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Stoneburner et al. Plast Aesthet Res 2020;7:13 I http://dx.doi.org/10.20517/2347-9264.2019.028 Page 9 of 18

Table 5. Recipient vessels
Recipient vessels No. of articles No. of extremities Percentage of extremities (%)
Posterior tibial 6 33 53.2
Anterior tibial 5 15 24.2
Peroneal 3 5 8.1
Sural 1 5 8.1
Popliteal 3 3 4.8
Femoral a./v. with saphenous graft 1 1 1.6
Total articles 7 62

a.: artery; v.: vein

Table 6. Complications in extremities based on timing of flap vs. frame placement
Simultaneous flap and frame Flap before or after frame P-value
Amputations 0/50 2/82 0.45
Flap failure 1/50 6/82 0.32

P < 0.05 used for statistical significance

graft (2.7%), and hardware (0.7%). Eleven of the 14 articles documented complications in 141 patients,
including nonunion (n = 11, 7.8%), malunion (n = 10, 7.1%), flap depression or irregularity (n = 10, 7.1%),
total flap loss (n = 9, 4.9%), partial flap loss (n = 6, 4.3%), infection requiring readmission or i.v. antibiotics
(n = 8, 5.7%), significant limb-length discrepancy (n = 8, 5.7%), bone exposure (n = 4, 2.8%), fracture (n = 2,
1.4%), hematoma (n = 2, 1.4%), skin graft complication (n = 1, 0.8%), and broken fixation wires (n = 1, 0.8%).
Ten of the 14 articles also discussed 140 extremities requiring reoperation (n = 42, 30%), by far mostly for
docking procedures, second flap surgery (n = 9, 6.4%), or amputations (n = 2, 1.4%).

Complications were further assessed based on timing of soft tissue coverage, which occurred
simultaneously with bone transport frame as well as before or after bone transport. Starting with
simultaneous placement of flap and frame, five of the 14 articles used this approach for 50 patients with
a mean age of 34.4 years in 50 extremities [Table 6 and Figure 2]. Three extremities needed reoperation;
however, none required amputation or a second flap surgery. These articles reported infections requiring
readmission or i.v. antibiotics (n = 5, 10%), nonunions (n = 4, 8.0%), malunions (n = 3, 5.8%), partial flap loss
(n = 1, 2%), total flap loss (n = 1, 2%), fracture (n = 1, 2%), and limb-length discrepancy (n = 1, 2%) in several
extremities. In contrast, seven of the 14 articles documented complications after soft tissue reconstruction with
flaps either before or after application of frame used for bone transport [Table 5 and Figure 2]. This method
included 82 extremities of 81 patients with a mean age of 32.9 years. A higher number of extremities required
amputations (n = 2, 2.4%), reoperation (n = 25, 30.5%), and second flap surgery (n = 7, 8.5%). Similar to the
simultaneous group, these articles reported total flap losses (n = 6, 7.3%), partial flap losses (n = 5, 6.3%),
nonunions (n = 7, 8.5%), malunions (n = 6, 7.3%), limb-length discrepancies (n = 7, 8.5%), infections
requiring readmission or i.v. antibiotics (n = 3, 3.7%), and fracture (n = 1, 1.2%) in a number of extremities.
Additionally, this group reported flap irregularities or depression (n = 8, 9.7%), bone exposures (n = 2,
2.4%), skin graft complication (n = 1, 1.2%), hematoma (n = 1, 1.2%), and broken fixation wires (n = 1,
1.2%). Of note, there was no statistical significance between the rates of any complication between the 2
groups.

Total flap loss, or flap failure, was identified in four different articles, one of which also reported
[81]
amputation as subsequent management. Of the four articles, only one employed the simultaneous “fix

and flap” technique, in which one flap failedout of the 34 reconstructions performed (2.9%). However, this
patient’s condition, flap choice, and postoperative management are not included. The remainder of the
[82]
studies [82,88,89] utilized flap surgery before or after fixation. Musharafieh et al. described 3 case reports,