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Kondra et al. Plast Aesthet Res 2022;9:36 https://dx.doi.org/10.20517/2347-9264.2021.121 Page 3 of 9

Chart review was performed by four separate reviewers (CJ, IR, JB, KK) across electronic medical records
(EMR) and paper charts. Patient demographics, body mass index (BMI), medical comorbidities, mechanism
of injury (MOI), wound location, Gustilo-Anderson (GA) fracture classification, and flap characteristics
were reviewed and analyzed. Primary outcomes of interest included flap complications, including flap
revision, flap necrosis, and flap loss. Secondary outcomes included infection rates, limb amputation,
ambulatory status, and duration until final ambulation. Ambulatory status was defined as either walking
unassisted, using an assistance device (i.e., walker, crutches, or cane), wheelchair, or limb amputation. Time
until final ambulation was calculated as the difference between the date of flap placement and the earliest
date of the highest level of ambulation, which was abstracted from any note in the medical record specifying
the patient’s highest ambulation.

SPSS Statistics 28.0 was used to analyze differences in patient demographics, injury characteristics,
postoperative complications, and ambulatory status. Descriptive statistical analysis for demographic data
included the means and standard deviations. Student's t-test was used to compare continuous variables, and
chi-square was used to analyze categorical data. P-values were reported as two-tailed and were indicated as
statistically significant if the alpha (α) value was less than or equal to 0.05.

RESULTS
In our single-institution review of microsurgical reconstruction, 187 lower extremity local flaps were placed,
68 (36.4%) of which were soleus muscle flaps. Only 16% of soleus flaps (n = 11) were performed after 2015.

Demographics
The average age was 39.4 years old (SD: 16.2) and the average BMI was 27.8 kg/m (SD: 5.3) across 63
2
(92.6%) males and five (7.4%) females. The most common comorbidity was tobacco usage (n = 36; 52.9%),
followed by hypertension (n = 17; 25.0%), and diabetes mellitus (n = 11; 16.2%); 44 patients (64.7%)
reported > 1 comorbidity. Illicit drug use was reported in 27.9% of patients (n = 19); the most common
substance was cocaine (n = 6; 8.8%) [Table 1].

Injury & flap characteristics
The most common MOI warranting reconstruction was auto versus pedestrian (n = 34; 49.3%), followed by
motorcycle collisions (n = 7; 10.1%), gunshot wounds (n = 5; 7.2%), and falls (n =5; 7.2%). Wound severity
was classified by the Gustilo-Anderson (GA) classification system for open fractures. Open fractures were
diagnosed in 56 patients, with GA fracture IIIB (n = 35; 50.7%) seen in over half of these patients, GA type II
occurring in 18 patients (26.1%), and GA type IIIC occurring in two patients (2.9%). Soleus flaps were
predominantly placed on middle-third leg wounds (69.6%) followed by distal-third injuries (32.4%)
[Table 2]; only one hemisoleus flap was placed, and no cross-leg free flaps were performed. Of note, a
significantly larger percentage of patients (53.6%) with high severity injuries (i.e., GA type IIIA-C) suffered
middle-third leg wounds (P = 0.009).

The most commonly fractured bone was the tibia, occurring in 62 of 63 patients (98.4%) with fractures, with
middle-third fractures being the most common fracture location (66.1%). Multiple concurrent unilateral
fractures were seen in the majority of patients, with the most common combinations being the middle-third
tibia/fibula (n = 17) followed by fracture of the distal-third tibia/fibula (n = 9). Eighteen patients suffered
multiple remote fractures, including contralateral lower extremity (n = 10), upper extremity (n = 9) and
pelvis (n = 7).