31-year-old male with a history of post-traumatic splenectomy 14 years earlier and overweight. He presented with pneumococcal sepsis that caused multiple organ failure (renal, respiratory, haematological and haemodynamic) and admission to the Intensive Care Unit (ICU). He remained intubated for 11 days and was subsequently transferred to the Internal Medicine ward. Due to poor perfusion secondary to sepsis, necrotic lesions appeared in the upper and mainly distal lower extremities. Initially assessed by Vascular Surgery, treatment with prostaglandins was indicated for 21 days. After improvement in general condition and disappearance of vital risk, and after 7 weeks admitted to Internal Medicine, he was transferred to Plastic Surgery for treatment of the residual necrotic lesions.
On admission to our department he presented multiple small lesions on the forearms, hands and thighs that epithelialised adequately with topical treatment. The most relevant complication was left plantar necrosis with extensive eschar in the plantar moulting area which was debrided in the hospital ward, left plantar anaesthesia, dry necrosis of the 3rd, 4th and 5th toes of the right foot and a right pretibial ulcer measuring 10 x 5 cm.

We performed surgical intervention for left plantar and right pretibial debridement and daily debridements on the ward to reduce most of the slough and bedsores. After 20 days of daily debridements in the patient's room, without local anaesthesia (no pain due to plantar anaesthesia and necrotic tissue), V.A.C.® therapy was started on the sole of the left foot to promote granulation, avoid superinfection and allow subsequent coverage of the defect. Polyurethane sponges (VAC GranuFoam®) were applied with continuous negative pressure of 125 mmHg for the first 48h and then continued with intermittent negative pressure (5 minutes with suction and 2 minutes without suction). Silver sponges (VAC GranuFoam Silver® ) were used for the first week to improve the antibacterial effect due to the persistence of sloughing. The VAC® container collected abundant exudate during treatment. We used the VAC ATS® Therapy System. The entire treatment lasted 20 days and sponge changes were performed 3 times a week.

The patient was able to continue doing physiotherapy exercises during the treatment, comfortably carrying his VAC® System in his hand, when he went to the sessions in a wheelchair.
The evolution was very favourable, with disappearance of residual slough, formation of bright red granulation tissue, without the appearance of superinfection and obtaining a suitable bed to receive a skin graft.

One week after withdrawal of VAC® therapy, the patient underwent surgery to cover the left plantar defect with a partial thickness skin graft taken from the thigh on the same side, amputation of the 3rd, 4th and 5th toes of the right foot and skin grafting on the residual right pretibial defect. The grafts attached adequately and the wounds healed well.

The patient was discharged after 4 and a half months of hospitalisation and 2 weeks after the skin graft coverage procedure. At discharge he was ambulating with the aid of crutches. Six weeks after discharge he was walking independently with the aid of a special insole fitted by the podiatrist, although he requires regular care by the podiatrist due to the plantar anaesthesia which requires strict monitoring of the skin in this area.

