Introduction

Increased limb salvage rates necessitate greater attention to flap durability during subsequent staged or revisional orthopedic procedures in the lower extremity. Direct evidence comparing outcomes in this specific context is limited, thus we compared the performance of muscle flaps (MF) and fasciocutaneous flaps (FCF) and sought to identify predictors of complications following flap re-elevation.

Methods

Adults (>18 years) with lower extremity injuries (knee and below) who underwent flap reconstruction and subsequent flap re-elevation for a secondary orthopedic procedure between years 2000 and 2020 were reviewed. Patient factors, operative details, and postoperative trajectory were documented. Complications following a secondary orthopedic procedure were classified as minor or major (Clavien-Dindo ≥ III). Categorical data were assessed for independence with Fisher Exact test and continuous variables with Mann–Whitney U test.

Results

Of 64 patients included (MF = 52, FCF = 12), 14.1% experienced a major complication with similar rates between FCFs (n = 2, 16.7%) and MFs (n = 7, 13.5%). However, the occurrence of a primary complication (OR = 7.82, CI [1.47–41.66]) and an unplanned secondary orthopedic procedure (n = 9, 100%) were strong predictors of major complications after flap re-elevation. Current smoking (OR = 6.39, CI [1.43–28.53]) and alcohol use (OR = 9.0, CI [1.92–42.40]) were also significant risk factors.

Conclusion

Our findings indicate that the risk of flap failure is primarily associated with patient factors and peri-operative trajectory, rather than flap type alone. We propose minimizing unplanned flap re-elevations or primary complications by selecting a flap that optimally obliterates dead space and provides durable coverage.