CASE REPORT

Using extended pedicle lateral gastrocnemius muscle flapwith antibiotic-impregnated calcium sulfate to salvage distalfemur chronic osteomyelitis: a case report

Chih-Hsun Lin & Wen-Hao Tzou & Hsu Ma

Received: 18 June 2011 /Accepted: 18 October 2011 /Published online: 3 January 2012# Springer-Verlag 2011

Introduction

Chronic osteomyelitis remains a challenge and requiresaggressive surgical treatment to be cured. The generalmanagement principle includes radical debridement, seques-trectomy or saucerization, muscle flap coverage, and specificantibiotic therapy. In refractory condition, the patient has toface the problems from long hospital stay, repeat operations,recurrent purulent discharge, poor quality of life, and evenamputation, finally. Besides inadequate debridement orsequestrectomy, poor vascular supply and low regionalantibiotic concentration are possible reasons for recalcitrantcases. With advancement and application in microsurgery,free muscle or fasciocutaneous flap for dead space obliterationin chronic osteomyelitis with bone defect has been announcedand successful [1–3]. However, local muscle flap is still achoice in conditions such as severe fibrotic change post-trauma of the adjacent soft tissue which impedes properrecipient vessel selection for microsurgery procedure [4]. To

elevate regional concentration of antibiotic and speed upbone regeneration in chronic osteomyelitis, there have beenmany bone substitutes incorporated with antibiotics, such asvancomycin-impregnated calcium sulfate (Osteoset®, WrightMedical, Arlington, TN) [5]. The case to be reported hereillustrates the successful salvage of a distal femur chronicosteomyelitis with bone cavity by extended pedicle lateralgastrocnemius muscle flap and antibiotic-impregnated calci-um sulfate in condition where microsurgery was not possible.

The patient was informed that their information has beensubmitted for publication and the patient gave the consent.

Case report

A 65-year-old man with history of cardiovasculardisease sustained a closed comminuted fracture of theright distal femur and tibia in a motorcycle accident8 years ago. The initial treatment at another hospitalconsisted of open reduction and internal fixation withplates and screws. Delayed union of the distal femurfracture was noted 6 weeks later, and wound breakdownwith drainage of the right thigh commenced. Because ofpersistent drainage and bone resorption at the fracturesite of the femur, additional debridement and parenteralantibiotic according to wound culture was applied,followed by removal of the internal fixation device.Under relative stable wound conditions, cancellous bonegraft was applied subsequently 3 months later. However,persistent drainage through sinus tract of fracture siteoccurred in the immediate postoperative period. Thenthe patient received debridement for several times and acourse of antibiotics but in vain. Open wound care withdirect wet dressing was used thereafter until he wasreferred to our plastic surgery department 1 year ago.

C.-H. LinYuanshan Veterans General Hospital,Yilan, Taiwan

C.-H. Lin (*)Plastic and Reconstructive Surgery,Antai Tian-Sheng Memorial Hospital,Pingdong, Taiwane-mail: penul22@yahoo.com.tw

W.-H. TzouOrthopedic Surgery, Yuanshan Veterans General Hosiptal,Yilan, Taiwan

H. MaPlastic and Reconstructive Surgery,Taipei Veterans General Hospital,Taipei, Taiwan

Eur J Plast Surg (2012) 35:775–778DOI 10.1007/s00238-011-0656-0

When we initially examined the patient, he had a 4×3-cm sinus tract with underlying bony cavity about 4×3×4 cm in size at the distal lateral aspect of the rightthigh (Fig. 1a) with foul odor and yellow-greenishdrainage from the depth of the wound. A large bonydefect with lytic-sclerotic change was present in the distalfemur as seen roentgenographically (Fig. 1b). Severe scarringand fibrosis over the right thigh from the middle to distalthird with overlying quadriceps muscle atrophy was noted.Methicillin-resistant Staphylococcus aureus was isolatedfrom deep tissue specimens. Chronic osteomyelitis wasidentified from bone tissue obtained in surgical debridementand sequestrectomy. Erythrocyte sedimentation rate was70 mm/h (<10–15 mm/h). After further extensive debride-ment of the wound including saucerization for twice,purulent discharge gradually decreased. Antibiotics in theform of vancomycin were given for 6 weeks.

In consideration of the difficulty in finding recipientvessels due to severe fibrosis at right thigh and knee, apedicled lateral gastrocnemius muscle flap was planned toobliterate the dead space. We extended the gastrocnemiusmuscle flap by transecting the muscle origin and makingsome linear incisions of the fascia of the muscle to obtain alarger arc of rotation (Fig. 2a, b). The flap was turned overto cover the right thigh and common peroneal nerve at thelevel of the fibula head. Vancomycin-impregnated calciumsulfate pellets (Osteoset®, Wright Medical Technology, Inc.Arlington, TN 38002, USA) was added in the bony defectof the femur to obliterate the remaining dead space andenhance regional drug concentration.

