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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 13 of 18

reflected in the longer than expected average time from injury (1.1 years), which ranged from within weeks
to up to three years. Two cases in the present study describe treatment within days to a few weeks, whereas
the other indicates over 40 years since initial injury, which better aligns with what is seen in our review
of the literature. Additionally, the present study includes a single article that reports flap and frame repair
[61]
of upper extremity injuries . Although there is a paucity of literature discussing the use of soft tissue
coverage and distraction osteogenesis in upper extremity reconstruction, the study was included to bring
light to the innovative, diverse applications of this technique.

The current gold standard for managing large soft tissue defects that cannot be closed directly is the “fix
and flap” protocol, which has several recognized advantages [4,51,59,60] . However, with respect to the results of
our literature review, only about one third of the extremities described underwent simultaneous flap and
frame placement. Similarly, this simultaneous approach is taken in only 1 of the 3 cases presented. While
this is partially due to the inclusion of older studies that were published prior to the acceptance of modern
“fix and flap” approach [7,9,41,61,62,65,84-86,88,89] , it is also important to note that the gold standard typically applies
to acute traumatic injuries, whereas many patients undergoing bone transport are patients with chronic
extremity issues.

With respect to reconstruction of bone, the present review measured the average bone defect to be
8.9 cm, which required intervention to restore limb length. The mainstay of distraction osteogenesis
is the application of the Ilizarov method for external fixation, although nowadays novel methods of
complementary internal fixation have been innovated with improved patient comfort, decreased infection
rates, and quicker recovery [43,91-95] . The present review identified that the majority of articles employed
external fixation consistent with the Ilizarov method. The remaining articles used variations of the Ilizarov
method, except one that used anterior double-stacking external fixation. However, for many reasons,
an array of surgical techniques may be used to tailor reconstructive approach to the individual’s unique
presentation.

While bone defects smaller than 8 cm can be successfully closed using bone grafting [7,9,96] , larger defects may
[97]
require a vascularized bone graft . Common vascularized bone grafts that have been described include
[8]
contralateral fibula and iliac crest . These operations, however, carry significant donor site morbidity and
are also limited by the size of the donor site [7,77] . For patients with large defects, the anatomy of the iliac
[27]
crest makes it unsuitable , and harvesting a contralateral fibula in a patient with unilateral lower extremity
[99]
[98]
trauma can be problematic due donor site complications and insufficient pedicle length . In certain
circumstances, specifically in previously infected femoral shafts, efficacy has been shown for vascularized
fibular grafts [100] . As seen in the present review, 62.3% of extremities were managed with both distraction
osteogenesis and bone grafting. Two of the three cases discussed similarly received bone grafts.

When comparing bone grafting with soft tissue coverage against resection and bone transport, results have
been shown to be similar, with significantly less limb length discrepancy in the bone transport group [101] .
Although distraction osteogenesis in combination with free flap reconstruction has clearly been proven
to be a useful treatment modality, the procedure is time consuming and can produce a multitude of
challenging complications if not approached with great care.

[7]
[94]
Some of the common complications associated with this procedure are bone exposure , nonunion ,
[90]
flap necrosis [102] , and downward depression of the flap . While some of the problems can be resolved
with conservative care or minor revisions, there are others with more serious consequences. As found
in the present review, flap failure may result from venous thrombosis or vasculature disruption due to
acute or chronic pathologies [81,82,88,89] . The articles described these losses in patients with large bony and
soft tissue defects undergoing a number of different free flaps (latissimus dorsi, rectus abdominis, and