Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia.
Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia.
J Reconstr Microsurg. 2024 May;40(4):253-261. doi: 10.1055/a-2153-2285. Epub 2023 Aug 14.
In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps.
Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status.
Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous ( = 28) and 41.7% received muscle flaps ( = 20). The most common comorbidities included diabetes mellitus ( = 29, 60.4%), peripheral neuropathy ( = 27, 56.3%) and peripheral vascular disease ( = 24, 50.0%). Methicillin-resistant or methicillin -sensitive were the most common pathogen in 18.7% ( = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 ( = 38) and 83.3% ( = 40), respectively. The overall rate of microsurgical flap success was 93.8% ( = 45). Osteomyelitis recurred in 25% of patients ( = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, = 0.973).
This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.
在患有慢性下肢（LE）伤口的患者中，慢性骨髓炎使达到充分治疗的难度增加。先前的研究表明，与接受筋膜皮瓣进行下肢肢体挽救的患者相比，接受肌肉皮瓣的患者骨髓炎复发的发生率更高；但是，这些研究并未局限于仅接受游离皮瓣的无创伤人群。因此，本研究比较了接受游离组织转移（FTT）的慢性骨髓炎患者进行 LE 重建时使用筋膜皮瓣与肌肉游离皮瓣的复发率。
回顾性分析了 2011 年 7 月至 2021 年 7 月间接受 FTT 的患者。将患者分为筋膜皮瓣和肌肉游离皮瓣组。主要结局包括骨髓炎复发、皮瓣并发症、肢体挽救和活动能力。
确定了 48 例患有伤口床慢性骨髓炎的患者，其中 58.3%（28 例）接受了筋膜皮瓣，41.7%（20 例）接受了肌肉皮瓣。最常见的合并症包括糖尿病（ = 29，60.4%）、周围神经病（ = 27，56.3%）和周围血管疾病（ = 24，50.0%）。耐甲氧西林或甲氧西林敏感的病原体在 18.7%（ = 9）的手术中最为常见。大多数患者接受了中位数为 3 次清创术，随后接受负压伤口治疗，最后接受 FTT。在中位数为 16.6 个月的随访中，肢体挽救率和活动能力率分别为 79.2%（ = 38）和 83.3%（ = 40）。显微外科皮瓣成功率为 93.8%（ = 45）。骨髓炎在中位数为 4.0 个月时在 25%的患者（ = 12）中复发。骨髓炎复发、皮瓣并发症、肢体挽救、活动能力和死亡率无显著差异。多变量分析显示，皮瓣组成仍然是非骨髓炎复发的无显著预测因素（优势比：0.975， = 0.973）。
本研究表明，在慢性 LE 伤口游离皮瓣重建后，皮瓣组成可能不会影响骨髓炎的复发，这表明应根据伤口特征和患者目标选择最佳皮瓣。
