75-year-old male with a history of arterial hypertension, type 2 diabetes mellitus, transient ischaemic attack, autoimmune hypothyroidism and mild cognitive impairment. He suffered a flame contact burn due to inflammation of his clothing by fanning a flame with diesel fuel, as a result of which he had deep dermal and subdermal lesions on both lower extremities, with a total body surface area burned of 20%. The burns were deep dermal on the posterior surface of both thighs and circumferential on both legs, with a plaque of subdermal involvement on the anterior surface of the left leg, as well as superficial dermal burns on the lateral thighs and face.
Resuscitation in the first hours after the accident was carried out in a hospital in another region, from where he was referred to the Intensive Care Unit of our hospital for further treatment of the injuries.
On the day of admission, we performed emergency escharotomies on both legs and completed initial resuscitation. During the first 3 weeks of hospitalisation we performed 4 sessions of serial debridement of the burned areas and coverage with meshed partial skin autografting of the anterior surface of the thighs in the defects caused by the exeresis of the deepest burns, and with dermal substitutes (Biobrane®) in the debrided areas of superficial burns, on the lateral thighs and in patchy areas of the legs One week postoperatively, we observed the loss of the graft on the anterior surface of the left leg.

In a new surgical session we performed debridement of the left pretibial area, with persistence under the graft of a burn that had not been eliminated during the previous surgeries. After adequate removal of this eschar, we observed a 20 cm long pretibial defect, with exposure of the tibia. The entire exposed periosteum was removed and vacuum therapy was started on the resulting defect. Vacuum therapy was applied using a VAC® device (KCI Clinic Spain SL), in continuous mode, at 125 mmHg. Cures were performed every 72 hours with chlorhexidine soap. No further debridement procedures were necessary in the operating theatre. After 45 days of vacuum therapy we verified complete coverage of the bone by granulation tissue and performed definitive treatment with partial skin autografts taken from the buttocks, after which we achieved complete closure of the wounds.

During the period of therapy, microbiological cultures of the underlying granulation tissue were positive for multidrug-resistant Pseudomonas aeruginosa, which the patient had previously also presented with in urine. We instituted systemic treatment with Imipenem and Cilastatin, and performed partial debridement of the more superficial and hypertrophic granulation tissue during the dressing changes in the room. After completion of the vacuum therapy and grafting of the defect, the patient showed no further signs of graft infection. He was discharged from hospital 100 days after admission, with difficulty in ambulation and rehabilitation treatment on an outpatient basis.