Treating Chronic Osteomyelitis of the Lower Extremities - Are Muscle Flaps Better than Fasciocutaneous Flaps? - A Retrospective Review of 20-Years of NTUH Experience and a Systematic Review of the Literature

Background: Surgical treatment of chronic osteomyelitis requires radical debridement, obliteration of dead space, and wound coverage by vascularized tissue transfer. Controversy remains about the relative effectiveness of muscle flaps and fasciocutaneous flaps in eradicating chronic osteomyelitis. Aim and Objectives: To compare by retrospective chart review and by systematic review the effectiveness of treatment of chronic osteomyelitis in the lower extremities using either muscle flaps or fasciocutaneous flaps. Material and Methods: This retrospective study included 26 admissions (22 patients) diagnosed with chronic osteomyelitis of the lower extremities and treated with flap reconstruction at National Taiwan University Hospital from 1991 to 2013. Of these admissions, 18 admissions underwent muscle flap reconstruction (M group), of which 11 received pedicled muscle flaps (PM subgroup) and 7 free muscle flaps (FM subgroup); and 8 admissions underwent fasciocutaneous flap reconstruction (FC group), of which 2 pedicled fasciocutaneous flaps (PFC subgroup) and 6 free fasciocutaneous flaps (FFC subgroup). The two groups and four subgroups were compared with respect to patient characteristics, surgical complications and treatment outcomes. A systematic review was conducted by searching medical databases in the past 30 years for flap reconstructions of chronic osteomyelitis in the lower extremities. Only studies in which there were more than 10 cases were included; a total of 13 publications were included. We combined the total cases and success cases and sorted them into 4 subgroups like our retrospective study. Results: In the retrospective study, the two main groups had no significant differences except regarding complication rate. The four subgroups had no significant differences except regarding treatment success rate. Total treatment success rate was 65.3%. Three flap losses occurred in the M group, all of which were in the FM subgroup. 5 recurrent infections were noted in the M group, of which 2 were in the FM subgroup and 3 in the PM subgroup. One recurrent infection was encountered in the PFC subgroup. Two minor complications, a hematoma and an external skeletal fixation (ESF) infection, occurred in the PM subgroup. The complication rates of these two groups were significantly different (55.6% in the M group and 12.5% in the FC group, p= 0.04) and the treatment success rates of these four subgroups were significantly different (73%, 29%, 50% and 100% in the PM, FM, PFC, and FFC subgroup, respectively; p=0.049). Systematic review found that the success rate was higher in the FFC subgroup but the difference was not significant (84%, 83%, 78% and 92% in the PM, FM, PFC, and FFC subgroup, respectively; p=0.096). Conclusions: Our retrospective study and systematic review found that muscle flaps and fasciocutaneous flaps for reconstruction of chronic osteomyelitis defects of the lower extremities had an equal treatment success rate. We chose a given flap-type based on the lesion site and size, the decision of the patient after careful explanation of the relative advantages and disadvantages of the flap-types, and the surgeon’s preference, confidence, and familiarity with the flap-types. Further study involving more patients should be conducted to achieve more convincing outcomes.