques, and free microvascular tissue transfer of muscle or composite graft tissues (eg, osteocutaneous). The patient with the combined problem of tibial osteomyelitis with bone loss and a soft tissue defect presents a special challenge for reconstruction, especially if the patient smokes and abuses alcohol. Although modern microvascular free tissue transfer techniques will

Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Christopher Bibbo, DO, DPM, FACFAS, Plastic and Reconstructive Surgery, 3400 Spruce Street, 10 Penn Tower, Philadelphia, PA 19103. E-mail address: [email protected]

most often offer the most effective method of treatment, a subset of patients still exists for whom a free tissue transfer will not be an option because of poor health or a refusal by the patient to undergo a free tissue transfer. In such patients, in an effort to avoid amputation, alternate reconstructive techniques might need to be considered. We describe the successful application of bifocal Ilizarov techniques (proximal distraction osteogenesis/distal compression osteogenesis) combined with a reverse sural fasciocutaneous flap to successfully manage a critical size, chronic methicillin-resistant Staphylococcus aureus, post-traumatic osteomyelitis with an associated soft tissue defect in a high-risk patient who had refused a free tissue transfer.

Case Report A 37-year-old, male alcoholic, who was a heavy smoker (40 packyear history) presented 2 years after having been treated at an outside institution with plating and skin graft coverage of a grade 3B open distal tibia fracture, and open reduction and internal fixation of an acetabular fracture. Subsequently, the patient developed femoral head avascular necrosis 6 months after his index surgery, for which a Girdlestone procedure was performed. At 20 months after the index tibia surgery, drainage developed from the lower leg wound, prompting his presentation to a second outside institution. Sinus tract cultures taken from the leg grew Enterobacter cloacae, which was treated with removal of the tibial plate and oral antibiotics. Eight weeks after plate removal, the tibial plate removal incision had failed to heal and continued to drain, prompting referral to our institution, with a chief complaint of an inability to bear weight on the left lower

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Fig. 1. (A) Clinical appearance of unstable limb and (B) close-up view of draining sinus with surrounding hostile, atrophic soft tissue envelope of distal leg.

extremity because of pain, deformity, and instability, accompanied by a chronic, draining leg wound. His social history was positive for continued tobacco use and alcohol use; his medications included amoxicillin/clavulanate for the draining leg wound. The physical examination revealed an anterior-medial leg wound surrounded by a large area of chronic, dysvascular scar tissue (Fig. 1). Clinically, an approximately 6-cm limb length discrepancy was apparent. The

entire limb was floppy and painful, and the hip range of motion was limited owing to pain. However, the hip girdle muscle function was intact, and the knee range of motion was full and pain free. The ankle range of motion examination was limited owing to a very unstable distal tibia and extreme tenderness. The leg edema was 2þ, and Doppler arterial signals were present for the dorsalis pedis, posterior tibial, and peroneal arteries. The sensation was intact to the foot.

Fig. 2. (A) Non-weightbearing radiograph and (B) gravity stress radiograph demonstrating osteomyelitis with bone loss and instability.

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Fig. 3. (A) Pelvic radiograph demonstrating 6-cm length inequality from loss of femoral head and neck (arrows). (B) Computed tomography study demonstrating total limb length inequality at each major joint segment (arrows).

Motor power to the limb was assessed at grade 4þ/5. Tendon excursion was noted to be limited over the distal one third of the leg. The patient could not bear any weight on his left lower extremity, prohibiting limb use for transfers, standing, and bipedal ambulation. Manual positioning of the left limb was required to allow postural changes, such as to sitting and laying, and personal hygiene. Radiographs demonstrated an erosive lesion of the distal one third of the

tibia, with greater than 2 cm of bone loss, shortening and fracture of the retained fibular osteosynthesis plate. Gravity-assisted radiographic views demonstrated gross motion at the distal one third of the tibia (Fig. 2). Pelvic radiographs and a computed tomography limb length study revealed a 6-cm limb loss at the hip secondary to the Girdlestone-type procedure (Fig. 3). The laboratory data on presentation was as follows: erythrocyte sedimentation rate of 15 mm/

Fig. 4. (A) Intercalary tibial defect after debridement. (B) C-arm image of the defect.

