title: Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity.
abstract: BACKGROUND
  Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects.
  
  
  METHODS
  The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1).
  
  
  RESULTS
  Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent.
  
  
  CONCLUSIONS
  Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.
authors.affiliation: Cleveland, Ohio From the Division of Plastic Surgery and the Department of Orthopedic Surgery, Metrohealth Medical Center, Case Western Reserve University.
authors.forename: Harvey
authors.initials: H
authors.lastname: Chim
authors.forename: John K
authors.initials: JK
authors.lastname: Sontich
authors.forename: Bram R
authors.initials: BR
authors.lastname: Kaufman
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005599:Fractures, Ununited / Q000150:complications / Q000601:surgery; D058752:Free Tissue Flaps; D006801:Humans; D007866:Leg / Q000601:surgery*; D007869:Leg Injuries / Q000150:complications*; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D019857:Osteogenesis, Distraction; D010019:Osteomyelitis / Q000601:surgery; D017695:Soft Tissue Injuries / Q000601:surgery; D013977:Tibia / Q000601:surgery; D013978:Tibial Fractures / Q000150:complications / Q000601:surgery; D014946:Wound Infection / Q000150:complications / Q000601:surgery*; D055815:Young Adult