Pedicled Soleus Muscle Flap for Salvage Therapy of Chronic Limb-Threatening Tibial Osteomyelitis: A Case Report

The resurgence of opiate and intravenous drugs abuse in the United States has presented a renewed challenge to surgeons in community-based hospital settings. Patients often present with complex wounds, and when complicated by concomitant osteomyelitis, these wounds require special attention and diligent care. Local rotational flaps have been used in the salvage therapy of limb-threatening lower extremity trauma for years, and have been adapted in part for the use in patients with chronic, limb-threatening osteomyelitis. The use of local rotational flaps for coverage of chronic osteomyelitis is a viable, proven, and well-founded surgical technique with excellent results. Within our hospital setting, we have seen an explosion of patients presenting with chronic, limb-threatening wounds related to intravenous and subcutaneous injection of a variety of illicit drugs. Here, we describe a case of a 24-year-old female with a history of intravenous drug abuse (IVDA) who presented with an extensive left lower extremity wound which had been progressing for several years. The patient was acutely intoxicated but otherwise healthy. Due to extensive tissue loss and osteomyelitis, initial evaluation deemed her leg unsalvageable. However, given the immense morbidity associated with lower extremity amputation the plastic surgery team felt that salvage should be attempted in this young woman. She underwent numerous tissue debridements, washouts, cadaveric skin grafting, and a pedicled soleus muscle flap with eventual autologous skin grafting. The patient was kept in the hospital during this time to allow her to detox and undergo psychiatric evaluation and therapy. This approach allowed her to regain nearly full use of her limb, gain employment, as well as abstain from further drug use. As the opioid epidemic continues in inner cities throughout the United States, the increased burden on local medical centers to care for chronic limb-threatening wounds will continue to rise. Locoregional flaps provide good results but may not be suitable for unreliable patients struggling with addiction. However, in motivated patients, our approach of inpatient detox and delayed reconstruction has shown promising results.