Annals of the MBC - vol. 4 - n' 4 - December 1991

THE TREATMENT OF TIBIAL OSTEOMYELITIS FOLLOWING BURN INJURIES

Gabilondo F.J., Torrero J.V., Llop M.

Department of Plastic Surgery and Burn Centre, Hospital Cruces, Baracaldo, Vizcaya, Spain

SUMMARY. The tibial osteomyelitis, underlying ulcers of the lower third of the leg in serious bums cases poses, after survival of the acute episode, a two-sided problem: (i) the cleansing of the bone of the affected and isolated zone which is the cause and location of the osteomyelitis, resistant to conventional treatment, and (ii) the covering of the ulcer in a zone which with difficulty provides soft parts, aggravated by the fact that the extremities are covered with grafts in patients with bad cutaneous covering and few donor zones. This accumulation of circumstances can be resolved by providing a cutaneous covering of good quality with its own vascularization from another area which closes the defect, not only of the ulcer but also of the larger zone of the cleansing of the bone in the alIceted area. To do this, we used a free skin flap with its vascular pedicle connected to the posterior tibial artery outside the zone of the pathology.

In cases of extensive burns whose gravity requires a large quantity of self-grafts to cover the zones with deep burn which have been previously removed, one must propose a second stage in their treatment with reconstruction problems which are difficult to resolve in patients with large areas of grafts. One of these problems is the presence of ulcers in the inferior extremities with bone involvement in the inferior third of the tibia, with exposed bone and episodes of underlying osteomyelitis. The solutions of this problem using techniques with neighbouring tissues, or using the other extremity which is also burned, are not fully appropriate to the therapeutic requirements. This is true of the case with which we are concerned, whose previous state can be seen in the figures (1, 2, 3).
After carrying out an arteriographic study (Fig. 4) we decided on the cleansing of the osteomyelitis area and the simultaneous closing with a large vascularised free skin flap, based on the pedicle of the radial artery (Figs. 5, 6).
The solution ~ with a long vascular pedicle of the radial vessels which are anastomosized in another place to the posterior tibial artery enables us to perform the closure previously referred to. This covers all the bone area treated with the racquet of appropriate dimensions obtained in the design of the forearm skin flap or Chinese forearm flap, with an acceptable immediate result which can be seen in the figures and which enables the patient to walk (1, 2, 3).

Osteomyelitis of the lower third of the tibia poses a challenge in its treatment which demands various aims: resection of the osteomyelitic zone of the bone,

Fig. 1 Tibial bone exposure of a burn patient Fig. 2 R.X. of the patient with the underlying damage

It is better to perform the vascular anastomosis as far as possible from, and in a proximal sense to, the zone of the pathology, as was done in the posterior tibial artery in a proximal sense for greater security. All this is possible with the free forearm skin flap chosen, if its vascular pedicle has considerable length and good size vessels.
Within the range of vascularized free skin flaps, it is also useful to simplify procedures to obtain greater safety in surgery. At the present time the forearm free skin nap has an important role, for various reasons:

• versatility of dimensions and design of the re-covering cutaneous flaps
• possibility of the provision of bone, tendons, nerves, etc. abundant length of the vascular pedicle adequate size of its vessels.

Fig. 3 R.X. of the underlying osteomyelitis Fig. 4 Arteriographic study

a covering with good vascularization and, in the case of patients with burns in both inferior extremities, the limited possibility of other traditional procedures such as cross-leg grafts, neighbouring flaps re-covered with grafts or muscular flaps in badly affected extremities and in a serious condition.
In the case that we present the patient had all of these extreme conditions, in addition to a state of muscular atrophy as a consequence of his inactivity and difficult rehabilitation. Nor was it possible to eliminate the pain or fever which impeded him from walking.
For all these reasons we decided on the above treatment whose advantages, in one surgical intervention, give a re-covering of good quality and adequate design of the racquet to use for reconstruction of the zone. These advantages make it worth the risk inherent in free skin flaps transplanted by microsurgery (Figs. 4, 5).

Fig. 5 The free flaps: immediate result Fig. 6 The result atter more time

RÉSUMÉ. L'ostéomyélite tibiale sous-jacente aux ulcères du tiers inférieur de la jambe dans les cas de brûlures sévères pose, après le moment aigu, un problème qui peut être appréhendé de deux façons: (i) le nettoyage de l'os dans la zone atteinte et isolée qui est la cause et.la localisation de l'ostéonryélite, résistante au traitement conventionnel, et (ii) la couverture de l'ulcère dans une zone qui offre peu de parties molles, ce qui est aggravé par le fait que les extrémités sont couvertes de greffes en des patients ayant une mauvaise couverture cutanée et peu de sites donneurs. Cette combination de circonstances peut être résolue en créant une couverture cutanée de bonne qualité avec sa propre vascularisation provenante d'une autre zone qui ferme le défaut non seulement de l'ulcère mais aussi de la zone plus grande du nettoyage de l'os dans la zone atteinte. Pour faire cela, nous avons utilisé un lambeau libre de peau avec le pédicule vasculaire relié à l'artère tibiale postérieure hors de la zone pathologique.

BIBLIOGRAPHY

1. Yang, Guofan et al.: Forearm free skin flap transplantation. National Medical Journal of China, 61: 139, 1981.
2. Song R., Gao, Ytizhi, Song Y., Yu Y., Song Y.: The forearm flap. Clinics in Plastic Surgery, 9: 21, 1982.
3. Lamberty B. G. IT, Cormack G.C.: The antecubital fasciocutaneous flap. British Journal of Plastic Surgery, 36: 428, 1983.
4. Webster M., Soutar D.S.: "Free Tissue Transfer", Butterworths, London,1986.
5. Gordon L.: "Microsurgical Reconstruction of the Extremities". Springer-Verlag Inc., New York, 1988.