Treatment of Chronic Traumatic Bone Wounds

Microvascular Free Tissue Transfer: A 13-Year Experience in 96 Patients

JAMES W. MAY, JR., M.D.,* JESSE B. JUPITER, M.D.,t G. GREGORY GALLICO, III, M.D.,*DOUGLAS M. ROTHKOPF, M.D.,* and PAULA ZINGARELLI*

During a 13-year period at the Massachusetts General Hospital,Boston, Massachusetts, 97 microvascular free tissue transfershave been performed for soft-tissue reconstruction in 96 patientsfollowing bone debridement for chronic traumatic bone wounds.These 96 patients comprise a continuation study of 18 originalpatients reported in 1982. During a 13-year follow-up period(mean, 77.1 months), 95.8% of these 96 patients have enjoyedcomplete wound closure with a lack of drainage after the de-bridement and free tissue transfer. Most of the patients (89.6%)encountered in this study are ambulatory without assist and 5.2%of patients have undergone amputation. Twenty-three per centof patients required subsequent segmental bone defect recon-struction in the lower extremity after infection eradication. Thepathophysiology of chronic traumatic bony wounds is differentfrom that of chronic hematogenous osteomyelitis and thus a highincidence of long-term successful management can be seenthrough complete wound debridement and adequate soft-tissuecoverage.

D ~\ ESPITE ADVANCES MADE in medical and surgicalmanagement, chronic traumatic bony woundscontinue to present a difficult problem in patient

management.' 22 The etiology ofbone wounds has shiftedfrom a primary infectious origin to trauma with the in-creasing mobility of our society. 3,4,23-33

In 1982, as a preliminary report,' we presented 18 pa-tients in whom microvascular free tissue transfers wereused to close chronic traumatic lower extremity woundswith no reported recurrence ofdrainage seen in any patientduring a mean 19.3-month follow-up interval.' Free tissuetransfers" 34"43 were chosen as the soft-tissue treatment forthese patients because the degree of bone debridementwould not be limited by the amount of available localreconstructive tissues. 19,20,44-72 The purpose ofthis report

Presented at the 11 1th Annual Meeting of the American Surgical As-sociation, April 11-13, 1991, Boca Raton, Florida.

Address reprint requests to James W. May, Jr., M.D., MassachusettsGeneral Hospital, ACC-4, Suite 453, Boston, MA 02114.

Accepted for publication April 22, 1991.

From the Division of Plastic and Reconstructive Surgery,Departments of Surgery* and Orthopedic Surgery,t

Massachusetts General Hospital, Harvard Medical School,Boston, Massachusetts

is to present the long-term follow-up data for those initial18 patients and to add 78 additional patients to this initialgroup. Thus the total of 96 patients have been followedafter bone wound debridement and free tissue transferreconstruction for a mean 77.1 months.

Patients and Methods

In our series of 96 patients a mean period of chronicbone exposure and drainage was 39.6 months, with a rangeof 6 weeks to 41 years. The mean age was 32.8 years, witha range from 11 years to 66 years and including 11 femaleand 85 male patients.

Five criteria for the diagnosis of chronic bone woundswere applied for patient selection in this study,' includingchronic open draining bony wounds for more than 6weeks, a positive culture from the wound at the time ofdebridement,73'74 histologic evidence of nonliving bonewith inflammatory changes, with or without bacteria, andx-ray findings consistent with chronic bone infections.With increasing experience scans75'02 have now been de-leted from our preoperative assessmentl'03 because intra-operative bone debridement"'" is now used in determin-ing with accuracy the extent of bone involvement.'05

Regional bone wounds included skull (1), upper ex-tremity (1), femur (7), tibia (66), and ankle-foot (21). Inall patients a microvascular free tissue transfer operationwas carried out, including latissimus dorsi muscle flapwith skin graft or skin island (80 flaps) gracilis muscleflap with skin graft (11 flaps), and groin flap (6 flaps). Ineach case a flap was chosen that adequately provided anabundance of well-perfused wound closing tissues. No

241

Ann. Surg. * September 1991

FIGS. IA and IB. (A) X-rayof distal tibial nonunion in a38-year-old woman with a6-year history of chronicdrainage and infected tibialnonunion. (B) Femoral an-giogram showing intact pos-terior tibial artery.

patient was included in whom local healthy flap tissueswere available.

