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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 15 of 18

There are several limitations to the present review. Due to the paucity of literature evaluating the
outcomes after utilizing soft tissue coverage and bone transport after critical bone loss for limb salvage,
this systematic review was limited to case reports and case series. Thus, the quality of studies included is
a limitation. In addition, the studies included are very heterogeneous with the parameters discussed and
outcomes evaluated, which led to an even smaller group of articles coinciding with any one parameter.
Given the degree of inconsistency in the way results were reported in each article, many studies had to
be excluded, leading to a lower power. Lastly, reoperation for cancellous bone grafting for nonunion was
frequently performed across articles; however, it remained unclear in the literature if this was an expected
complication that needs anticipated surgery vs. an actual complication. These events were included under
the category of bone grafting.

In conclusion, the reconstruction of extremities with critical bone loss, whether due to acute trauma,
nonunion, or chronic osteomyelitis, remains a significant challenge for surgeons. Our findings suggest
that no one surgical approach is superior, and the treatment algorithm ultimately remains a decision to be
made between the surgeon and the patient. In patients with bone defects too extensive for autologous bone
grafting or in patients who are not candidates for this approach, a combination of bone transport with soft
tissue reconstruction remains an excellent choice for satisfactory functional outcomes.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Stoneburner J, Azadgoli B, Carey J, Marecek G
Performed data acquisition, as well as provided administrative, technical, and material support:
Stoneburner J, Azadgoli B, Howell A, Tucker D

Availability of data and materials
All data is shared through the included tables and figures.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020.

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