One week later, the muscle flap was resurfaced withsplit-thickness skin graft. Postoperative recovery wasuneventful, and the sinus was obliterated (Fig. 3a). There

Fig. 1 a A draining sinus(arrow) at the distal lateralaspect of the right thigh withsevere scarring and muscleatrophy of the quadriceps. b Abony defect with sequestrumand osteolytic-sclerotic change(arrow) in the right distal femur

Fig. 2 a Extend the flap by transecting the muscle origin at the distalfemur (arrow: common peroneal nerve). b Extend the flap by makinglinear incisions of the muscle fascia

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is no relapse of osteomyelitis in at least 12 months follow-up. The only minor complication was a transient numbnessat the lateral aspect of the foot for about 3 months.Erythrocyte sedimentation rate decreased to 12 mm/h grad-ually, and X-ray revealed cortical trabecular bone formationat 6 months (Fig. 3b). The patient could ambulate byhimself without aids after 3 months.

Discussion

Severe distal femoral fractures may be associated withdevascularization of cortical bone, soft-tissue loss, andsignificant morbidity. Chronic osteomyelitis usually repre-sent as refractory course which severely impair the patient’squality of life, increase health insurance payment, or evenamputation despite extensive surgery [1]. Early andcorrective treatment protocol is necessary for the limbsalvage [2]. The principle of the treatment of chronicosteomyelitis is infection eradication with systemic antibi-otic therapy and local management with radical excision ofthe infected tissue and obliteration of the remaining deadspace [3]. Adequate debridement and coverage with awell-vascularized tissue are mandatory for a successfuloutcome. According to the experience at the Universityof Texas Medical Branch in Galveston, TX, the averagenumber of operations for a limb-salvage patient is about3.8 procedures [4].

The staging system according to Cierny–Mader is themost useful for the therapeutic management by surgeons[4]. The clinical stage of this patient is IIIBL, a full-thickness, cortical sequestration, and/or cavitation with bothmedullary and cortical involvement that is stable mechan-ically after debridement [5]. The reconstruction procedures

include viable hard and soft tissue transfers, cancellousbone grafts, or vascularized soft tissue [4, 5].

Muscle flaps (either local or free-transfer) are highlyresistant to infection, and they provide the necessaryenvironment for the eradication of infection and woundischemia associated with chronic osteomyelitis [6]. Localmuscle flaps, delayed flaps, and myocutaneous island flapshave been used extensively in the management of chronicinfection with encouraging results [1]. With advancement inmicrosurgery, free flaps usually represent a better option incases where the condition of the patient is not a limitingfactor. Muscle or fasciocutaneous free flaps may both beused, and in cases, with major bone loss, a free vascularizedbone graft can be considered.

Selection of recipient vessels around the knee ordistal femur is not easy because the popliteal or suralartery cannot be used in a defect at the anterior surfaceof the knee, and other branches of the superficialfemoral or circumflex femoral artery are less reliable[7]. In a condition with locally vascular compromise andextensive scarring at the right thigh related to previoussurgical procedures (plates and screws management,post-traumatic infection, peri-operative infection, etc.),recipient vessel selection is much more difficult anddissection is more dangerous. Meanwhile, with the disuseatrophy of the quadriceps muscle due to joint stiffness inthis patient, regional muscles of the right thigh arenot preferred for reconstruction. Thus, the hemi-gastrocnemius muscle flap is an easily applied flap forsoft tissue reconstruction around the knee, though it israrely mentioned in supra-knee/distal femur reconstruc-tion. In consideration of the limited arc of rotation, wetried to extend the flap as long as possible by transectingthe muscle origin at the distal femur and making

Fig. 3 a Postoperative view(clinical, 6 months), completeobliteration of the wound andsinus. b Postoperative view(X-ray, 6 months), bonesubstitute resorption and somecortical trabecular boneformation (arrow)

Eur J Plast Surg (2012) 35:775–778 777

incisions of the muscle fascia. With this maneuver, thereach of this flap can be extended for complete woundedge approximation in our patient. Wei et al. used aninterposition vein graft to extend the flap length, but thisis indicated for more distant wounds. In this fibrotic anddeep-seated space, microvascular anatomosis is techni-cally highly demanding [8].

In conclusion, a well-vascularized soft tissue is neces-sary for the salvage of chronic osteomyelitis at lower limbs.At distal femur, the selection of flaps or recipient vessels issometimes not easy due to regional compromised softtissue. In this case, the dead space can be obliteratedcompletely by extending the lateral gastrocnemius muscleflap with innovative biomaterials.

Conflict of interest None of the authors have any conflict of interestto disclose.

Funding There are no study sponsors or funding sources.

References

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4. Cierny G 3rd, Mader JT, Penninck JJ (2003) A clinical stagingsystem for adult osteomyelitis. Clin Orthop Relat Res 414:7–24

5. Kinik H, Karaduman M (2008) Cierny–Mader Type III chronicosteomyelitis: the results of patients treatedwith debridement, irrigation,vancomycin beads and systemic antibiotics. Int Orthop 32:551–558

6. Mathes SJ, Alpert BS, Chang N (1982) Use of the muscle flap inchronic osteomyelitis: experimental and clinical correlation. PlastReconstr Surg 69:815–829

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