Discussion: The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis

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I would like to begin by applauding Dr. Hong and his colleagues on this very impressive case series, in which 120 patients with chronic osteomyelitis of the lower extremity were treated with a free perforator flap, with or without a chimeric segment of muscle. The authors’ results, including a mere 4 percent flap loss and 8 percent recurrence, speak convincingly to their refined skill and the efficacy of their treatment protocol. In striving to spare both muscle at the recipient site and arterial runoff at the donor site, the authors’ approach epitomizes the modern evolution of microsurgery. This well-deserved praise notwithstanding, we must recognize that this study is scientifically flawed and that its conclusions are, at best, only partially valid.
The authors emphasize the importance of (1) complete débridement, (2) dead space obliteration, and (3) vascular coverage. These points constitute as fundamental and widely known a concept as there is in plastic surgery, appreciated at least since Godina and probably since Hippocrates. The question posed in this study is whether a perforator flap will work as well as a muscle flap. However, this study did not answer this question, because in 36 percent of cases the authors used myocutaneous flaps (albeit with the physiologically irrelevant distinction of being chimeric flaps). To their credit, the authors’ approach of a chimeric perforator flap is far more elegant than an old-fashioned myocutaneous flap, but strictly from the standpoint of infection eradication, they are in the same category. Thus, their analysis is fatally confounded.
I agree, and the literature has long supported, that a skin flap is a perfectly acceptable choice for coverage of extremity defects, with or without osteomyelitis, provided the wound is fully débrided and dead space is obliterated (by vascular tissue or an antibiotic spacer of some kind). However, these authors seem to have a strong bias against muscle flaps, and I do not understand why. There are relative advantages and disadvantages to each, with neither being clearly superior.
The authors must admit that a muscle flap can be better at obliterating dead space, or they would not have included muscle in over one-third of their cases. Thus, from the standpoint of disease treatment (as in the title of this article), muscle flaps have a slight advantage, and the authors’ own algorithm corroborates this.
Skin flaps, in contrast, are arguably a little easier to monitor, and—with longer tolerance of ischemia than muscle—may also have higher salvageability. A skin flap may also be more durable to subsequent trauma over the subcutaneous surfaces of the leg, particularly if the flap resides directly over a thick plate.
It is often said that a muscle flap is harder to reelevate if additional surgery is later required; I would agree that this can be a major issue in the upper extremity, where tendon gliding and joint mobility are critical, but in the lower extremity, a mature muscle flap is easy to reelevate and reclose, especially if it was placed over an antibiotic spacer. The orthopedists at my institution do not even notify me for this stage of the reconstruction; they simply incise along one margin of the mature flap, place the cancellous bone graft, and perform a simple closure.
Cosmetically, at least at the donor site, skin flaps have a distinct disadvantage if a skin graft is required (Fig. 1). Even if a skin graft is not required, we should remember that the anterolateral donor site is not without some morbidity,1 whereas the gracilis donor site is virtually ideal, with a very inconspicuous scar and no functional compromise.

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