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Complex Wound Management Following Hip Disarticulation After Traumatic Garbage Truck Accident
Andre Rafizadeh, MD, Jason DeGiovanni, MD, Katherine Kozlowski, Jordan D. Frey, MD
University at Buffalo Jacobs School of Medicine, Buffalo, NY
17-year-old male patient presented as a polytrauma after being run over by a garbage truck twice. After undergoing major trauma damage control in the form of vascular, thoracoabdominal, pelvic, genitourinary, and spinal operations, plastic surgery was consulted for management of his left hip disarticulation wound complicated by progressive necrosis secondary to a common iliac artery occlusion. We performed several debridements prior to definitive wound coverage. Various reconstructive options were considered including a filet, gluteal, rectus abdominis, and upper extremity flaps, however we wanted to preserve his right lower extremity and core for future stabilization and the wound required a large surface area. Lastly, a free flap was discussed but the recipient site lacked arterial inflow. Thus, we created an AV loop graft utilizing his right saphenous vein hooked up to right deep inferior epigastric artery prior to flap inset. Despite initial success, the AV loop had thrombosed on post-operative day twelve. Given limited remaining vessels, we raised a left latissimus/parascapular chimeric flap with left radial artery inflow. The post-operative course was complicated by arterial thrombosis on post-operative day two requiring revision, followed by venous congestion requiring revision and leech therapy, and ultimately flap excision secondary to further compromise. After which time we continued with further wound debridement, bone burring, and hardware removal until adequate vascularization was visualized. Finally, an artificial dermal matrix with subsequent application of autologous skin cell suspension combined with meshed split-thickness skin grafting. The patient was discharged to a rehabilitation facility where his wound remains covered.
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