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Fig. 5. (A) Delayed reverse sural flap. (B) Plain radiograph of tibia after application of Ilizarov and acute distal compression and proximal corticotomy for distraction osteogenesis.

hr; C-reactive protein of 1.3, and white blood cell count of 12,000 mL. Subsequent hip aspiration with cultures and 16S polymerase chain reaction was negative for infection. The physical examination, laboratory, and radiographic findings were consistent with osteomyelitis of the distal tibia (Cierny-Mader type IVB) (1), with a distal tibial nonunion (Paley type B3) (2). Overall, the surgical reconstructive area represented a Bibbo class 2-B host-surgical site (3).

The patient was counseled extensively regarding the risks and benefits of both amputation and limb salvage. The patient refused amputation and also refused free tissue transfer for limb salvage. Thus, an alternate reconstructive effort was planned, with en bloc resection of the osteomyelitic tibia (acute shortening with compression osteogenesis) combined with distant distraction osteogenesis (proximal lengthening). The soft tissue defect resulting from excision

Fig. 6. (A) Posterior view of flap (arrow) and skin grafted donor site. (B) Close-up of flap covering the skin defect (arrow).

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of the diseased scar and sinus tracts was to be covered by a local flap. Adjunctive parental antibiotics were to be determined by the results from deep intraoperative cultures. A final staged hip reconstruction of either hip replacement or fusion was planned. The patient was instructed to stop all previous antibiotics for 2 weeks before surgical reconstruction to avoid erroneous culture results. He was also strongly counseled regarding tobacco and alcohol cessation, but he did not comply. Reconstructive Technique Lower extremity salvage and restoration of the limb length was executed in 2 stages: immediate below the knee leg reconstruction followed by hip reconstruction for the pelvic discontinuity. Stage 1: Below the Knee Leg Reconstruction The leg reconstruction was begun by creating a proximal tibial corticotomy by connecting multiple, fine drill holes with an osteotome, followed by applying a proximal fine wire frame assembly (IlizarovÔ, Smith & Nephew, Memphis, TN). Next, all atrophic tissues and scar were excised through an oblique ellipse, resulting in a large soft tissue defect. The osteomyelitic tibia was resected to viable, bleeding bone (ie, marrow, periosteum, cortex), resulting in a 6-cm intercalary tibial defect (Fig. 4). The deep posterior leg compartment, encased in scar, was dissected, with release of the posterior neurovascular bundle. The fractured hardware was removed, and a partial fibulectomy was performed to ensure free mobility, allowing acute shortening. The remainder of the external fixator was assembled, and immediate compression of the distal tibial segment was performed (Fig. 5). Despite acute shortening, a significant residual soft tissue defect remained, requiring reconstruction. Because of the patient’s high-risk profile, a reverse sural flap was elevated in a delayed fashion, leaving intact the proximal skin margin and the short saphenous vein (axial delay technique; Fig. 5). Because of the patient’s smoking history, a 7-day flap delay was undertaken before completion of both flap elevation procedures, matching the delay period for distraction osteogenesis of the tibia. During the delay period, the vacuum-assisted closure dressings were changed every 3 days using a sterile bedside technique. However, immediate postoperative distal compression osteogenesis was initiated (0.25 mm every 6 hours). After a 7-day delay period, flap elevation was completed and inset (Fig. 6). A split-thickness skin graft and vacuum-assisted closure dressing was placed over the flap donor site; proximal distraction osteogenesis was also initiated (0.25 mm every 6 hours). The reverse sural flap had healed by 8 weeks after insetting. The donor site skin graft had healed 100% over the surface area. The patient was discharged to a subacute care facility 2 weeks postoperatively. Stage 2: Hip Reconstruction After an 8-week course of parenteral vancomycin, cemented total hip arthroplasty was performed through a standard posterior approach, with intraoperative sciatic nerve monitoring (owing to the acute lengthening of 6 cm with placement of the hip prosthesis). Immediate weightbearing on the external fixator was allowed after total hip arthroplasty, with continuation of the proximal distraction and distal compression osteogenesis. The patient was discharged home within 1 week; the patient resumed smoking when at home. Thus, the distal tibia compression osteogenesis site was treated with an adjuvant ultrasound external bone stimulation (ExogenÔ, Smith & Nephew, Memphis TN). At approximately 18 weeks, computed tomography demonstrated healing of the distal tibial site. The proximal tibia was lengthened a total of 5 cm, with adequate bone regenerate achieved at

