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Diamond et al. Plast Aesthet Res 2019;6:20 I http://dx.doi.org/10.20517/2347-9264.2019.26 Page 9 of 11

enrolled and randomized with critical limb ischemia to either open or endovascular revascularization at
a mean 3.1 year follow-up: the trial showed a 56% mortality rate, 38% amputation-free survival and thirty
patients and (7%) living with an amputation. This of course represents a morbid group of individuals
meeting particular selection criteria of the trial, many of whom may be precluded from the surgical stress
of free tissue transfer. However, when wound-directed therapy with Integra Bilayer Wound Matrix (Integra
[24]
Lifesciences, Plainsboro NJ) and skin graft was added to a similar group of individuals, Iorio et al. improved
limb salvage rates. Limb survival was compared across 105 individuals with 121 foot/ankle wounds
according to tissue type exposed and presence of high-risk factors: 61% of those with bone exposure
and osteomyelitis were salvaged, 71% of diabetic wounds were salvaged and 59% of diabetics with bone
involvement avoided amputation. When provided with thin perforator flaps at our center (18/20) 90% of
individuals avoided amputation with osteomyelitis, (21/22) 92%, of diabetics were salvaged, all of whom
were high-risk for amputation, and 89% (8/9) of individuals with both diabetes and osteomyelitis avoided
amputation.

[2]
Hong et al. demonstrated a survival benefit over time in 2016 while utilizing the “Angiosome and
[2]
Supermicrosurgery Concept” principle and techniques for the management of diabetic foot wounds. Hong et al.
salvaged 84.9% of individuals over five-year follow-up. However, Dr. Hong also noted limited success in
those individuals requiring preoperative revascularization. During a regression analysis, revascularization
was associated with limb-loss independent of other high-risk features similar to our findings. We came to
similar findings as Dr. Hong’s with regard to limb ischemia requiring revascularization-lending caution to
future patient selection.

With regard to osteomyelitis, flap coverage has been widely studied by several groups over the last
[10]
four decades [25,26] . In 1982, Chang and Mathes described 21 patients with chronic osteomyelitis who
underwent muscle flap coverage with a success rate of 90%, two patients (10%) developed recurrent
[11]
infection postoperatively . Then, in 1991 James et al. demonstrated the long term effect of muscle flap
coverage in the management of 34 patients with chronic osteomyelitis with 89% of success rate over
a long-term follow up (> 5 years, mean 7.4 years). Reconstructive surgeons readily accepted muscle
flaps as a standard for management of Gustillo IIIB defects with osteomyelitis in the 1990’s. Eventually
[1]
fasciocutaneous flaps started to make a presence in the early 2000’s. Salgado et al. demonstrated in animal
model that both muscle and non-muscle flaps provide a viable option for wound coverage of osteomyelitis
[3]
defects. A recent publication by Hong et al. assessed the efficacy of perforator flaps in the treatment of
chronic osteomyelitis in a retrospective study including 120 patients who underwent reconstruction for
chronic osteomyelitis of the lower extremity; their flap loss rate was 4.2% and partial flap loss rate of 8.3%
with remission rate of 91.6% in one-stage reconstruction. These findings in line with ours in terms of 6.8%
[2]
rate of flap loss overall and 5% rate of partial flap loss in the osteomyelitis group. Hong et al. utilized 30 superficial
circumflex iliac (SCIP) flaps, 1 thoracodorsal artery perforator (TDAP), and 41 ALT flaps but did not
describe the plane of elevation. With our contribution of 16 superthin (N. 10) and suprafascial (N. 6) ALT’s
utilized for osteomyelitis, we estimate the number of published reports of utilizing superthin (periscarpal)
and suprafascial flaps for the management of osteomyelitis is in the range of 50-100 worldwide to date.

Notable limitations of this study include our small sample size lending to type 1 error in the comparison
of moderate-sized groups of patients with low overall complication rates - necessitating larger numbers
to strongly power our conclusions over time. We uniformly relied on the ALT flap at our institution for
wounds necessitating coverage by free tissue transfer, which assists in limiting selection biases but is of
course a unique practice. The unique referral pattern from foot and ankle surgery, podiatry and vascular
surgery along with availability to perform free-tissue transfer in this setting may also be difficult to repeat
across centers. This study does not include a number of patients managed by local pedicled flaps, skin
grafts, dermal substitutes and local tissue rearrangement. Our limited mean follow-up of 13.8 months