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The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis

2017; Lippincott Williams & Wilkins; Volume: 141; Issue: 3 Linguagem: Inglês

10.1097/prs.0000000000004155

1529-4242

N. Kerfant, Nicolas Bertheuil, Baptiste Bertrand, Weiguo Hu, Christian Herlin, B. Chaput,

Orthopedic Infections and Treatments

Sir: We have read with great interest the article by Hong et al. entitled “The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis.”1 Every plastic surgeon dealing with coverage of lower limb osteomyelitis has experienced difficulty in the choice of flap—muscle or fasciocutaneous flap, pedicled or free—especially considering that no evidence base exists in the literature to distinguish among these different procedures. Indeed, many authors have shown nonsuperiority of muscle flap in coverage of open leg fracture.2,3 However, the subject is still debated with regard to chronic osteomyelitis, with much controversy. In their study, the authors reported an important cohort of 120 patients treated with free perforator flaps in chronic osteomyelitis with a very impressive flap success rate of 95.8 percent and a primary remission rate of 91.6 percent.1 The main problem of studying chronic osteomyelitis is that the ability to predict recurrence differs greatly depending on the Cierny-Mader classification and bone loss.4 In this study, 36 percent of the patients were treated with chimeric flaps, including anterolateral thigh flaps, combined with vastus lateralis, which highlights the importance of obliterating the dead space with a vascularized tissue. We believe that the most important message is not that the fasciocutaneous flap is superior to muscle (because only a randomized controlled study can give a response) but, as the authors emphasized, the necessity for aggressive débridement in one or multiple stages and cavity obliteration to avoid any chronic fluid collection, followed by appropriate antibiotic therapy. In Cierny-Mader grade III or IV, dead space should be filled after bone excision, and muscle is a good tissue because of its great plasticity, but the dead space can also be obliterated with adipose tissue. Indeed, a chimeric flap can be harvested with a fasciocutaneous segment that can be undermined and placed in the cavity. Discussing this article, Henry et al. ensure that the muscle flap is easy to reelevate. In our experience, muscle tissue is more delicate than skin and is damaged by multiple reelevations, especially in case of recurrence of sepsis with need of repeated approach. We nonetheless consider that muscle flaps are robust, and very suitable for frail patients. Perforator flaps remain more difficult to achieve and, consequently, less easy to perform for the majority of reconstructive teams. It appears difficult to compare the anterolateral thigh flap and the gracilis flap. Indeed, the gracilis flap is a very useful option with inconspicuous scarring in lower limb coverage, but it is indicated for small to medium longitudinal defects, whereas the anterolateral thigh flap is able to cover small to large defects. Cosmetically, a skin graft is less often required at the donor site when skin flap is elevated in the superficial fascia plane as shown by Hong and Chung5 (Fig. 1), and it achieved very acceptable cosmetic results if compression was used for several months on the flap (Fig. 2).Fig. 1.: Donor site (14 × 9-cm anterolateral thigh flap elevated in the superficial fascial plane).Fig. 2.: Cosmetic result of ankle coverage after 12 months of compression.The choice of the flap should always be guided by limiting potential scarring but also by avoiding functional consequence. In our opinion, the use of rectus abdominis muscle should be avoided completely because of long-term pain and frequent abdominal hernia resulting from parietal denervation after several years. We would like to thank the authors for sharing their experience and for offering the opportunity to discuss this difficult clinical situation. DISCLOSURE The authors have no financial interests to declare in relation to the content of this communication. No external funding was received. Nathalie Kerfant, M.D.Department of Plastic, Reconstructive, and Aesthetic SurgeryCHU BrestBrest, France Nicolas Bertheuil, M.D., Ph.D.Department of Plastic, Reconstructive, and Aesthetic SurgerySouth HospitalUniversity of Rennes 1Rennes, France Baptiste Bertrand, M.D.Department of Plastic SurgeryLa Conception HospitalAssitance Publique–Hôpitaux de MarseilleMarseille, France Weiguo Hu, M.D.Department of Plastic, Reconstructive, and Aesthetic SurgeryCHU BrestBrest, France Christian Herlin, M.D., Ph.D.Plastic and Reconstructive Surgery and Burns UnitCHU MontpellierMontpellier, France Benoit Chaput, M.D., Ph.D.Department of Plastic, Reconstructive and Aesthetic SurgeryRangueil HospitalUniversity Paul SabatierToulouse, France