Segmental Cylindrical Gracilis Free Flap for Dead Space Obliteration in Chronic Midfoot Osteomyelitis Secondary to Ballistic Injury: A Case Report

Abstract

Chronic osteomyelitis of the midfoot, particularly following high-energy trauma such as a landmine injury, presents a formidable challenge due to the region's limited soft tissue envelope, complex anatomy, and the critical need for effective and durable dead space obliteration. While various flap options have been described, there remains no consensus on the optimal approach for managing deep defects in the midfoot, especially in cases complicated by prior surgical procedures. We present the case of a 23-year-old male who developed chronic midfoot osteomyelitis following a landmine explosion. Despite multiple debridements, targeted antibiotic therapy, and initial soft tissue coverage with an anterolateral thigh (ALT) flap, a persistent 6 × 5 cm (30 cm³) dead space remained, consistent with a Cierny–Mader type III-A classification. A segmentally harvested gracilis muscle flap was designed and sculpted to conform to the dimensions of the cavity, then inset into the defect. Microvascular end-to-side anastomosis was performed to the anterior tibial artery and two accompanying veins, and the flap was covered with a split-thickness skin graft. The postoperative course was uneventful at the recipient site. Mild serous drainage from the donor site, attributed to fat necrosis, resolved completely with conservative elastic compression therapy. At 12-month follow-up, the patient remained infection-free, was fully ambulatory without assistance, and imaging confirmed complete obliteration of the dead space. This case suggests that a segmentally harvested gracilis muscle flap may offer a viable, anatomically conforming single-stage option for managing complex midfoot osteomyelitis in selected patients. In individuals with prior treatment failure, this approach may help reduce surgical burden, enhance infection control, and support not only physical but also psychological recovery through resolution of a prolonged disease course.