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Page 6 of 18 Stoneburner et al. Plast Aesthet Res 2020;7:13 I http://dx.doi.org/10.20517/2347-9264.2019.028

defects [70,73,74] . Notably, this methodology has been well studied in the treatment of scaphoid AVN [66,68,75] ,
with studies reporting up to 100% of patients achieving union [76,77] and level III evidence that it is superior
to 1,2-intercompartmental supraretinacular artery graft [68,77,78] . Finally, these studies have reported limited
to no complications at both donor and recipient sites [73,77,79,80] .

METHODS

Literature review
A systematic review of the literature was performed using PubMed database in adherence with PRISMA
guidelines. Combinations of the following search terms were used: “‘bone transport’ AND ‘free tissue
transfer’”, “‘Ilizarov’ AND ‘free tissue transfer’”, and “‘distraction osteogenesis’ AND ‘soft tissue coverage’”.
No limits were placed on any of the search queries. All articles were independently reviewed by two
authors. Following the primary search, titles and abstracts were either included or excluded based on
predefined eligibility criteria. Inclusion criteria included bone transport as research theme, involvement of
soft tissue coverage, relevance to limb salvage, and general population as the sample. Articles were limited
to English language and review articles, letters, and comments. Subsequently, evaluation of the full text of
selected articles was similarly performed and their bibliographies were assessed for additional articles to
include.

Articles that described patient outcomes, details of bone transport, and type of soft tissue coverage were
included. Studies were excluded if they had inadequate data, did not involve a combination of bone
transport and soft tissue coverage, or were anecdotal in nature.

The following data from each article were extracted: sample size, mean patient age, indications for
intervention, type of flap, use of additional modalities (antibiotic beads or bone substitute, vein or bone
graft, and hardware), details of bone osteogenesis (average bone and soft tissue defect, time-to and rate of
distraction, and total distraction), postoperative events (complications, total or partial flap loss, skin graft
complication, hematoma, nonunion, malunion, infection, recurrent osteomyelitis, broken fixation wires,
flap depression, bone exposure, fracture, limb-length discrepancy, second flap surgery or reoperation, and
amputation), average follow-up, satisfaction, weight bearing status, and success rate.

Unpaired t-tests were utilized to assess if complication rates were statistically significant between the
simultaneous placement of frame and flap and the placement of the flap before or after fixation. Fisher’s
exact test was used to compare differences in complication rates in patients with acute and chronic wounds.
Statistical significance was determined at P < 0.05.

Case series
A retrospective review was conducted of patients undergoing bone transport with simultaneous soft tissue
coverage performed at the Keck Hospital of the University of Southern California between 2016 and 2019.
Three non-consecutive cases performed by a single plastic and orthopedic surgeon are described below.

RESULTS
Our initial literature search identified 91 unique articles, of which 13 full text-articles were assessed for
inclusion. Six full-text articles from the search were ultimately included, added to eight articles selected
from additional search. These 14 articles [7,9,61,65,81-90] were utilized for analysis [Figure 1].

The selected articles included bone transport with soft tissue reconstruction in 145 patients with a mean age
of 33.4 years and a total of 146 extremity injuries (142 lower extremity and 4 upper extremity injuries). Ten of
the 14 articles included average duration of follow up [Table 1] [7,9,61,65,81-90] . Patients were followed over 3.3 years