Surgical management of cutaneous and musculoskeletal complications in fulminant sepsis

INTRODUCTION: Surgical management of purpura fulminans is required as in the acute as in the sequelae period. A retrospective case review of these sequelae, procedures which have been performed in the different moments and the outcomes was undertaken. METHODS AND MATERIALS: We reviewed retrospectively 13 patients treated in our hospital from 1993 to 2003. 8 males and 5 females, with a median age of 2 years old (4 days-14 years) were managed. 70% were meningococcical. The most common areas were low extremities (92%), upper extremities (76%), lips (n=1), nose (n=1) and genitalia (n=1). Most of cases were bilateral (n=11) although two patients presented isolated affectation in one of the extremities. The procedures were classificated depending on the surgical moment. Clinical follow-up was attempted on all surgical patients; we evaluated the aesthetic, functional and psychosocial outcomes. RESULTS: One child died along the first 24 hours; 11 required early surgery and all of them required late interventions. 50% in the serie had necrosis over 15%. In Intensive Care Unit, it was necessary to do 6 fasciotomies (extirpating muscle in 2) and escharectomies and debridements in 8. Early amputations were made in 2 patients: both of them required ampliation in the following days. The cutaneous defects were covered with skin allografts and artificial dermis. During the sequelae period, 8 amputations were necessary (the four extremities in one case). Other procedures were coverage with autologous skin grafting (n=7), Zplasties, Wplasties (n=5), myocutaneous flaps (n=3), release of contractures (n=3) and osseus resection (n=5). There were skeletal growth disturbances which were managed with osteotomies (n=3), realineations(n=3), application of Ilizarov (n=2) and Hoffman (n=2) frames; Nowadays, 6 patients have a complete independent functionning with the use of orthotics (n=3) and prosthetics (n=3) CONCLUSION: The pediatric surgeon has an important role in management and prevention of complications in patients with purpura fuminans. Urgent actuation and close follow-up decreases the morbidity; furthermore, the early reparation of sequelae improves their adaptation in school, in the family and in the society despite the physical disability.