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Page 10 of 18 Stoneburner et al. Plast Aesthet Res 2020;7:13 I http://dx.doi.org/10.20517/23479264.2019.028

Figure 2. Percentage of patients with complications after extremity soft tissue reconstruction, broken down by timing of soft tissue flap
vs. bone transport frame placement

one of which is a 52-year-old male with a compound comminuted fracture of the distal leg, a resultant
14-cm tibial bony defect, and a large soft tissue defect. He received a free rectus abdominis muscle flap,
which failed secondary to venous thrombosis about 55 days after injury. He then had a second and
successful free rectus abdominis flap. Months later, he underwent bone transport, resulting in full weight
[88]
bearing capacity 18 months after injury. Hutson et al. denoted two flap failures out of 19 extremities
undergoing reconstruction with flaps first. The methods utilized were two latissimus dorsi free flaps to
recipient posterior tibial arteries anastomosed in either end-to-side or end-to-end fashion, both resulting
in flap failure. The patients were reported to later undergo bone distraction, although further soft tissue
[89]
rearrangement, if any, was not mentioned. Lastly, Chim et al. reported on 28 extremities undergoing flap
reconstruction before or after fixation, three of which failed. One patient had successful bone transport
and was managed with distraction lengthening of soft tissue, whereas the other two had concurrent failure
of distraction and were managed with amputations. One amputation occurred in a 34-year-old patient
with a Gustilo II infected bony nonunion after a motor vehicle collision and an associated wound size of
2
50 cm , who had a failed gracilis free flap to recipient posterior tibial artery with end-to-side anastomosis
and venous commitantes in end-to-end fashion. The other amputation was on a 57-year-old patient with
2
a Gustilo IIIB acute bone loss defect due to a crush injury and an associated wound size of 700 cm , which
was managed with a latissimus dorsi free flap through end-to-side anastomosis of posterior tibial artery
and end-to-end anastomosis to anterior tibial venous commitantes.

Four studies with a total of 32 patients described the management of acute injuries. Regarding union, there
was one nonunion and three malunions, while no patients suffered a refracture. Regarding the flap, there
were 5 losses (three total and two partial) and 9 flap irregularities. Sixteen patients required a secondary
reoperation, and seven of them were for the flap specifically. One patient suffered from a deep infection.