Page 71 - Read Online

Page 8 of 11 Diamond et al. Plast Aesthet Res 2019;6:20 I http://dx.doi.org/10.20517/2347-9264.2019.26

Table 4. Characteristics of 20 patients who underwent perforator based flaps for
treatment of lower extremity osteomyelitis
No. (%) Clearance a
Soft tissue defect location
Calf/Knee 7 35 7 (100%)
Ankle 5 25 4 (80%)
Foot 8 40 7 (87.5%)
Bone involved
Tibia 5 25 5 (100%)
Fibula 2 10 2 (100%)
Calcaneus 5 25 4 (80%)
Ankle mortis/carpus 6 30 6 (100%)
Metatarsal/phalangeal 2 10 1 (50%)
Tissue based diagnosis 20 100
Cierney-Mader classification
I - Superficial 12 60 12 (100%)
II - Medullary 3 15 2 (67%)
III - Isolated (Sequestrum) 1 5 1 (100%)
IV - Diffuse 4 20 1 (75%)
Hardware present and kept in place (4/4) 100 4 (100%)
External fixator present 2 10 2 (100%)
Microorganism
Staph epidermidus, coagulase negative staph. MSSA 13 65 12 (92%)
MRSA 1 5 1 (100%)
Enterobacter 2 10 2 (100%)
Streptococcal 1 5 1 (100%)
Corynebacterium 1 5 1 (100%)
Proteus sp. 1 5 0 (0%)
Stenotrophomonas 1 5 1 (100%)
Flap thickness
Subfascial (Thick) 4 20 4 (100%)
Suprafascial 6 30 5 (83%)
Superthin (Periscarpal) 10 50 9 (90%)
Bone union achieved across fracture line (8/9) 89%
External fixator exchanged for internal hardware or removed (2/2) 100%
Amputation 2 10
Radiographically healed compared to preoperative (7/9) 78%
Osteomyelitis recurrence 2 10%

a Osteomyelitis clearance as defined by lack of local recurrence of boney osteomyelitis, discontinuation of antibiotic, healed soft-tissue
envelope, clearance of deep-space infection

In subgroup analysis of our highest risk populations nine diabetic patients had osteomyelitis and three
more had critical limb ischemia. Although this is a small sample size, outcomes in this population are
mixed: none experienced recurrence of osteomyelitis defined as clinical evidence of bone infection by
clinical exam, radiography or tissue pathology within the surgical site; five of our patients were fully
weight-bearing in less than four months while three of them never fully ambulated due to conservative
management of secondary ulcers in the same extremity, and one patient went on to amputation due to
severe peripheral artery disease. Only one flap loss occurred due to extensive arterial thrombosis despite
early intervention within the osteomyelitis group [Table 3].

Microvascular tissue transfer in high-risk individuals harboring vascular disease, osteomyelitis and
the Charcot foot improves upon outcomes achieved with alternative standard of care pathways.
Revascularization alone as demonstrated in the “Bypass versus Angioplasty in Severe Ischemia of the Leg
[23]
Trial” (BASIL Trial) offers limited salvage rates with shortened up overall amputation-free survival and
mortality when compared to revascularization plus wound directed reconstructive surgery. Of 250 patients