Page 70 - Read Online

Diamond et al. Plast Aesthet Res 2019;6:20 I http://dx.doi.org/10.20517/2347-9264.2019.26 Page 7 of 11

Table 3. Flap complication and reported Limb salvage rates
1
Total N N.59 = 59 Osteomyelitis N.20N = 20 CLI N.12 = 12 Charcot N.22 P-value 2
Ambulatory 54 (91%) 17 (85%) 10 (83%) 20 (90%) 0.110
Non-ambulatory 5 (9%) 3 (15%) 2 (17%) 2 (9.1%) 0.217
Amputation 2 (3.4%) 2 (10%) 2 (17%) 2 (9.1%) 0.252
Amputation free 57 (96.6%) 18 (90%) 10 (83%) 20 (90%)
Osteomyelitis clearance 18 (90%) 10 (83%) 18 (81%)
Flap complication 18 (30%) 8 (40%) 5 (42%) 7 (31.8%) 0.260
Complete flap loss 4 (6.8%) 1 (5%) 0 (0%) 0 (0%) 0.699
Partial flap loss 3 (5.1%) 1 (5%) 2 (17%) 2 (9.1%) 0.983
Flap infection 4 (6.8%) 2 (10%) 1 (8.3%) 1 (4.5%) 0.598
Dehiscence 6 (10.2%) 1 (5%) 1 (8.3%) 4 (18.2%) 0.653
Flap revision 9 (15%) 1 (5%) 1 (8.3%) 0 (0%) 0.841
1 CLI: critical limb ischemia, defined as patients with at least one of the following: single-vessel runoff, severe peripheral vascular disease,
2
multi-vessel arterial disease, multi-level arterial disease; P-values reported after univariate comparison of patients with Osteomyelitis to
those without across all outcomes
Overall donor site complication rates were as follows: seroma, 5% (n = 3); neuropathy, 5% (n = 3); contour
irregularity, 3.4% (n = 2); and site infection, 3.8% (n = 2). No differences in donor site complication
rates were noted between groups. Flap complication rates including complete flap loss, partial flap loss,
wound dehiscence and flap infection were 6.8%, 5.1%, 10.2%, and 6.8%, respectively. Again, no significant
differences between groups were noted. Table 3 demonstrates complication rates across high-risk
individuals harboring critical limb ischemia, Charcot foot, and osteomyelitis. Eight flap revisions were
needed, none of which were related to an osteomyelitis recurrence.

Sub-group analysis in the diabetic population revealed no cases of complete flap loss, two cases of partial
flap loss, four cases of wound dehiscence and one of flap infection, complication rates of 0.0%, 9.1%, 18.2%
and 4.5%, respectively [Table 3]. No differences between the osteomyelitis and non-osteomyelitis groups
within the diabetic population were noted. Our sub-group analysis demonstrated comparable outcomes
amongst a group of diabetic patients with osteomyelitis and Charcot foot.

Table 4 describes variegations in the osteomyelitis group and associated salvage rates. Cierny-Mader
osteomyelitis class, flap type and presence of comorbidity did not significantly alter osteomyelitis clearance
(P > 0.05) for each univariate comparison.

A multivariable regression was performed after stepwise entry of variables associated with limb-loss and
amputation with (P < 0.1). Preoperative revascularization was independently associated with limb loss
OR 6.1 (P < 0.05). Osteomyelitis, Charcot foot, diabetes, the presence of critical limb ischemia, and flap
elevation plane were not in and of themselves independently associated with limb loss.

DISCUSSION
In this study of lower extremity free tissue transfers with ALT flaps, we compared complication rates
and outcomes across three elevation planes in settings of osteomyelitis, charcot collapse and critical limb
ischemia. We did not find any significant differences between the groups using either one of the three
planes of elevation in terms of major complication as flap revision, flap infection; wound dehiscence,
partial and complete flap loss. Important to note, the distribution of flap types between groups harboring
osteomyelitis was comparable (superthin: P = 0.174; suprafascial: P = 0.792; and subfascial: P = 0.284).
Interestingly, there were no differences between major flap complications within the diabetic population
and Charcot foot. These findings further support the use of skin-only and fasciocutaneous flaps in the
setting of osteomyelitis. We demonstrate that thin flaps can assist in boney healing and clearance of
infection despite a lower metabolic demand compared to muscle flaps.