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Page 14 of 18 Stoneburner et al. Plast Aesthet Res 2020;7:13 I http://dx.doi.org/10.20517/2347-9264.2019.028

gracilis) through both end-to-end and end-to-side anastomoses to either anterior or posterior tibial vessels,
consistent with the most frequently used surgical techniques. While two patients eventually underwent
amputations, this adverse event was seen in only 1.4% of all extremities. Likewise, there was no statistically
significant difference in rates of flap failure or amputation between the extremities that were managed
according to the “fix and flap protocol” versus the placement of a flap before or after the frame. While the
difference in outcomes between the most commonly used free flaps, the rectus abdominis and latissimus
dorsi flaps, would be beneficial to evaluate, this was not possible given the nature of the studies. Nearly all
of the case series that were included in our review reported multiple different types of flaps that were used
in their patients, however the results were not separated according to flap type.

Looking further into patient complications, the present study indicates that injuries managed in the acute
setting were significantly more likely to undergo secondary surgical repair, compared to those who were
chronic. While this may be due to more controlled surgical management of chronic wounds predating
the beginning of the study time, the variability in injuries, patient morbidities, surgeon expertise, and
postoperative care limits the value of this finding.

An additional issue that can arise during the distraction process is the necessity to revise pin position or
flap configuration. In cases of flap necrosis, however, distraction is often delayed or stopped altogether,
necessitating additional procedures such as bone grafting [102] . Thus, meticulous planning of the flap in
addition to careful postoperative care is crucial for successful reconstruction.

Deciding the reconstructive method for soft tissue coverage can be challenging, as the options to choose
from are vast. In the articles reviewed, free flaps and muscle flaps were more commonly utilized than
rotational flaps and fasciocutaneous flaps, respectively. As for specific flaps, rectus abdominis flaps were
used for the greatest number of extremities, whereas free latissimus dorsi flaps were cited in the greatest
number of distinct articles. Microsurgical technique varied, with end-to-end anastomosis being used
almost as often as end-to-side anastomosis. Recipient vessels were most commonly the anterior and
posterior tibial arteries, although a diverse set of choices exist. Given the comparable success rates with all
of these different techniques, flap choice is often left to the discretion of the surgeon.

Aside from infection and fracture, the present review found that simultaneous placement of flap and frame,
or the “fix and flap” protocol, had fewer reported adverse events overall [Figure 1]. These results align
with the well-documented faster union times but differ from reported lower infection rates in the current
literature [59,60] , given that our review actually found a higher rate of infection in the simultaneous placement
of flap and frame. Two of the cases presented required additional surgeries, one for knee arthrofibrosis and
foot deformity and the other for flap elevation, bone grafting, and docking.

Other factors must be taken into consideration when attempting to mitigate the risk of flap loss, with one
[62]
of which being rate of bone transport. While Jupiter et al. concluded that the free tissue and the native
tissue undergo equal amounts of stretch and lengthening, Horas et al. [103] noted a difference in speed
between bone transport and soft-tissue movement, which could potentially jeopardize the vascular pedicle
secondary. This risk increases with the amount of transport needed. Interestingly, all of the papers assessed
in the review performed distraction at a rate between 0.75 and 1 mm per day, indicating that there is
agreement that this range of rates produces optimal results.

Although limb salvage and reconstruction through soft tissue coverage and distraction osteogenesis comes
with substantial risk of complications and reoperations, outcomes remain strong. Over 98% of patients were
ultimately weight bearing, and article authors on average reported rates of success and patient satisfaction
as greater than 98%. All three of the case examples outlined in the present study are fully weight bearing as
tolerated and working with physical therapy.