Dual-modality perfusion mapping in a complex pretibial wound: A case report

Complex pretibial wounds in older adults are common, difficult to clinically assess and at high risk of progression to skin necrosis. Despite this challenge, intra-operative assessment of viability remains subjective (colour, capillary refill and bleeding) and carries the risk of both under- and over-debridement. We describe a dual-modality approach combining handheld infrared thermography (IRT) and intra-operative indocyanine green fluorescence angiography (ICG-FA) to enable single-stage, precision debridement and resurfacing in a frail patient with a complex pretibial wound. A 91-year-old man on apixaban presented with a pretibial haematoma/laceration following a road traffic collision. Bedside IRT using a handheld camera demonstrated a central hypothermic zone over the most contused skin. Following initial debridement guided by clinical assessment and IRT, ICG-FA performed with the SPY-PHI system (Stryker) demonstrated residual areas of reduced flourescence requiring further excision. Immediate split-thickness skin grafting and negative-pressure wound therapy were subsequently performed with uncomplicated recovery and complete graft take at first post-operative review. This combined strategy highlights the complementary roles of IRT for rapid, non-contact surface screening and ICG-FA for intra-operative perfusion assessment, together supporting accurate tissue preservation and immediate reconstruction.