Surgical Muscle Flap in the Early Phase of Infectious Treatment of a Fracture-Related Infection

Postoperative (PO) infection after trauma is one of the most feared complications, and large extensions of raw area remain a challenge for patient rehabilitation. To describe a case of fracture-related infection (FRI) of tibial plateau osteosynthesis (OS) treated with early surgical muscle flap and prolonged antimicrobial therapy. Presentation of a clinical case of early FRI in the left leg with extensive necrosis of the operative wound, with debridement and total exposure of the OS, requiring a surgical muscle flap in the initial phase of infection treatment. A 55-year-old man after a car accident with a comminuted fracture of the left tibial plateau underwent external fixation and, after 10 days, definitive osteosynthesis with plate and screw. On admission: Hb 14.3, Hct 40.8, leukocytes 9300, and CRP 0.06, with Hb drop to 9.3, Hct 26.4, and CRP rise to 22.96 after 10 days. On postoperative day 14, the operative wound developed drainage and extensive soft tissue necrosis. Vancomycin and meropenem were started with collection of 5 tissue fragments for culture and two biopsies for pathology. Debridement of all necrotic area was performed and, in the same procedure, a muscle flap and skin graft were performed. Tissue fragment culture grew Klebsiella oxytoca and bone fragment culture from the left leg grew Enterobacter cloacae and Stenotrophomonas maltophilia, and pathology of the pretibial region showed an ulcerated skin lesion associated with exacerbated chronic inflammatory process, suppurative, extending to skeletal striated muscle tissue. On postoperative day 15, CRP dropped to 1.04 and Hb to 10.8 and Hct to 33.6. Treatment with ciprofloxacin and trimethoprim-sulfamethoxazole (TMP-SMX) was given for 12 weeks with fracture consolidation and good flap integration. However, during follow-up, after one year, the patient presented a fistula in the upper region of the left leg, requiring removal of fixation material with assistance from plastic surgery and a new cycle of antimicrobial treatment with TMP-SMX for 6 weeks, with culture collection and two samples positive for S. aureus. The patient had no further complications after 5 years of follow-up. Treatment of an FRI may require a multidisciplinary team with participation of the orthopedist, plastic surgeon, and infectious disease specialist for safer and faster rehabilitation.