July 2017 #PRSJournalClub: “The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis”

by Ara A. Salibian, MD (@AraSalibianMD)

The July #PRSJournalClub had a fantastic discussion on an excellent article in this month’s @PRSJournal entitled “The Efficacy of Perforator Flaps in the Treatment of Chronic Osteomyelitis” with Dr. JP Hong (@JP_joonpio_HONG), Dr. Terence Goh (@TGoh19) and Dr. Peter Hyunsuk Suh (@Suh_Hyunsuk) from the Department of Plastic Surgery and Orthopedic Surgery at the Asan Medical Center in Seoul. The study presented an impressive series of patients with chronic osteomyelitis who underwent reconstruction with a variety of perforator flaps.

Click here to read the study as well as view this month’s comprehensive collection of #PRSJournalClub articles.

In this retrospective review, Hong et al. examined the efficacy of perforator flaps to treat chronic osteomyelitis defects present for at least 6 weeks in 120 patients with at least 2 years of follow-up. After adequate workup and serial debridements, the authors utilized various perforator flaps to fill dead space and provide soft tissue coverage. Bony reconstruction, when needed, was performed after stabilization with either bone grafting or vascularized fibula flaps. The authors analyzed rates of flap loss, osteomyelitis recurrence, remission and amputation as well as correlation of different factors with recurrence. After an average of 1.74 debridements, 77 patients underwent reconstruction with perforator-only flaps (most commonly anterolateral thigh [ALT] and superficial circumflex iliac artery [SCIP] perforator flaps) and 43 patients had combined ALT flaps with an independently pedicled vastus lateralis muscle. There were 5 cases (4.2%) of total flap loss and 10 cases (8.3%) of partial flap loss. Ten patients (8.3%) developed recurrence which was treated with secondary free flaps, local flaps or debridement and closure. An impressive 91.6% primary remission rate and 98.3% secondary remission rate were reported at 2-year follow-up. Predictors of chronic osteomyelitis recurrence were found to be peripheral vascular disease (OR 5.111, p=0.017) and vascular injury (OR 5.111, p=0.017). The authors also presented two interesting cases of Cierny-Mader grade III and grade IV chronic osteomyelitis treated with debridement, antibiotics beads, SCIP flaps and secondary bone grafting. The authors demonstrated that a stepwise approach to these difficult problems including thorough debridement, reconstruction of bony defects with grafts or osseous free flaps, obliteration of dead space with muscle or deepithelialized skin flaps and coverage with skin-only perforator flaps to “replace like with like” offers excellent outcomes in the treatment of chronic osteomyelitis.

This month’s podcast featured an exciting discussion with special guest moderator Dr. Noopur Gangopadhyay (@DrNGangopadhyay), Assistant Professor of Plastic Surgery at Ann & Robert H. Lurie Children’s Hospital of Chicago who is fellowship-trained in both #microsurgery and #craniofacial surgery. As usual, she was joined by PRS Resident Ambassadors Chad Purnell (@ChadPurnellMD), Jordan Frey (@JordanFreyMD), and Shuja Shafqat (@shujashafqatmd). The panel shared a great discussion on muscle versus skin flaps in the setting of chronic osteomyelitis, zone of injury in limb trauma, and reconstruction of bony defects. Click the link below to listen to this excellent and enlightening podcast.

On July 23rd and 24th, the PRS journal hosted one of the most interactive #PRSJournalClub discussions yet!  The two-day event involved lively dialogue among the authors and countless numbers of #boardcertified surgeons, residents, students and many others in the field of #PlasticSurgery. Excellent questions were posed with enlightening responses from the authors that created an educational and enjoyable forum of discussion. Noteworthy topics included the idea of the zone of injury as a three-dimensional and not two-dimensional space to allow for more flexible recipient vessel selection as well as timing of coverage and secondary procedures. The authors also emphasized the importance adequate debridement of all tissue types prior to reconstruction as well as the need for a multi-specialty approach in the care of chronic osteomyelitis patients.

Click on the tweets below to check out the great discussions!
















Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s