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Stoneburner et al. Plast Aesthet Res 2020;7:13 I http://dx.doi.org/10.20517/2347-9264.2019.028 Page 11 of 18
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There were five studies that characterized their wounds as chronic. However, Lowenberg et al. (1996)
reported the lone study to clarify their complications and describe them. Of their 23 patients, six suffered
from a complication. Ones of note include two with nonunion, one with malunion, and one with partial
loss of a flap, in deep infection. Additionally, there was an increased rate of second surgery (P = 0.049), as
five patents needed a second surgery - one for a flap replacement specifically following initial failure.

Despite significant complications and reoperations, 98.8% (range of 92.9% to 100%) of patients averaged
from 6 articles were ultimately weight bearing, and the success rate was 98.4% (range of 92.8% to 100%)
averaged across 11 articles. One of the 14 articles reported a satisfaction rate of 100% from the 34 patients
involved.

Cases
Case 1: free anterolateral thigh flap with taylor spatial frame first
A 69-year-old male with a history of obesity and hypertension was involved in a motor vehicle collision
40 years prior that resulted in an open tibia fracture that was treated with plate fixation at that time. He
recovered from that surgery and did well without complication until 2 years prior to presentation when he
was found to have purulent drainage around the plate, which was treated at an outside facility with serial
debridement and skin grafting. He was ultimately referred to our center at Keck Hospital and was found
to have chronic osteomyelitis of the tibia. After thorough debridement of bone and soft tissue, he was
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left with 17.5-cm bony defect of the tibia and a wound that was approximately 100 cm . The bony defect
was temporized with antibiotic spacer and culture-directed intravenous antibiotics until cultures were
negative, at which point the patient was placed in a hexapod frame. Five days thereafter, he received free
flap coverage of his large wound with an anterolateral thigh (ALT) fasciocutaneous flap anastomosed in
end-to-side fashion into the posterior tibial vessels. Bony transport was initiated once he had completed
6 weeks of i.v. antibiotics and he could be scheduled for surgery for corticotomy, which was 98 days after
his initial external fixator placement. He was distracted at a rate of approximately 0.5-1 mm per day. After
two subsequent surgical revisions of his multiplanar external fixator, he underwent removal of the external
fixator 505 days after his initial ex-fix placement, and he underwent a Masquelet procedure to complete
bony union. He did suffer equinovarus deformity of the foot, for which he received tendon lengthening and
ankle-spanning external fixation, as well as arthrofibrosis of his knee, for which he underwent two lysis of
adhesions and quadricepsplasty. Currently, he is weightbearing as tolerated and proceeding to follow with
physical therapy. At his most recent follow-up four years after presentation, he had achieved bony union
but developed an infection for which he is currently being treated with oral antibiotics and is scheduled to
undergo surgical irrigation and debridement.

Case 2: free latissimus dorsi and rotational gastrocnemius flap with delayed NuVasive precise frame
A 45-year-old man sustained a left Gustilo-Anderson IIIB tibia/fibular shaft fractures with an associated
distal fibular fracture, for which he underwent debridement and open reduction external fixation at an
outside facility. He was transferred to our services when it was determined that he would need soft tissue
coverage of his extremity. He was taken to the operating room for debridement of necrotic fibula stripped
of periosteum and antibiotic spacer placement. His bony defect was approximately 8 cm and his soft tissue
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wounds were approximately 75 cm . Five days after his initial debridement at our institution, the patient
received both a free latissimus myocutaneous flap anastomosed in end-to-end fashion to the anterior tibial
vessels as well as a rotational gastrocnemius myocutaneous flap for coverage of a more posterior wound.
Split thickness skin grafting was employed to cover his remaining non-critical wounds. He proceeded
with physical therapy and was ultimately weight bearing; however, it thereafter became apparent that he
had nonunion of his tibia fracture, likely due to the extensive zone of injury. As such, 276 days after this
initial treatment, he was taken to the operating room for placement of motorized magnetic transport nail
(Nuvasive, Aliso Viejo, CA) for bone transport. He started distraction 11 days after placement of bone