Myocutaneous versus fasciocutaneous free flap in the treatment of lower leg osteitis.

Preliminary reports have indicated that debridement of all necrotic soft tissue and bone is a highly efficient method in treatment of lower leg osteitis, if combined with free flap transfer. Yet the question, whether fasciocutaneous or musculocutaneous flaps are the better choice, is controversial. To answer that question, we looked at the files of 69 patients who underwent surgical treatment of osteitis of the leg between 1982 and 1989. Those patients underwent an agressive debridement and closure of the soft tissue defect by free flap transfer in a single stage operation. Long term follow up was possible for 50 patients (72%). Out of these patients two groups were formed: Those being treated treated with musculocutaneous (mc) - and those with fasciocutaneous free flap (fc). In mc-group the 30 patients received 33 flaps, 20 patients of fc 21 flaps. We lost 3 Latissimus dorsi and 2 Parascapular flaps. Flap survival rate was 91% in both groups. The rate of early reexploration was much higher in the mc-group. We could demonstrate, that free flap transfer itself is not the final step in the treatment of osteitis. Only 30% of mc-patients were cured after the transfer. The remaining 21 patients needed another 4.09 (mean) operations. The rate in fc with 65% cured patients was significantly higher. The remaining 7 patients required 3.57 (mean) subsequent operations. Relapse of infection after free flap transfer occurred in 33% (10 pat.) in mc. We found a range of 1 to 6 recurrent fistulas. Five patients have been free of drainage for more than 4 years. Two are still suffering from active infections. Amputation as a final solution in that group had to be done in 3 patients (10%). In the fc-group only 10% (2 pat.) showed a relapse of infection. Both had only 1 fistula. One of these patients has been drainage free for more than 4 years now, one is still active. There were no amputations in that group. So taking the 4 year drainage free time as a measure, mc-group showed an overall success rate of 83%. In fc-group it was much higher with 95%. From our clinical experience we cannot agree with the hypothesis of an antiinflammatory effect of muscle flaps, which has been discussed so often in the literature.