PMC6457015_01
(a) Left tibiofibular shaft open fracture (Gustilo grade IIIb). (b) Left
lower leg open fracture contaminated by roadside soil. (c) The orthopedic
surgeon performed open reduction and internal fixation of the tibiofibular
fracture. (d) We performed an ALT musculocutaneous flap, harvested from the
ipsilateral leg, for defect reconstruction. Recipient vessels were the
anterior tibial artery and its concomitant veins. (e) The patient's
postoperative course was uneventful. However, the proximal part of the flap
started to show mild bluish changes 9 days following reconstruction. (f) The
size of the affected area gradually increased day by day, and dry gangrenous
changes ultimately developed over the proximal one-third of the by 35 days
following reconstruction.
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This report is about a 62-year-old male with uncontrolled type II diabetes mellitus diagnosed 4 years ago and an open tibiofibular fracture of the left lower extremity caused by a traumatic motorcycle accident (Gustilo grade IIIb) (Figure 1(a) and (b)). After open reduction and internal fixation, an anterolateral thigh (ALT) myocutaneous flap was harvested to cover the exposed bone and for defect reconstruction (Figure 1(c) and (d)). The proximal part of the flap began showing a mild bluish change 9 days following reconstruction (Figure 1(e)). The size of the affected area gradually increased, and dry gangrenous changes ultimately developed over the proximal one-third of the flap 35 days following reconstruction (Figure 1(f)).
(a) Orange cottony colonies grew on the Sabouraud dextrose agar. (b)
White-cottony colonies grew on the brain heart infusion agar. (c) Cover
slide under a light microscope showed septated hyphae with acute branching
(lactophenol cotton blue stain, x1000). (d) Cone-shaped microconidia, the
characteristic of Fusarium (lactophenol cotton blue stain,
x1000). (e) Debridement of the gangrenous flap was performed on 35 days
following reconstruction. (f) The periodic acid Schiff stain demonstrates
septated, acute angled fungal hyphae, and spores in the tissues from the
left lower leg (x1000).
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An infectious disease specialist used standard mycological procedures and grew Fusarium species from two separate cultures at different intervals (Figure 2(a) and (b)). A light microscope examination with lactophenol cotton blue stain revealing septated and acute branching hyphae with microconidia spores (Figure 2(c) and (d)). Debridement of gangrenous flap (Figure 2(e)) was performed at 35 days following reconstruction. Specimen pathology revealed a deep fungal infection with clustered fungal spores and septated, acute angled hyphae with extensive necrosis of adjacent tissues (Figure 2(f)).
At 2-year follow-up, the flap was viable with adequate bone union.
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We arranged for a split-thickness skin graft from the ipsilateral leg, and at 2-year follow-up, the flap was viable with adequate bone union (Figure 3).