An alternative therapeutic strategy for infected large bone defect and massive soft-tissue loss of leg-is free flap reconstruction inevitable?

[PURPOSE] This study aims to report the clinical and radiographic outcomes of a non-flap therapeutic strategy for the limb salvage of infected composite bone and soft-tissue defects of a leg, attempting to describe some new techniques regards the docking of bone ends.

[METHODS] Twelve patients with infected large tibial bone defect (mean size 12.1 ± 2.8 cm) and massive soft-tissue loss (mean size 254.5 ± 60.2 cm) who were treated with the non-flap therapeutic strategy between 2014 and 2019 were retrospectively reviewed. Clinical and radiographic results were evaluated and analyzed. The results of bone and function were assessed by the Paley criteria. The exercise capacity of patients was evaluated based on the following four aspects: walking, running, jumping, squatting, and going up/down the stairs.

[RESULTS] During the treatment, shortening and re-lengthening technique was applied in six patients, bone transport technique in 12, submarine technique (SMT) in six, balloon dilatation technique (BDT) in seven, and soft-tissue incarceration creating technique (SICT) in seven. The mean external fixation time (EFT) and external fixation index (EFI) were 675.6 ± 179.2 days (range, 366-1040 days) and 60.1 ± 13.9 days/cm (range, 47.0-95.5 days/cm), respectively. Soft-tissue defect was successfully repaired for all patients. After a mean follow-up of 43.5 ± 23.2 months (range, 13-103 months), bone result was classified as "excellent" in ten patients, as "good" in one and "poor" in one, while functional result was graded as "excellent" in four patients and "good" in eight.

[CONCLUSIONS] The non-flap therapeutic strategy could be cautiously considered as an alternative treatment for the large lower limb composite defects.