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Kondra et al. Plast Aesthet Res 2022;9:36 https://dx.doi.org/10.20517/2347-9264.2021.121 Page 7 of 9

II fractures. Studies have shown higher-grade injuries associated with a greater risk of complications;
notably, GA type III injuries are often associated with higher amputation rates and delayed
revascularization as they commonly result from blunt and high-velocity trauma [17,18] . Similarly, among the
two patients who suffered from type IIIC injuries, both patients had arterial injuries and one patient
required an amputation. In such high severity open fractures, flap coverage and bony union can improve
[18]
the likelihood of achieving full ambulation by six months postoperatively .
Eight patients suffered arterial injuries, two of which required revisional surgery. One of these eight patients
required an AKA after suffering a significant injury with a GA type IIIC open fracture, arterial and nerve
injuries, two unilateral leg fractures, and two remote fractures, with a history of hypertension and use of two
illicit substances. All these factors increased the likelihood of complications with limb salvage and ultimately
resulted in amputation. As mentioned previously, the clinically grave picture preoperatively reflected the
severity of the injury and strongly influenced the outcome. It is important to note that a preoperative
[5]
angiogram may be of added benefit , especially in the setting of severe trauma, to confirm the patency of
major perforators when considering flap design. Free tissue transfer should be considered as a final
reconstructive option for larger wounds in the middle- or distal-third leg or those involving trauma to the
soleus or its perforators .
[5]

Donor site morbidity is a considerable outcome involved in flap harvest. Although muscle flaps are reported
as imparting an acceptable functional outcome in the literature, a potential unknown ambulatory morbidity
is associated with this option, is variable across patients, and may be reflective of the injury itself. This
notion might be reflective of the increase in pedicled perforator flaps and reflective of our surgical trend
[12]
in which 16% of soleus flaps were placed after 2015. However, given severe tissue disruption in traumatic
injuries, pedicled fasciocutaneous perforator flaps may be of limited use in such situations, thereby
supporting the versatile soleus muscle flap . Following the transfer of the soleus muscle, Knopp et al.
[12]
[19]
used isokinetic testing three years postoperatively and found a mean reduction in muscle-strength flexion of
30%. While it has been reported that functional donor site morbidity is mild in patients who had a complete
recovery from the index trauma, patients can still demonstrate deficits and compensatory motions during
[20]
more challenging activities (i.e., fast/uphill walking) . Further research should focus on flap type and its
correlation with long-term ambulation.

This study was limited in focus to soleus flaps alone and commented explicitly on the location of soleus flap
placement and outcomes. Our group has parallel publications examining flap choice based on wound
location as well as local versus free flap implementation; however, the aim of this particular study was to
describe the trends and outcomes of soleus flap usage at a large Level 1 trauma center. One of the
limitations of this study is the variability in outpatient follow-up; fifteen patients had no long-term follow-
up after discharge. While the mean follow-up time from discharge date to latest follow-up with PRS was 3.7
months (SD: 6.8), the average date of highest ambulation across the whole cohort was 5.4 ± 9.8
postoperatively. The average time to ambulation for those who achieved fully independent ambulation was
7.5 months (SD: 7.2). Additionally, the duration of time until final ambulation was reached may be higher
than we report since patients are more likely to return for follow-up when experiencing postoperative
complications or requiring a medical device that helps them ambulate. In contrast, fully ambulatory patients
are less likely to follow up, and the exact date of final ambulation may be unknown. Future studies could
implement more frequent follow-ups through phone or telehealth visits. Other limitations include patient
loss to follow-up and possible errors that could have occurred during the crossover between EMR and paper
charts, providing mixed difficulty across chart reviews with a certain paucity of data.