Flap Use for Wound Coverage After Spinal Hardware Infection: A Systematic Review of the Literature

Reconstructing spinal defects complicated by surgical site infection (SSI) is challenging, with SSIs occurring in 1%-4% of spine surgeries, often involving hardware exposure. These infections increase hospital stays, costs, and risks of poor outcomes. Effective management strategies are crucial for addressing infected spinal wounds.

We conducted a systematic review following PRISMA-P guidelines across six databases. Included studies reported flap coverage for spinal reconstructions with or without hardware. Outcomes of interest included flap loss, partial flap necrosis, wound dehiscence, venous thrombosis, and infection rates. Quality was evaluated using ASPS criteria and the ROBINS-I tool.

Out of 4436 articles, 32 studies were included, comprising 969 patients, with 496 undergoing reconstructions for infected chronic wounds. The mean patient age was 52.1 years. Infection contributors included spinal instrumentation, radiotherapy, smoking, and diabetes, with Staphylococcus aureus being the most common organism (52.7%). Paraspinal muscle flaps and latissimus dorsi flaps were most frequently used. Out of the 27 studies that investigated the need for hardware removal, eight reported patients required it in the postoperative period. The pooled flap survival rate was 89%, with muscle flaps showing higher effectiveness compared to fasciocutaneous flaps (92% vs. 85%). Other complications included wound dehiscence (12%), flap necrosis (8%), and reinfection (10%).

This study provides evidence-based insights into managing complex spinal defects. Flap reconstruction remains a viable solution for soft-tissue coverage, highlighting the importance of tailored surgical planning based on defect characteristics and patient factors.