Patient Management

Each patient was assessed clinically and a mutual de-cision was made regarding the possibility of treatmentresulting in a functional extremity."' 05"'06 Once decisionfor debridement and reconstruction was made, anarteriogram 105-108 was performed (Figs. la and b). Aninitial wound debridement was carried out under generalanesthesia where all exposed and contaminated or necroticbone was debrided under loupe magnification with a me-chanical burr. During debridement cultures and biopsyspecimens were taken from bone as well as soft tissue torule out a chronic cutaneous carcinoma.44"09'1'0 Thewound was then treated with moist dressings with repeatclinical examination of the wound to be certain that allnonvitalized and devascularized bone had been removed.If gross tissue necrosis persisted, an additional formal de-bridement was done. At the final procedure, redebride-ment was performed under intravenous antibiotic ad-ministration and a microvascular free tissue transfer (Fig.

2) was performed by two surgical teams working in donorand recipient sites. Free muscle flaps with skin grafts areused almost exclusively, with the procedure lasting be-tween 6 and 8 hours. Immediately before, during, andafter the operation, antibiotics were administered intra-venously for at least 1 week. Antibiotics were selected byour infectious disease consultants based on culture dataachieved at the time of initial bone debridement. In mostof our patients, antibiotics were administered intrave-nously for 6 weeks after operation.2""1'"2 After soft-tissuehealing, bone grafting was done ifindicated, and 6 monthsafter operatively, as in this case, ambulation and rehabil-itation (Figs. 3a to c) were well underway.

Results (Tables 1, 2, and 3)*Fate ofthe Initial 18 Patients*

The original 18 patients have now been followed for amean of 124.3 months (range, 114 to 156 months). A

* Study period ended August 1990.

242 MAY AND OTHERS

CHRONIC TRAUMATIC BONE WOUNDS

FIG. 2. Bony wound at thetime of surgical debridementand free latissimus dorsi flapcoverage.

single patient underwent a secondary tibial realignmentprocedure 1 year after successful wound debridement andclosure. Following this procedure the wound drained for10 days after operation, with antibiotic resolution of cul-ture identified pseudomonas aeruginosa organisms similarto those from his original chronic wound. He has unitedhis tibial osteotomy and has remained drainage free forthe following 7 years. An additional patient underwentfoot amputation for a painful foot and ankle 2 years aftersuccessful free flap chronic ankle wound closure. At thistime his wound was well healed and vessels were patentby direct operative inspection with negative deep culturestaken at the time of amputation.Thus recurrence of drainage occurred in 7.1% of the

original 18 patients followed for more than 10 years.

13- Year Cumulative Study in 96 Patients*

Ofthe patients in our cumulative study, a single patienthad microvascular failure of two sequential gracilis mi-crovascular free tissue transfers. The flaps were debridedin this patient and he ultimately had wound closure bylocal flap expansion techniques. He has remained drainagefree. Thus the ultimate free tissue transfer failure rate inthis study was 2.1%.

