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Free-Tissue Transfer for Limb Salvage in Purpura Fulminans

MacLennan, Susan E. M.D.; Kitzmiller, W. John M.D.; Yakuboff, Kevin P. M.D.

Plastic and Reconstructive Surgery: May 2001 - Volume 107 - Issue 6 - p 1437–1442
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A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the “zone of injury.” Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-toend anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage. (Plast. Reconstr. Surg. 107: 1437, 2001.)

Cincinnati, Ohio

From the Division of Plastic, Reconstructive, and Hand Surgery at the University of Cincinnati College of Medicine and Shriners Hospitals for Children-Cincinnati Burns Hospital. Received for publication July 19, 1999; revised June 8, 2000.

Presented at the American Society for Reconstructive Microsurgery Annual Meeting in Miami Beach, Florida, in January of 2000.

Kevin P. Yakuboff, M.D.

Division of Plastic, Reconstructive, and Hand Surgery

University of Cincinnati College of Medicine

231 Bethesda Avenue

Cincinnati, Ohio 45267

©2001American Society of Plastic Surgeons