Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity

Abstract

Background: Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects.

Methods: The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1).

Results: Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent.

Conclusions: Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.