Ischemic necrosis post AAA repair  secondary to osteomyelitis  and medullary infarcts
    This presentation  demonstrates limb loss after  an  aortic aneurysm  resection.This 58 year old male  has an extensive history of peripheral vascular disease.He was brought to the  operating room with a known AAA(6cm) and a history of claudication.Other than being a heavy smoker he had  few risks factors.He did have a long standing history of claudication at less than 100 feet.In the  ten years prior to this he had undergone  two previous femoral-popliteal grafts (long saphenous vein and Gortex).His graft was known to be occluded  for  three years  and he previously elected conservative management.Once the aneurysm expanded to > 5cm,  a decision was made to operate.Given the previous bypass history an angio was done confirming the infrarenal  AAA plus the (L) superficial occlusion with marginal one vessel runoff in the anterior tibial artery

   The man was brought to the OR and given the benefit of resection of the AAA with an aortobifemoral graft.At the end of this procedure he was found to have a cool ischemic (L) leg with no pulse by doppler.The patient underwent immediate exploration and a femoral graft  using  Gortex.The anterior tibial doppler signal returned and the foot pinked up.

    This was followed by  the development of an anterior compartment syndrome and foot drop(mild).The man was  discharged ambulatory with a palpable dorsalis pedis pulse but a minor foot drop with a splint.He was subsequently seen three weeks later  for a soft tissue infection in the anterior compartment .  Debridement  under local anaesthesia revealed pus and necrotic muscle.The foot drop  progressed and the patient developed trophic changes  to his toes secondary to abnormal  posturing.   Serial  visits ensued with eventual debridement of the entire anterior compartment  going down onto the dorsum of the foot

  The patient was finally admitted to hospital in a septic state with a tense edematous hot anke and lower limb.It was initially felt to be a septic arthritis but little pus was found at exploration.Plain X-rays were consistent with  osteomyelitis .MRI confirmed this but also demonstrated a significant tenosynovitis and several medullary infarcts particularly  in the ankle joint.Faced with sepsis and basically a useless limb the patient elected  a below knee amputation and was discharged one week later and  is now ambulatory with a prosthesis