Older age is a predictor for hardware failure in open lower extremity fractures requiring free flap coverage

The primary objective of this study was to investigate incidence and factors associated with hardware failure in a cohort of patients with open tibial and ankle fractures who underwent free flap coverage in conjunction with open reduction and internal fixation (ORIF) and hardware placement. Secondary objectives were to determine incidence of fracture union and limb salvage. Finally, we sought to identify flap-related factors that might impact rates of infection, flap failure, and nonunion.

A consecutive single-surgeon series was studied. Baseline patient characteristics, flap-related factors, incidence of hardware failure, amputation, and non-union were extracted and analyzed.

A total of 37 consecutive patients with a mean age of 38.9 ± 16.4 years were included, with a mean postoperative follow-up of 703.4 ± 459.6 days. There were 9 patients (24.3 %) with hardware failure and deep tissue infection. Time from injury to flap and time from last ORIF to flap were not significantly different between patients with hardware failure and those without. Flap type (muscle versus fasciocutaneous), smoking status, diabetes and body mass index were not associated with hardware failure. Multivariate regression analysis controlling for potential confounders showed that older age in patients was the only significant factor predicting hardware failure. Bone union was achieved in 29 (78.4 %) patients. Mean time from surgery to radiological signs of union was 329.3 ± 425.3 days.

In patients requiring free flap reconstruction and ORIF for open tibial and ankle fractures, age was the only significant non-modifiable risk factor for hardware failure.