Free-tissue transfer for limb salvage in purpura fulminans

A series of 13 patients is described to demonstrate the experience of the a uthors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a los s of flap in one patient. The flaps were used for lower-extremity salvage i n six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as menin gococcus and pneumococcus. Clotting derangements and systemic vasculitis of ten 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 salvag e. Microsurgical reconstruction in patients with purpura fulminans is a for midable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platele t counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be b eneficial. The systemic nature of the vascular injury does not permit micro vascular anastomosis to be performed outside the "zone of injury." Extensiv e vascular exposure, even at a great distance from the wound, does not reve al a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too s evere to sustain a patent anastomosis. Patients often have peripheral neuro pathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.