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Beyond The Fibula: Free Tissue Transfer Combined With Masquelet Technique And Distraction Osteogenesis Are Effective For Limb Salvage
Salma Abdou, MD1, John Stranix, MD2, David Daar, MD3, Devan Mehta, MD3, Pierre Saadeh3, Jamie Levine, MD3, Philipp Leucht, MD PhD3, Vishal Thanik, MD3.
1MedStar Georgetown University Hospital, Washington, DC, USA, 2University of Virginia, Charlottesville, VA, USA, 3NYU Langone Health, New York, NY, USA.

Purpose: Osteocutaneous reconstruction for segmental long bone defects is challenging due to concomitant injuries and limited donor sites. While they remain the gold standard for these defects, osteocutaneous free flaps may not always be feasible. There is a paucity of data on limb salvage outcomes following combined soft tissue reconstruction and bone transport or induced membrane technique (Masquelet) procedures. Methods: We reviewed a consecutive series of open tibia fracture patients undergoing soft tissue reconstruction at our institution. Only patients with critical size bone defects undergoing distraction osteogenesis or the Masquelet technique were included. Information on patient demographics, method of bone and soft tissue reconstruction, and postoperative outcomes were included. Results: Fourteen patients were identified, with the majority (12, 85.7%) being male. The average age was 35.9 12.6 years old and BMI was 22.7 8.4. All patients suffered Gustilo type IIIB type fractures, with the majority (13, 92.9%) of etiologies being traumatic in nature. Half of the group received muscle flaps and the rest received fasciocutaneous flaps. Among the seven fasciocutaneous flaps, the majority were anterolateral thigh flaps (6, 85.7%). The rectus abdominis muscle flap was the most common muscle flap type (5, 71.4%). Ten (71.4%%) patients underwent distraction osteogenesis (DO) and the remaining patients underwent the induced membrane technique. Five patients required re-exploration for venous insufficiency, of which the majority (4, 80%) were salvaged. The number of patients with soft tissue infection, hardware infection, and osteomyelitis was 3 (21.4%), 3 (21.4%), and 2 (14.3%), respectively. The average bone gap length was 65.7 31.3 mm (range, 20-120 mm). In the DO group, average external fixation duration was 245 days (range, 47-686 days). In the induced membrane technique group, the average duration of the first stage (i.e., time from antibiotic cement spacer placement to bone grafting) was 95 days (range, 42-181). Bone union rate, as determined by radiographs, was 85.7%. There was one complete flap failure (7.1%). One patient underwent below the knee amputation after failing DO and developing chronic osteomyelitis and infected nonunion. Conclusion: Non-osteocutaneous flap methods of limb reconstruction are a viable option in patients with segmental long bone defects, with a bone union rate of 85% and limb salvage rate over 90% in patients with Gustilo IIIB type fractures.


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