During the mean postoperative follow-up period of77.1months (range, 15 months to 156 months), there havebeen three additional patients that have manifested furtherdrainage after their initial operative sequence (Table 3).In one patient chronic drainage since 1942 following an

attempted knee fusion was unsuccessfully treated by de-bridement and free latissimus dorsi flap transfer. In thispatient drainage reoccurred 24 weeks after the initial flaptreatment and has persisted since that time. An additionalpatient developed drainage from the area ofa distal tibialnonunion, which previously had been draining for 6 years.This patient's drainage reoccurred 1.5 years after initialtreatment and responded to re-elevation of the flap andsecondary removal ofthe retained sequestrum. After thisthe patient has remained drainage free for the past 5 years.A third patient underwent a free latissimus dorsi transferto multiple areas oftibial chronic drainage with recurrentdrainage occurring from the distal tibial region within 2weeks of flap transfer. This area responded favorably toredebridement and adjustment of the initial flap. Thispatient ultimately underwent an above-the-knee ampu-tation for instability of the knee and poor lower leg func-tion. At the time of the above-the-knee amputation, no

evidence of chronic bony drainage or chronic bone in-fection could be found (Table 3).

Three patients in this series have died (Table 3). Thecause ofdeath in this group included metastatic sarcoma,intraoperative anesthetic death at the time of bone graftreconstruction, and nonmedicinal drug overdosage. Atthe time ofpatient death, all free flaps were healed withoutevidence of drainage.

Four patients with wounds ofthe femur, 3 with woundsofthe ankle-foot, and 27 of 66 patients with involvementof the tibia required bone grafting as tertiary procedures.All underwent successful bone graft procedures with

243VOl. 214.o NO. 3

MAY AND OTHERS

FIGS. 3A-C. (A) Appearance of muscle flap donor sitethrough short transaxillary incision. (B, C) Lateral viewand front view ofcontoured muscle with healed skin graft,5 months after operation and 3.5 months after a cancellous(tibial three centimeter defect) iliac wing bone graft. Shewas ambulatory 6 months after operation without braceor crutch.

union, with the exception of two tibial patients who cur-rently have established nonunions (Table 2). The patientswith healed bone grafts and all other living patients areambulatory, with the exception of one additional patientwho underwent below-the-knee amputation for a painfulbone graft with tibial nonunion, but without evidence ofinfection (Table 3).

DiscussionThe pathogenesis of chronic traumatic bony wounds

is substantially different from that of hematogenous os-teomyelitis. With hematogenous osteomyelitis,33 bonyinfection usually occurs in the sinusoids of the endostealblood supply33"'3'114 in the metaphyseal region of longbones. Here pathologic bacteria come to rest in a regionof relative blood stagnation with low oxygen tension. The

infection becomes established in this region and beginsto overwhelm the local host response,"5 as pus underpressure begins to spread down the medullary cavity.33"'6When the advancing infection has overcome the perfusioncharacteristics of the endosteal blood supply, frank bonynecrosis may intervene."7 This is even more likely in caseswhen the infection perforates through the bony cortexand begins to elevate the periosteum with additional lossof blood supply. A patient may be treated successfullywith intravenous antibiotics alone, but if progressive bonenecrosis has occurred, it becomes more difficult for thehost defense mechanisms plus antibiotics to counter ef-fectively the persistence of bacteria plus dead bone.' 16,117The ultimate result of this process may be significant bonenecrosis potentially extending throughout the length ofthe involved long bone.32'33'118

244 Ann. Surg. * September 1991

CHRONIC TRAUMATIC BONE WOUNDS

TABLE 1. Complications ofFree Tissue Transfer Wound ClosureSeen in 96 Patients

PercentageComplication Number of total

1. Free flap failure 2 2.12. Re-exploration of flaps 7 7.33. Recurrent drainage 4 4.24. Brachial plexus neuropraxia 7 7.35. Donor/recipient site hematoma 6 6.36. Skin graft loss 4 4.2