Fig. 7. Final appearance of the reconstructed lower extremity showing a healed soft tissue envelope, restoration of the anatomic axis, an adequate limb length, a solid regenerate (arrowhead), and a healed distal tibia (arrow).

20 weeks. The external fixator was dynamized for 2 weeks before removal for a total of 22 weeks in the Ilizarov external fixator. The external bone stimulator was continued over the proximal regenerate for 8 additional weeks after removal of the external fixator. At 24 months of follow-up, he had complete union of both the proximal and the distal tibia osteogenesis sites (Fig. 7). A residual 1-cm limb length discrepancy was treated with a shoe insert. At the latest followup examination, the patient had resumed all activities of daily living. Discussion The treatment of tibial osteomyelitis, especially methicillinresistant S. aureus in a compromised host, remains a challenge. I agree with previous investigators (4–6) that an aggressive surgical approach, coupled with intensive medical treatment (antibiotic therapy), is required to achieve a successful outcome in infected distal tibial nonunions. Because of the poor correlation between superficial/ sinus tract culture and deep culture results (7), adequate debridement is imperative; the antibiotic therapy must be guided by the deep operative culture results. If the results of cultures from the deep operative specimens are negative or inconclusive (owing to antibiotic suppression, sampling error, or a quiescent infection) 16s polymerase chain reaction should be used to assist the surgical and infectious disease teams in determining the appropriate course of antibiotics. Furthermore, in my experience, especially for osteomyelitis occurring in a relatively poorly vascularized area, such as a traumatized distal tibia with poor soft tissue coverage, I will use parenteral antibiotics, which can be better supervised in noncompliant patients.

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In addition to adequate debridement of the infected and/or necrotic bone in cases of tibial osteomyelitis, any sinus tracks and devitalized tissues within the overlying soft tissue envelope should also be excised. Proper management of a hostile soft tissue envelope is critical for achieving a successful outcome. When free tissue transfer is not an option, local rotation flaps, such as fasciocutaneous and myocutaneous flaps, can provide coverage of soft tissue defects in cases of tibial osteomyelitis (8,9). The reverse sural fasciocutaneous flap has traditionally been thought to be provided by retrograde flow from branches of the peroneal artery that feed the very small sural artery, which accompanies the sural nerve. The short saphenous vein provides venous outflow. However, recent investigators have demonstrated that inclusion of the sural nerve is not always required. Also, although the sural artery contributes to the blood supply of the flap, the short saphenous vein and the accompanying arterial peroneal/posterior tibial artery perforator plexus within the underlying the deep adipose tissue play a more critical role in defining the vascular territory of the distally based reverse sural flap (10). The complications associated with the reverse sural flap are not insignificant, with larger published series reporting a combined major and minor complication rate of 50% (11,12). In high-risk patients, such as diabetics, smokers, the obese, and elderly patients, the incidence of complications can be especially high; in 1 large series, the complication rate approached 75% (12). In these at-risk groups of patients, the flap necrosis rates have been increased by as much as fivefold (10), and flap delay techniques have been recommended highly to help mitigate complications in high-risk patients (11,12). Osteogenesis is a well-described physiologic response of bone to the technique of intermittent compression or distraction to the bone, the principles of which were elucidated by the work of Ilizarov. Combined compression and distraction osteogenesis techniques have been proved successful in managing tibial osteomyelitis with and without intercalary segment defects of the long bones (13–15). The technique of acute temporary limb shortening and angulation to facilitate soft tissue closure has also been described (14–17). However, several limitations to the technique exist, including a finite limit to the acute shortening that can be achieved, owing to impingement of redundant tissues. Also, acute intentional angulation can result in neurovascular compromise in atherosclerotic patients. Finally, technical complications arising from the transport of bone over great distances can also occur (13). To solve these limitations, the use of local rotation flaps, in conjunction with monofocal acute limb shortening and distant monofocal bone regeneration (bifocal technique of compression and distraction), can provide a solution to these issues, such as was illustrated in the present case. The Ilizarov technique is so

