Multimedia Exhibit Looks at Flap Coverage for Limb Reconstruction in Open Fractures

By: Terry Stanton

Comprehensive instructional encourages surgeons to ‘question classical orthopaedic concepts’

The Scientific Exhibit 81 “Flapping Is Not Only for Plastics: How Soft Tissue Coverage Impacts Bone Healing” provides a multimedia overview of different flap coverage options (pedicle flaps vs. free, muscle vs. fasciocutaneous) for both upper and lower extremity fractures, with algorithms that can help orthopaedic surgeons choose appropriate flaps based on injury site, fracture type, extent of soft-tissue damage, and operative plan (fracture fixation/reconstruction).

From a technical standpoint, the exhibit evaluates differences in surgical flap transfer, harvest, and elevation, along with rates of flap failure and donor site morbidity among common flap types. The exhibit surveys current recent evidence to survey how flaps composed of different tissues differ in prevention of wound desiccation and infection, serve as sources of osteoprogenitor cells and growth factors, and contribute to revascularization aiding in fracture healing.

In the text introduction to the exhibit, Devan Mehta, MD; Philipp Leucht, MD; and their coauthors explain, “Local and free flaps not only serve to provide coverage, but also play a vital role in the process of bone healing in patients with open fractures and extensive soft-tissue damage (Fig. 1). In this scientific exhibit, we explore the different options of flap coverage for upper and lower extremity open fractures, how they differ in technical approach, and how they provide variable environments for fracture healing.”

Technically, the scientific exhibit addresses the following surgical situations:

Local vs. free tissue transfer

  • Local flaps, such as rotational flaps, are technically easier to implement owing to their close proximity to the defect. Furthermore, they do not require microsurgery and, as a result, flap failure rates are lower as they are less susceptible to ischemia. However, local flaps may not always be possible due to extensive soft-tissue loss at the site of injury.
  • Microvascular free flaps are technically more difficult to implement because the soft tissue is harvested from a site distant to the defect and they require microsurgical anastomosis. Microvascular free flaps have higher failure rates than local flaps, and depending on tissue type, have higher levels of donor site morbidity.


Fig. 1 Intraoperative images of a 33-year-old man who presented with a right Gustilo IIIC tibia fracture after a motorcycle accident. The patient required revascularization, a sural nerve cable graft, Achilles tendon reconstruction, and plate fixation of the tibia. Excessive soft-tissue damage (A) required free flap coverage. A free anterolateral thigh flap was elevated from the patient’s left thigh and transferred to the site of the defect (B). Microvascular anastamoses were made between the flap vessels and the posterior tibial vessels.

Courtesy of the department of orthopedic surgery and the Hansjörg Wyss department of plastic surgery, NYU Langone Health.

Muscle vs. fasciocutaneous

  • Muscle flaps are more difficult to harvest and manipulate compared to their counterparts and cause higher levels of donor site morbidity and loss of muscle function. However, they conform better to complex defects.
  • Fasciocutaneous flaps are advantageous because they are simple to implement; however, their flap necrosis rate is twice that of muscle flaps.

Need for future flap elevation, manipulation, or debulking

  • Fasciocutaneous flaps better tolerate secondary procedures—a consideration that needs to be taken into account with complex multistage procedures (eg, Masquelet reconstruction, staged antibiotic bead placement).
  • Muscle flaps have aesthetically less desirable results and frequently require revisions and debulkings.

From a basic science perspective, the exhibit explains how a surgeon must consider several factors when deciding on an optimal tissue type for fracture healing.

The exhibit notes that evidence has shown that muscle flaps are superior in eliminating bacteria from the wound bed and the fracture site.

In an interview, Dr. Mehta summarized the takeaways from the exhibit:

“It is well understood that soft-tissue coverage is vital to the reconstructive effort of traumatic open fractures,” he explained. “Soft tissue provides healing bone with an osteogenic environment. For decades, the ‘reconstructive ladder’ has provided surgeons with a framework that informs decisions on exactly how to cover open fractures (secondary intention, primary closure, skin grafts, local flaps, free flaps). However, it is important to understand that this model may be too simplistic, and in order to maximize the healing potential of bone while limiting patient morbidity, other considerations need to be made. Specifically, we must heed basic science considerations and technical considerations,” he said.

“On the basic science side, surgeons need to understand that the two classic flap types (muscle vs. fasciocutaneous) are not equal when it comes to providing healing bone with vascular supply, osteoprogenitor stem cells, growth factors, and a barrier against infection. On the technical side, surgeons need to understand that taking certain types of tissue for flaps can lead to significant donor site morbidity, be aesthetically unappealing, obliterate dead space differently, and react to multiple operations differently.

“This exhibit expands upon these ideas and urges surgeons to make more informed decisions when it comes to soft-tissue coverage. It also encourages surgeons to question classical orthopaedic concepts and to perform clinical studies investigating whether certain types of flaps allow for more efficient bone healing and if there is a clinical difference between using muscle and fasciocutaneous flaps,” Dr. Mehta said. “Also, in the basic science realm, if we can understand specifically and exactly what contributions soft tissue provides to healing bone, then we will not only be able to optimize bone healing, but we may open the door to creating better biologics that we can use for our patients.”

Dr. Mehta’s and Dr. Leucht’s coauthors of Scientific Exhibit 81 are Dalibel M. Bravo, MD; Salma Abdou, BA; and Vishal Thanik, MD.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at