This well-established pathophysiologic process shouldbe contrasted with a dissimilar process seen in most cases

of traumatic bone infection. Under traumatic circum-stances a perfectly healthy and viable bone becomes in-vaded by bacteria through traumatic introduction. Duringthis process bony"19-2 and soft-tissue blood supply in theregion oftrauma may be interrupted, creating severe tissuedamage and cellular death'26"127 in varying degrees to thebone and soft tissues.'28 Under these circumstances, ifthewound were sterile and could be closed with well-perfusedsoft tissues, the devascularized bone could be invaded byvascular cutting cones and ultimately would be revascu-

larized and repopulated with osteocytes."7 This is an

identical process to that observed to occur when bonegrafts are accomplished under sterile conditions or whenwounds with minimal contamination are closed with earlywell-vascularized soft-tissue coverage.' However, undertraumatic circumstances with a high concentration of in-oculated bacteria, an ideal milieu exists devoid of bloodsupply'29 for the proliferation and feeding of bacteria inthe accompaniment ofserum-filled dead space. When thebacterial process is active with significant proliferation,the vascular cutting cone mechanism for revascularizationis halted.' 17 Under these circumstances the extent of ne-

crotic bone is usually limited to that amount of bone ini-

TABLE 2. Classification ofChronic Traumatic Tibial Bone Wounds(after surgical debridement)

Time toNo. of Ambulation*

Classificiation Patients (months)

Type I (tibia intact not requiring bonegraft) 39 1.5

Type II (tibia intact with bone graftrequired for functional structuralsupport) 5 5.5

Type IIlt (tibial defect 6 cm or less,with intact fibula) 14 11.4

Type IVt (tibial defect larger than 6 cm,with intact fibula) 5 12.0

Type V (tibial defect larger than 6 cm,without intact ipsilateral fibula) 3 12.7

* Time to ambulation without crutch or upper extremity assist.t A single patient underwent amputation for a painful leg in this group.

245TABLE 3. Ultimate Result ofBone Wound Closure

and Reconstruction in 96 Patients*

PatientResult Number Percentage

Drainage recurrence 4 4.2Amputation for inadequate

leg or foot 5 5.2Died 3 3.1Tibial nonunion 2 2.1Ambulatory without assist 86 89.6

* Percentages total more than 100% because some patients are includedin more than one category.

tially devascularized because the wound is in fact openedby the traumatic process before it becomes contaminatedand infected. Thus pus under pressure cannot extend thebone necrosis process. This is the reverse of what occursin hematogenous osteomyelitis, which may need to beopened (incised and drained) by the surgeon to avoid theextension of bone necrosis. Thus the extent of nonlivingbone seen in traumatic bony wounds is usually dictatedby the initial trauma and is not likely to be as extensiveas that seen in severe and neglected cases of chronic he-matogenous osteomyelitis.49

If the differences in the pathophysiology as describedcan be translated into practice management, then it shouldbe possible in traumatic chronic bony wounds to debridecompletely the localized ischemic"0 130-134 or nonlivingbone and soft tissues and to close the wound with well-perfused tissues.49"35"36We have selected a subset group of our patients who

have required free tissue transfers as our study group totest this hypothesis. In this group the size ofthe flap chosento fill the defect was not limited by the availability oflocaltissues. Thus the bone and soft-tissue debridement couldbe based only on disease removal considerations ratherthan the concern always present when local tissues areused as to whether there will be enough tissue to close thewound. 149

In this 13-year study, 4 of 95 patients (4.2%) with suc-cessful free transfers have manifested recurrent drainageafter initial treatment. After secondary treatment only asingle patient remains with recalcitrant drainage. An ad-ditional subgroup of patients (five) underwent amputa-tion. This group comprises one patient who had persistentdrainage and an unsatisfactory extremity and four patientsin whom, in retrospect, an incorrect judgment was madeas to the salvageability ofthe patients' lower legs and feet.It is our feeling that the initial drainage recurrence ratein four patients represented our inability to recognize anddebride completely the wound and should not suggestthat the thesis of long-term, successful wound treatmentin chronic traumatic bony wounds is not possible. It is ofinterest to note that ofthe three patients with tibial chronic

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MAY AND OTHERS

bony wounds who failed to maintain wound closure, allthree had type I (intact tibia) tibial status after wounddebridement. In two of these patients it was recognizedthat a borderline debridement was done to avoid makingthe tibia unstable, thus avoiding a more complex defectbone graft reconstruction. Thus ironically it was psycho-logically easier for the surgeon to debride a tibia that al-ready had a defect than it was to debride an intact tibiato the point that a defect was created to solve the boneinfection problem.

