Free tissue transfer within the sickle cell population has a high complication rate secondary to an elevated risk for thrombosis associated with the procedure which is compounded with the ischemia-related sickling inherent to the sickle cell disease (SCD) [1, 2, 3, 4, 5]. The choice of free flap depends greatly on the location and size of the skin defect. The most common free flap options for lower extremity reconstruction are the anterolateral thigh flap, the radial forearm flap, the lateral arm flap, the gracilis muscle flap, the rectus abdominis flap and lastly the latissimus dorsi flap and its variations ^[6]. I Gracilis free flaps are often thought of as the work horse of the lower extremity flaps with overall success rates in optimized patients ranging from 92% to 94% [9, 10]. Despite this high success rate, there has only been one previously reported successful free gracilis flap ^[8]. This case involved reconstruction of medial and anterior ankle wounds that resulted after necrosis of surgical incisions following intramedullary nailing of a distal tibia fracture in a patient with sickle anemia using a previously published protocol.

This is a 20 year old female with past medical history significant for sickle cell anemia, cardiomyopathy secondary to a ventricular septal defect and multiple occurrences of osteomyelitis who sustained a closed, distal third tibial shaft fracture through a segment of infarcted bone after a ground level fall (Fig. 1 and 2). The patient underwent uncomplicated suprapatellar nailing of the tibia fracture (Figs. 3 and 4). At the 1 month follow up visit, there was evidence of full thickness skin necrosis of the medial and anterior incisions around the ankle that were used to insert the distal tibial locking screws (Figs. 4 and 5). The patient started on a 6-week course of intravenous cefazolin and operative debridement of the necrotic tissue was performed. Serial debridements resulted in a medial wound approximately 5 × 8 cm with exposed bone and exposed intramedullary nail and an anterior wound measuring 5 × 5 cm with exposed tibialis anterior tendon (Figs. 6 and 7). Due to the exposed fracture, implant, and tendon, the decision was made to proceed with free tissue transfer for wound reconstruction. Due to the dimensions of the wounds and their orientation, a free gracilis was chosen to reconstruct both wounds. Pre-operative fractionated HbS was measured at 24% and therefore exchange transfusion was not necessary. The patient was warmed pre-operatively and multiple intraoperative warming devices were utilized throughout the case including an underbody and overbody warming system. Total hemoglobin was measured throughout the surgery to ensure it remained above 7.0. All irrigation fluids utilized intraoperatively were warmed in a fluid warmer and the flap was kept wrapped in warm saline-soaked laparotomy sponges throughout the case. 5000 units of heparin was systemically administered just prior to ligating the arterial pedicle to the gracilis muscle flap and the total ischemia time was 54 min. Post-operatively, the patient was started on a heparin infusion to target an aPTT between 50 and 70. The patient was started on oral aspirin 325 mg on post-operative day 2. A dangle consisting of increasing time periods of allowing the leg to hang off the bed while monitoring tissue oxygenation was started on post-op day 5. The heparin infusion was continued for 14 days post-operatively and then the patient was transitioned to lovenox 30 mg BID. The flap healed completely with no evidence of wound healing issues with bone union obtained at the final visit 11 months post-. (Fig 8).

This case report describes the second published gracilis free flap in a patient with SCD using an anticoagulation protocol derived from previous successful published case reports. Most of the literature on free flaps in the sickle cell population are for the treatment of non-healing ulcers, as opposed to soft tissue defects secondary to trauma [4, 5, 6, 7, 8]. Wound reconstruction in the trauma population creates multiple additional challenges when compared to otherwise healthy patients seeking care for ulcers as trauma patients typically present with multiple different injuries, such as head traumas, lacerations, and penetrating injuries compounding already challenging cases. In addition, trauma patients tend to have more complex follow up regimens which can cause poorer compliance which further complicates outcomes due to the scarcity of published reports on free tissue transfer in patients with sickle cell, there is no one established perioperative protocol that has been widely adopted. This creates challenges when patients require free tissue transfer at facilities where this procedure is not commonly performed on this population. Often the nature of the injuries precludes transfer of these patients to higher volume centers which may have more experience in treating these problems. Certainly, if perioperative and anticoagulation protocols exist in high volume reconstructive microsurgery centers, publication of these protocols would be invaluable to other surgeons or institutions when they come across this problem. There is still limited data regarding free flap utilization within the sickle cell population and careful consideration should be taken with each case to determine what type of flap and the appropriate donor site. We implemented a successful perioperative protocol with a detailed anticoagulation plan and to successfully reconstructed lower extremity defects using a gracilis free flap in a patient with SCD. The details of this case including the anticoagulation management plan should be added to the literature for consideration in future cases. (Fig. 9-11).

There are few reported cases of free flaps utilized in the sickle cell population and even fewer of these cases were used to close a soft tissue defect following lower extremity trauma. Further publication of successful free tissue transfers in patients with sickle cell anemia including perioperative and anticoagulation protocols is necessary to improve patient outcomes. Thus, our patients’ successful flap placement can add to the existing literature and hopefully help in the success of future free flaps in this population.

The use of a free flap in the treatment of a soft tissue defect of a patient with SCD is not an absolute contraindication and should be considered as a viable treatment option for certain patients.