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Page 4 of 18 Stoneburner et al. Plast Aesthet Res 2020;7:13 I http://dx.doi.org/10.20517/2347-9264.2019.028

angulation/translation, rotation, and shortening). In addition, this system has the ability to utilize computer
accuracy [36-38] . Studies have shown this to be as effective as, but not superior to, classical Ilizarov DO in
overall clinical outcomes [38-41] , while some advantages include use for residual deformity following Ilizarov
[36]
DO, lower rate of return to the OR, and the ability to correct in all planes .
Finally, the pull wire system is a newer technique that can induce bone transport with utilizing both
[42]
internal and external fixation through medullary nail placement . This dual distraction method provides
similar rates of healing to classical Ilizarov DO, while limiting the risks associated with long-term external
[33]
fixator use [42,43] . Rozbruch et al. (2008) also suggested that there is expedited bone healing and a
decreased risk of refracture of the site of bone transport.

Soft tissue coverage in lower extremity trauma
In many cases of lower extremity trauma, free tissue transfer becomes necessary in an attempt at limb
salvage. While successful flap reconstruction may be achieved, complication rates are relatively high in
lower extremity reconstruction for a variety of reasons, which may include trauma-induced edema, pre-
existing vascular conditions, other patient comorbidities, or poor patient compliance during postoperative
recovery.

In a meta-analysis conducted by Xiong and colleagues on free flap reconstruction of lower extremity
[44]
defects, total flap loss and the rate of thrombosis were both found to be about 6% . Overall, 26.1% of
the flap losses were due to venous thrombosis, whereas 10.1% were due to arterial thrombosis. Minor
complications such as hematoma, partial necrosis, infection, and wound dehiscence occurred at rates
[44]
between 4.0% and 8.0% .
Given the heterogeneity of lower extremity trauma, several different reconstructive options can be utilized
by the plastic surgeon, depending on the size of the defect, the structures involved, and the comfort level of
the surgeon.

Historically, muscle flaps were believed to reduce infection rates in contaminated wounds. However, more
recently, free fasciocutaneous flaps have proven to be comparable to muscle flaps in terms of success rates,
infection rates, and bony union in lower extremity reconstruction [4,45-47] . Additionally, fasciocutaneous flaps
are thought to be simpler to re-elevate for subsequent orthopedic procedures, require fewer secondary skin
graft procedures, and result in lower donor site morbidity [46-49] .

[50]
In a meta-analysis conducted by Bekara et al. , the most commonly used free flaps for distal third lower-
limb reconstruction were found to be the latissimus dorsi muscle flap (25.5%), anterolateral thigh flap (19.7%),
[50]
rectus abdominis muscle flap (8.5%), gracilis muscle flap (8.4%), and serratus anterior flap (6.4%) . The
majority of flaps used (56.5%) were muscular flaps, followed by fasciocutaneous (42%) and fascial (0.5%). The
most common pedicled-propeller flaps were reportedly posterior tibial artery perforator (5.86%), peroneal
artery perforator (30.1%), sural artery perforator (5.6%), metatarsal artery perforator (2.0%), anterior tibial
artery perforator (1.6%), lateral retromalleolar artery perforator (1.6%), and dorsalis pedis artery perforator
[50]
(0.3%) .
Regarding free versus pedicled flaps in reconstruction of the distal third of the lower limb, the same review
[50]
by Bekara et al. concluded that, while partial flap necrosis is higher in pedicled-propeller flaps, wound
dehiscence and infection rates are higher in free flaps. Failure and overall complication rates were similar in
[50]
both groups .

In addition to the flap that is used, the reconstructive surgeon must also select the appropriate recipient
vessel and anastomotic technique. While studies have shown no difference in complication rates between