Soleus muscle flap for reconstruction of lower extremity trauma. Workhorse or glue factory?

Abstract

Aim: Soleus muscle flaps have traditionally been a reliable tool in the plastic surgeon’s armamentarium for lower extremity reconstruction and limb salvage. In the modern era, many surgeons prefer free flaps. This study sought to evaluate trends and outcomes of soleus flap reconstruction after lower extremity injury in a large cohort at a Level 1 trauma center. Methods: This is an Institutional Review Board -approved, retrospective chart review that was undertaken at Los Angeles County + University of Southern California Medical Center from 2007 to 2021. Patient demographics, Gustilo-Anderson fracture classification, flap characteristics, and outcomes were collected and analyzed. Outcomes of interest included failure rates, postoperative complications, and long-term ambulatory status. Results: Of 187 local leg flaps, 68 (36.4%) were soleus flaps, with 84% of soleus flaps performed prior to 2016. The flap loss rate was 0.0%. Eighteen (26.1%) flaps demonstrated > 1 complication, including osteomyelitis/hardware infection (n = 12), flap revision (n = 6), and amputation (n = 2). Long-term follow-up demonstrated 35.3% of patients ambulating independently after an average of 7.5 ± 7.2 months, with the remainder needing a wheelchair or walking assistance device. Conclusion: Although soleus flap loss rate was 0%, the findings demonstrate more infections than expected; this must be considered in light of pre-existing patient comorbidities possibly deterring free flap placement. Additionally, our results reveal that only 16% of soleus flaps were performed after 2015. As surgeons consider the reconstructive ladder for lower extremity trauma, a rotational soleus muscle flap should not be overlooked in the modern era of free flap tissue transfers and might be a more optimal flap choice in certain patients with multiple comorbidities.