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versatile that, in select cases, such as was recently reported by Bibbo et al (18), it can be used as a technique to provide soft tissue coverage. In conclusion, tibial osteomyelitis with bone loss and a soft tissue defect remains a challenge to treat. When free tissue transfer is not a reconstructive option, limb salvage can still be achieved with the Ilizarov distraction and compression osteogenesis and a local rotation flap, such as the reverse sural flap. References 1. Cierny G III, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res 414:7–24, 2003. 2. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop Relat Res 241:146–165, 1989. 3. Bibbo C, Hatfield PS. Platelet rich plasma concentrate to augment bone fusion. Foot Ankle Clin North Am 15:641–649, 2010. 4. Fitzgerald RH Jr, Ruttle PE, Arnold PG, Kelly PJ, Irons GB. Local muscle flaps in the treatment of chronic osteomyelitis. J Bone Joint Surg Am 67:175–185, 1985. 5. Cierny G III, DiPasquale D. Treatment of chronic infection. J Am Acad Orthop Surg 14:S105–S110, 2006. 6. Tetsworth K, Cierny G III. Osteomyelitis debridement techniques. Clin Orthop Relat Res 360:87–96, 1999. 7. Chakraborti C, Le C, Yanofsky A. Sensitivity of superficial cultures in lower extremity wounds. J Hosp Med 5:415–420, 2010. 8. Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 119:138e–148e, 2007. 9. Yoshimura M, Shimada T, Matsuda M, Hosokawa M, Imura S. Treatment of chronic osteomyelitis of the leg by peroneal myocutaneous island flap transfer. J Bone Joint Surg Br 71:593–596, 1989. 10. Mojallal A, Wong C, Shipkov C, Hocuoq C, Recchiuto J, Brown S, Rohrich R, SaintCyr M. Redefining the vascular anatomy and clinical applications of the 567 sartorius muscle and myocutaneous flap. Plast Reconstr Surg 126:1240–1252, 2010. 11. Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 112:129–140, 2003. 12. Parrett BM, Pribaz JJ, Matros E, Przylecki W, Sampson CE, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg reconstruction. Plast Reconstr Surg 123:1499–1504, 2009. 13. Bobroff GD, Gold S, Zinar D. Ten year experience with use of Ilizarov bone transport for tibial defects. Bull Hosp Jt Dis 61:101–107, 2003. 14. Demir B, Gursu S, Oke R, Konya NM, Ozturk K, Sahin V. Shortening and secondary relengthening for chronically infected tibial pseudarthroses with poor soft tissues. J Orthop Sci 14:525–534, 2009. 15. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases. J Orthop Trauma 18:150–157, 2004. 16. Nho SJ, Helfet DL, Rozbruch SR. Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame. J Orthop Trauma 20:419–424, 2006. 17. Lerner A, Fodor L, Soudry M, Peled IJ, Herer D, Ullmann Y. Acute shortening: modular treatment modality for severe combined bone and soft tissue loss of the extremities. J Trauma 57:603–608, 2004. 18. Bibbo C, Karnik SS, Albright JT. Ilizarov wound closure method for traumatic soft tissue defects. Foot Ankle Int 31:628–633, 2010.

Reverse sural flap with bifocal Ilizarov technique for tibial osteomyelitis with bone and soft tissue defects.

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk pa...
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