Grand Rounds Vol 10 pages 34–37

Specialities: Orthopaedic surgery; Plastic surgery

Article Type: Case Report

DOI: 10.1102/1470-5206.2010.0009

� 2010 e-MED Ltd

Free flap reconstruction following lower

leg trauma in the presence of

rhabdomyolysis

R.P. Lahiria, A. Roshana, K.M. Burnandb and A.J. Durrania

aDepartment of Plastic and Reconstructive Surgery, Addenbrookes Hospital,

Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK;bDepartment of Vascular Surgery, Norfolk and Norwich University Hospital

NHS Foundation Trust, Norfolk, UK

Corresponding address: Mr R.P. Lahiri, CT1 in Plastic and Reconstructive Surgery,

Department of Plastic and Reconstructive Surgery, Addenbrookes Hospital,

Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK.

Email: rajlahiri@doctors.org.uk

Date accepted for publication 26 April 2010

Abstract

Rhabdomyolysis is considered a relative contra-indication to free tissue transfer because of the

formation of free radicals that cause endothelial damage to the microcirculation. We describe the

case of a young man who required free tissue transfer coverage of a large open fracture of his

right tibia and fibula. This was performed successfully in the presence of rhabdomyolysis.

Keywords

Free tissue transfer; rhabdomyolysis; ischaemia–reperfusion injury.

Introduction

Rhabdomyolysis is considered by some authors to be a relative contraindication to reconstructive

surgery by free tissue transfer. This is because of the accumulation of free radicals that cause

cellular damage to the microcirculation and potentially cause flap compromise. We present a case

of successful lower leg free flap reconstruction following trauma in the presence of

rhabdomyolysis, which we have not found described previously described in the literature.

Case report

A 22-year-old male presented to the Emergency Department at Addenbrookes Hospital following

a road traffic accident. He hit a tree at high speed and had to be extricated from the vehicle,

which took approximately 2h. He was managed according to the advanced trauma life support

(ATLS) protocol and his primary survey was clear with a Glasgow coma score (GCS) of 12/15.

He had obvious deformity in both thighs and radiographs revealed open fracture of his left

femur (Fig. 1a), closed fracture of his right femur (Fig. 1b) and open fractures of his right tibia

(Gustillo and Anderson IIIb) and fibula (Fig. 1c). There was no neurovascular compromise to either

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leg. With the patient haemodynamically stable, he was transferred for a computed tomography

(CT) scan as per hospital protocol, which revealed no intra-cranial, intra-thoracic or intra-

abdominal pathology.

He was immediately taken to theatre by the orthopaedic on-call team who performed intra-

medullary nailing of the right femur, washout of the left femoral fracture and debridement and

external fixation of the right tibia. The left femoral fracture was not fixed immediately as the

wound was significantly contaminated and was deemed to require a second look prior to free flap

reconstruction. Following the operation, the patient was transferred to the intensive therapy unit

(ITU) where he was sedated and ventilated. All haematological and biochemical investigations

were within normal parameters following surgery other than a creatine kinase (CK) level of 5970.

The patient remained stable in ITU for 3 days, with his CK rising to greater than 11,000. His

rhabdomyolysis was treated by forced alkaline diuresis. He did not meet the hospitals’ criteria for

haemofiltration which also requires deranged renal function or hyperkalaemia (Table 1).

(a) (b)

(c)

Fig. 1. (a) Radiograph of fractured left femur (open). (b) Radiograph of fractured right femur (closed). (c) Radiograph offractured right tibia and fibula.

Free flap reconstruction and rhabdomyolysis 35

Five days after admission, with a CK of 4892, the patient returned to theatre for a left femoral

nail, right tibial nail and left latissimus dorsi (LD) free flap reconstruction and split skin grafting

of the middle third of the right tibia. This was in accordance with the national guidelines for

management of open fractures in lower limb trauma[1]. The flap was raised in standard fashion

with good flow and reperfusion of the flap following anastomosis. The ischaemia time was 55min.

Skin grafts were taken from the right thigh to cover the (LD) reconstruction. Following surgery,

the patient returned to ITU where his CK rose to 13,944 and was restarted on forced alkaline

diuresis. He remained haemodynamically stable and his CK decreased gradually to less than 2000

over the next 3 days. In this same period, the free flap reconstruction remained clinically healthy

with good Doppler flow monitoring.

Four days following free flap reconstruction of his right leg, the patient was discharged to the

plastic surgery ward where he continued to improve with no complications regarding his free flap

reconstruction and 95% take of the skin graft covering the flap. After 1 week on the ward, the

patients’ CK had returned to normal and all other haematological and biochemical markers were

within the normal range. Following physiotherapy and occupational health assessment, the

patient was discharged 1 month after his admission. He was seen in the plastic surgery outpatient

clinic 6 weeks after discharge and was making excellent progress with respect to his flap (Fig. 2).

