Elevating Lower Extremity Reconstruction: An Algorithmic Approach to Free Flap Re-Elevation.

Background: Free flap (FF) reconstruction is frequently required for soft tissue coverage after significant orthopedic trauma of the lower extremity (LE). While usually the final step in limb salvage, re-elevation of the previously inset FF may be necessary to restore a functional limb. In this study, we present our algorithm for LE FF re-elevation and review our experience to identify factors associated with successful limb salvage and return to ambulation.

Methods: A retrospective, single-institution review was conducted of adult patients with LE wounds who required FF reconstruction from 2016-2021. From this cohort, patients that required re-elevation of their LE FF were identified. Successful FF re-elevation was defined by limb salvage and return to ambulation.

Results: During the study period, 412 patients with LE wounds required flap reconstruction. Of these patients, 205 (49.8%) underwent free tissue transfer, and 39 (9.5%) met our inclusion criteria. From this cohort, 34 had successful FF re-elevations, while 1 was non-weight bearing and 4 elected for amputation due to chronic complications unrelated to their FF. Univariate analysis revealed the total number of FF re-elevations (p < 0.001), the frequency of re-elevation indicated for orthopedic access (p < 0.001), and infections necessitating return to the operating room (p = 0.001) were each negatively associated with limb salvage and return to ambulation.

Conclusion: The described algorithm highlights the preoperative planning and meticulous flap preservation necessary for the successful coverage of critical structures following FF re-elevation. Our data demonstrates that LE FFs can be safely re-elevated for hardware access or flap revision. In these complex cases of LE trauma, management by a multidisciplinary team is essential for successful limb salvage.