Experimentally it has been shown that well-perfusedmuscle flaps'08"'37 with increased oxygen7'130'138-143 dealwith bony wounds in an optimal way and promote woundhealing.'" In the experience of others4` 129,35,42,43 145 andin the discussion of our initial patient presentation,' itwas noted by experienced workers in this field that oneshould not overstate the findings of our preliminary re-port.146"47 We fully agreed with this position and statedit in our initial report: "one cannot say that chronic boneinfection was permanently cured or prevented in any pa-tient in this study." However we went on to state that itwas encouraging that the mean drainage-free period of19.3 months for the patients in our initial report was seen'considering that most patients with failure of treatmentof chronic bony wounds will recur within the first yearafter treatment.4"48 If one looks at the long-term resultsof our original 18 patients presented in 1982,' there hasbeen recurrence of drainage in a single patient with an-tibiotic resolution during a mean follow-up period of 1 16months (10.3 years). This 7.1% drainage recurrence rateis in the same range as our 4.2% drainage recurrence rateseen in our overall cumulative series followed for a mean77 months. It is of interest that in the overall series ourfour recurrent drainage patients drained within a mean 7months ofthe their original treatment, making it unlikelythat the overall group recurrence rate will be significantlygreater than that of our initial 18 patients.The primary cause, in our series, of failure in chronic

bony wound treatment was inadequate bone debride-ment."49 The microsurgical free tissue transfer has donemore in our patient management to allow freedom ofdebridement than any other single development in themanagement of patients with chronic bony wounds. Ifonly a small amount of nonliving bone and significantbacteria are left behind,'50 an established sequestrum andseed for ultimate failure over time may ensue. 142,105,135,150

It is possible that the degree and the extent of boneinfection could require a debridement, which is inconsis-tent with skeletal reconstruction from a practical viewpoint. Under these circumstances draining woundmaintenance or even amputation surgery may be in thepatient's best interest. 151"152 Using our recently developedclassification'05 for chronic bony wounds ofthe tibia (Ta-

ble 2), our ability has been enhanced in advising the pa-tient as to the time and bone reconstructive commitmentthat will be needed to achieve a functional limb.We continue to be enthusiastic over the use of free

muscle transfers "'05 53'154 covered with skin grafts.'05"155"156This method of wound closure provides minimal donorsite deformity, and with denervated muscle'57-'6' used tofill the recipient site, excellent wound contour has beenachieved and maintained'62 during the length ofour study.Of course a free tissue transfer should only be used whenan adequate and well-tolerated local means of soft-tissuewound closure is not available.'33"'05 However the decisionas to how much bone and soft tissue to debride shouldbe based on local tissue viability and not on the volumeoflocal reconstructive tissue available to close the wound.

It would appear that chronic traumatic bony wounds aretheoretically successfully treatable by thorough debridementand soft-tissue reconstruction. One would find little dis-agreement with the concept that extremity amputation cancure chronic bony wounds.'5' Thus the concept of localwound (bone and soft tissue) amputation with extremitysalvage by soft- and hard-tissue reconstruction should notseem illogical. A 4.2% recurrence rate during a mean 77-month follow-up period in these 96 patients compares fa-vorably with other reports5 9s1 29,30,35,43145152,163-165 andmethods.4'5'7'8"l1133, 166-188The treatment of chronic traumatic bony wounds is

difficult and it is not surprising that significant pessimismhas existed concerning the cure of such patients.35"47"89On the other hand, it is possible that this pessimism31 inpart has been based on the lack of total involved boneand soft-tissue wound debridement in the face ofinabilityto completely cover the recipient wound with well-vas-cularized tissues. Perhaps some day "cure rates"4 will bereported in patient series with chronic traumatic bonywounds rather than disease-free interval.4"90 We believethat the freedom ofdebridement provided by the almost-unlimited microsurgical free tissue wound closure tech-nique has provided a very high chance of successful long-term wound management in patients with chronic trau-matic bony wounds. It would appear that the results fromour 13-year study are consistent with this interpretation.Bony reconstruction of the lower extremity after infectioneradication is the major challenge facing reconstructivesurgeons in the future.

