PMC5459457_01
Case 1. (a) Gross appearance of the wound. Open fracture and attachment of necrotic tissue and associating Pseudomonas aeruginosa infection can be seen. (b) X-ray image at the time of first medical examination. Degeneration of the tibial cortex is observed.
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The patient was first brought to the emergency room and was treated using negative-pressure wound therapy (NPWT); however, trauma site infection appeared after 4 days and he was transferred to our department (Figure 1).
Intra-operative view of Case 1. (a) View after the debridement process. The denuded tibialis posterior tendon and flexor digitrum longus tendon are preserved as much as possible. (b) Indocyanine green was injected at two sites around the left anterior superior iliac spine area to identify the left inguinal lymph nodes. (c) The flap was made and raised to include the identified lymph nodes.. ICG: indocyanine green; LN: lymph node.
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ICG lymphography was then performed to identify the lymph flow and the inguinal lymph nodes in the left inguinal region (Figure 2(b)). An 8 x 15 cm free tissue flap was harvested containing two lymph nodes (Figure 2(c)) and the flap was anastomosed to the branches of the anterior tibial artery and vein.
Post-operative view of Case 1. (a) Complete epithelialization of the wound is observed after a 10-month post-operative follow-up. (b) The functional impairment in the ankle joint is kept to a minimum. The patient is able to stand on tiptoes. (c) Post-operative ICG imagining shows accumulation of ICG in the transplanted lymph nodes, thus confirming the attachment of the nodes.. ICG: indocyanine green; LN: lymph node.
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No other post-operative complication was observed and the flap and skin graft had attached successfully (Figure 3(a)). After a post-operative period of 2.5 years, the ankle joint function and toe flexion movements suffered only minimal impairment (Figure 3(b)) and the patient had recovered to a point where he could play soccer without any problems. Post-operative ICG lymphography confirmed the accumulation of ICG in the transplanted lymph nodes within the flap, indicating the lymph node had successfully attached to the recipient area (Figure 3(b)).
PMC5459457_02
Case 2. (a) Pre-operative view showing an extensive contused scar and refractory ulcerations in the anterior right crus. Bone denudation is also observed under the ulcerations. (b) Intra-operative view of the ulceration sites. Partial debridement of the exposed anterior side of the tibia is performed.
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Examination revealed a 15 x 3 cm wide scar in the right tibial area, within which there were two ulceration sites with pus-like discharge (Staphylococcus aureus (2+), Enterobacter aerogenes (1+), Strebtococcus agalactiae (1+)) (Figure 4(a)). The excess tissue in the anterior part of the tibia was shaved off (Figure 4(b)) and the bare area was covered by the 5 x 8 cm flap (Figure 5).
Intra-operative view of Case 2. A superficial circumflex iliac artery flap containing lymph nodes was harvested from the left inguinal area.. LN: lymph node.
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The excess tissue in the anterior part of the tibia was shaved off (Figure 4(b)) and the bare area was covered by the 5 x 8 cm flap (Figure 5).
Post-operative view of Case 2 after 29 months. Complete epithelialization of the scar is observed and skin ulcerations and osteomyelitis complications have ceased.
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No post-operative complications were observed and the wound area healed successfully (Figure 6).