Review of soft tissue coverage options in distraction osteogenesis of the extremity

Aim:To review the choices of soft tissue coverage in distraction osteogenesis of the extremity.Methods:A PubMed literature search yielded 14 articles included for systematic review.Data were extracted from each article if available(sample size,patient age,surgical indications,type of flap,use of additional modalities,method of bone osteogenesis,postoperative events,follow-up,satisfaction,weight-bearing status,and success rate).Unpaired t-tests were performed to compare complication rates.A retrospective review of three cases was also conducted.Results:Fourteen articles discussed 145 patients with a mean age of 33.4 years and 146 extremity injuries followed over 3.3 years on average.Indications included chronic osteomyelitis or nonunion(58.2%)and acute trauma(41.8%).Average time from injury was 1.1 years.Ilizarov frame was used in 12 articles.Free flaps(88.0%)or rotational flaps(12.0%)were used,with muscle flaps(96.7%)being most common.Most extremities received free latissimus dorsi or rectus abdominis flaps.Bone grafts and antibiotic beads were often used in conjunction.Although complications and reoperations were not uncommon(up to 30%),98.8%of patients on average were ultimately weight bearing and all articles reported>91%success rate.Additionally,the rates of any complication were not statistically different between"fix and flap"protocol and flap or frame first.Lastly,a three-patient case series is presented.Conclusion:Bone transport with soft tissue reconstruction remains an excellent choice for patients with large bony defects or who are unable to undergo autologous bone grafting.Not one surgical approach to limb salvage is superior,and decision should be made on a case by case basis between the surgeon and the patient.

Soleus muscle flap for reconstruction of lower extremity trauma.Workhorse or glue factory?

Aim:Soleus muscle flaps have traditionally been a reliable tool in the plastic surgeon’s armamentarium for lower extremity reconstruction and limb salvage.In the modern era,many surgeons prefer free flaps.This study sought to evaluate trends and outcomes of soleus flap reconstruction after lower extremity injury in a large cohort at a Level 1 trauma center.Methods:This is an Institutional Review Board-approved,retrospective chart review that was undertaken at Los Angeles County+University of Southern California Medical Center from 2007 to 2021.Patient demographics,Gustilo-Anderson fracture classification,flap characteristics,and outcomes were collected and analyzed.Outcomes of interest included failure rates,postoperative complications,and long-term ambulatory status.Results:Of 187 local leg flaps,68(36.4%)were soleus flaps,with 84% of soleus flaps performed prior to 2016.The flap loss rate was 0.0%.Eighteen(26.1%)flaps demonstrated>1 complication,including osteomyelitis/hardware infection(n=12),flap revision(n=6),and amputation(n=2).Long-term follow-up demonstrated 35.3% of patients ambulating independently after an average of 7.5±7.2 months,with the remainder needing a wheelchair or walking assistance device.Conclusion:Although soleus flap loss rate was 0%,the findings demonstrate more infections than expected;this must be considered in light of pre-existing patient comorbidities possibly deterring free flap placement.Additionally,our results reveal that only 16% of soleus flaps were performed after 2015.As surgeons consider the reconstructive ladder for lower extremity trauma,a rotational soleus muscle flap should not be overlooked in the modern era of free flap tissue transfers and might be a more optimal flap choice in certain patients with multiple comorbidities.