title: Coverage of exposed hardware after lower leg fractures with free flaps or pedicled flaps.
abstract: OBJECTIVE
  The placement of osteosynthetic materials in the leg may be complicated by hardware exposure. Successful soft tissue reconstruction often provides a critical means for limb salvage in patients with hardware exposure in the leg. Free flaps are currently considered the standard surgical procedure for soft tissue coverage of the wounds with internal hardware exposure. However, to date, no conclusive literature shows the superiority of a specific type of flap.
  
  
  METHODS
  The current review compares data from the literature concerning outcomes and complications of free and pedicled flaps for exposed osteosynthetic material preservation in the leg.
  
  
  RESULTS
  A total of 81 cases from twelve different articles presenting internal hardware exposure of the leg were analyzed in our study. Thirty-two patients underwent immediate reconstructive surgery with pedicled flaps, while forty-nine patients underwent free flap reconstruction. The overall survival rate for pedicled flaps was 96.77%, while for free flaps it was 97.77%. The overall implant preservation rate was 78.12% for pedicled flaps and 53.33% for free flaps. With reference to postoperative complications, the overall complication rate was 46.87% for pedicled flaps and 10.20% for free flaps.
  
  
  CONCLUSIONS
  No significant difference was found in terms of overall flap survival. However, a significant difference was found regarding successful implant preservation (78.12% in the pedicled flap group vs. 53.33% in the free flap group). In particular, the first observation appears to be in contrast with the current trend of considering the free flaps the first choice procedure for soft tissue coverage of the wounds with internal hardware exposure. Nevertheless, a higher occurrence of postoperative complications was observed in the pedicled flap group (46.87% vs. 10.20%). The choice of the most appropriate reconstructive procedure should take into account several issues including the size of the wounds with internal hardware exposure, the possibility of soft tissue coverage with pedicled flaps, the availability of recipient vessels, general conditions of the patients (such as age, diabetes, smoking history), patients' preference and presence of a microsurgical team. However, according to the results of this review, we believe that pedicled flap reconstruction should be reconsidered as a valid alternative procedure for skin tissue loss with hardware exposure whenever it is possible.
authors.affiliation: Division of Plastic and Reconstructive Surgery, "Sapienza" University of Rome, Rome, Italy. nefer.fallico@gmail.com.
authors.forename: N
authors.initials: N
authors.lastname: Fallico
authors.forename: F
authors.initials: F
authors.lastname: Somma
authors.forename: E
authors.initials: E
authors.lastname: Cigna
authors.forename: L A
authors.initials: LA
authors.lastname: Dessy
authors.forename: M
authors.initials: M
authors.lastname: Tarallo
authors.forename: D
authors.initials: D
authors.lastname: Ribuffo
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects* / Q000295:instrumentation; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D016268:Internal Fixators / Q000009:adverse effects*; D007866:Leg; D023821:Limb Salvage; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D013524:Surgical Flaps / Q000098:blood supply; D013529:Surgical Wound Dehiscence / Q000601:surgery*; D014947:Wounds and Injuries / Q000601:surgery