Following regular orthopaedic follow-up, the patient began weight bearing 4 months after the

injury.

Discussion

The management of lower leg trauma with significant tissue loss has improved significantly with

the advent of free tissue transfer. Godina demonstrated that free flap transfer within 72 hours

Table 1. The relationship of CK to operative procedures in the first 9 days of admission

Day of admission CK level Operative intervention

1 3733 Debridement and external fixation right tibia, washout left

femur and intra-medullary nail right femur

1 (post-op) 5790

3 9798

4 11373

5 4892 Left femoral nail, right tibial nail and left LD free flap

reconstruction

6 13944

7 10956

8 8859

9 2047 Transferred to plastic surgery ward

Fig. 2. Free LD reconstruction of open right tibia fracture (Gustillo and Anderson IIIb).

36 R.P. Lahiri et al.

produced significantly less flap failures, less post-operative infections, shorter bone-healing time,

shorter hospital stay and fewer operative procedures[2]. Naique et al.[3] demonstrated that there is

an increased incidence of complication rates and revision surgery in patients with grade IIIb open

tibial shaft fractures who are not initially treated at a specialist centre.

Rhabdomyolysis is literally defined as the dissolution of striped muscle[4]. It has many causes

including trauma, infection and drugs[5]. It results in the leakage of intracellular muscle

constituents including electrolytes, myoglobin and lactate dehydrogenase and most commonly

presents with myalgia, weakness and gross pigmenturia[5]. Cellular damage in rhabdomyolysis is

believed to be caused by uncontrolled leakage of reactive oxygen species[4]. The management of

rhabdomyolysis involves aggressive hydration, forced diuresis, alkalinisation of urine and

haemofiltration if required[5].

Free tissue transfer in the trauma situation is advised within 7 days of injury for optimum

results[1] and involves an obligatory period of ischaemia and reperfusion injury after division of

the pedicle[6]. Factors involved in ischaemic–reperfusion injury to free flaps include reactive

oxygen species, leucocytes and complement and these are the main factors that can lead to flap

failure[7]. Rhabdomyolysis is seen as a relative contra-indication to free tissue transfer due to the

generation of reactive oxygen species which causes damage to the microcirculation as a result of

the swelling of endothelial cells, vasoconstriction and increased capillary permeability. Many of

these actions are caused by up-regulation of the xanthine oxidase system, and in rat models,

allopurinol has been shown to reduce the formation of reactive oxygen species and increase flap

survival[7].

Teaching point

This case illustrates that successful early free flap reconstruction in the trauma setting is possible

in the presence of rhabdomyolysis, which has not previously been described in the literature. To

minimise the complications of rhabdomyolysis, it is important for the clinician to recognise the

condition as early as possible. Management should be performed according to hospital protocol,

but involves aggressive intravenous fluid resuscitation aiming for a urine output of greater than

200ml/h[4]. If plasma CK continues to rise, forced diuresis using mannitol can minimise

intratubular haem pigment deposition and act as a free radical scavenger[5]. Alkalinisation of

urine using sodium bicarbonate prevents myoglobin toxicity in the nephron and uric acid crystal

formation. If symptoms continue to worsen, haemofiltration can be used to treat acute renal

failure[4]. Although the renal function was not deranged in this case, it is important to pre-

operatively maximise the renal function of the patient with rhabdomyolysis in order to minimise

the reactive oxygen species burden caused by free tissue transfer and rhabdomyolysis.

References

1. Nanchahal J, Nayagam D, Khan U, et al. Standards for the management of open fractures of

the lower limb. Royal Society of Medicine; 2009.

2. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast

Reconstr Surg 1986; 78: 285–92.

3. Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for

combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br

2006; 88: 351–7.

4. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med 2009; 361:

62–72. doi:10.1056/NEJMra0801327. PMid:19571284.

5. Huerta-Alardı́n AL, Varon J, Marik PE. Bench-to-bedside review: rhabdomyolysis – an overview

for clinicians. Crit Care 2005; 9: 158–69.

6. Siemionow M, Arslan E. Ischemia/reperfusion injury: a review in relation to free tissue

transfers. Microsurgery 2004; 24: 468–75. doi:10.1002/micr.20060. PMid:15378577.

7. Im MJ, Hoopes JE, Yoshimura Y, et al. Xanthine: acceptor oxido-reductase activities in

ischaemic rat skin flaps. J Surg Res 1989; 46: 230–4. doi:10.1016/0022-4804(89)90062-0.

Free flap reconstruction and rhabdomyolysis 37