Recalcitrant Osteomyelitis Treated by Multiple Flaps and Negative Pressure Wound Therapy with Instillation

Abstract

A 70-year-old man with diabetes mellitus underwent total knee arthroplasty (TKA) for osteoarthritis secondary to infectious arthritis seven years ago. Revision TKA was followed by knee fixation because of latent infection two years ago. However, arthrodesis failed in nonunion because of the recurrence of infection. The knee was treated by thorough debridement, the placement of antibiotic-impregnated cement spacers (AICS) and negative pressure wound therapy with instillation (NPWTi) . After one month, a medial gastrocnemius flap and medial soleus flap with a mesh full thickness skin graft (FTSG) were transferred. Two months later, osteosynthesis with double plates and vascularized fibula graft (VFG) transfer with a peroneal flap were performed. The peroneal flap became necrotic and the plates were exposed. After NPWTi was repeated seven times over two months, the lateral gastrocnemius flap and tensor fasciae latae flap with the mesh FTSG were transferred. At the follow-up at one year and three months, the vascularity of the VFG and bone formation were confirmed without infection symptoms. Surgical vascularization with NPWTi is suggested to be effective for recalcitrant osteomyelitis.