Acknowledgments

The authors thank the surgical residents and fellows in the Divisionof Plastic Surgery and Orthopedic Surgery who assisted in the manage-ment of the patients reported. They also thank Drs. Al Shiller, HenryMankin, A. W. Karchmer, and Ronald Malt for their advice, support,and assistance in this study and Marjorie Ciampa for technical assistancein preparing this manuscript.

246 Ann. Surg. * Septembet 1991

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DISCUSSION

DR. M. J. JURKIEWICZ (Atlanta, Georgia): Dr. May had 190 referencesin this article. Clearly he researched the literature. He neglected a sig-nificant paper, however, that was published in 1920 by Alan Kanavel inSurgery, Gynecology, and Obstetrics. It was read before the Chicago Sur-gical Society on the management of wounds with noncollapsing walls.Kanavel observed that dead space management in patients with suchwounds was enhanced by flap transposition, and he usually used muscle.He applied the principle with success in patients with osteomyelitis

of the femur and of the mandible, with chronic empyema, and withchronic draining sinus tracts of the frontal bone, pelvis, and lower ab-domen.

These data by Dr. May and his colleagues confirm the observationsof Kanavel, unaccountably lost and forgotten until the past decade.

So too do our data at Emory, compiled by George Cierny of the Or-thopedic Service and Foad Nahai on the Plastic Surgery service. Therewere 189 patients treated in this 5-year period, 91 by transposition ofmuscle and 98 by free flap transfers, similar to the data from the MGH.There was a 97% long-term relapse-free rate in this 5-year period. Therewere no free flap losses at all in this series.Our patients are evaluated for treatment options by taking into account

not only the extent of trauma, nonviable dead bone, and wound factorsall under the rubric of dead space management, but also by consideringhost factors.May I ask what factors you take into account in an attempt to answer

the often crucial question ofamputation versus attempt at limb salvage?

You rely on 6 weeks of IV systemic antibiotics based on recommen-dations ofyour infection disease consultants. Ifour patients are candidatesfor 6 weeks of antibiotics, Cierny incorporates this into the dead spacemanagement by appropriate antibiotic-impregnated beads. These beadsthen are removed in 6 weeks, preserving the cavity and thus facilitatingthe secondary bone grafting. About half of our patients are so treatedand the other half by primary grafting as part of the initial dead spacemanagement. I wonder if you would comment on this approach.

Finally I think you need to elaborate on the 7.3% rate of neuropraxiain harvesting the donor muscle in your series.

I believe the study has broad implications in chronic wound manage-ment, well beyond osteomyelitis of bone, in treatment of wounds withnoncollapsing walls from whatever cause and in whatever location. Con-sider Kanavel's principle in the use of a well-vascularized flap transferfor wound management.

DR. STEPHEN J. MATHES (San Francisco, California): This paper nicelydemonstrates the versatility of microvascular composite tissue trans-plantation for coverage of complex wounds, whether they be located inthe lower extremity or in other areas.Of interest in 1983 here in Boca Raton, I had the opportunity to

present a paper entitled "Coverage of the Infected Wound," which alsoincluded a review of the use of muscle flaps in a retrospective group ofpatients who presented with complex open infected wounds. My studyincluded 27 patients with chronic osteomyelitis involving the lower ex-tremity. Because all these patients are now well beyond 5 years since