Arch Hand Microsurg.  2018 Sep;23(3):206-216. 10.12790/ahm.2018.23.3.206.

The Usefulness of Perforator Flaps for the Definitive Management of Exposed Hardware in Patients with Lower Extremity Fracture

  • 1Department of Plastic & Reconstructive Surgery, Ajou University Hospital, Suwon, Korea.
  • 2Department of Orthopaedic Surgery, Ajou University Hospital, Suwon, Korea.


Hardware exposure after the lower extremity fractures operation is challenging to manage and requires long-term treatment. The traditional management of exposed hardware usually includes hardware removal. The purpose of this study was to evaluate the proper treatment for the cases with exposed hardware in patients with lower extremity fracture.
Between October 2011 and October 2015, a total of 14 cases of hardware exposure who had previously been managed for lower extremity fractures required surgical debridement, revised surgery by the orthopedic surgical team and reconstruction with fasciocutaneous perforator flaps. A retrospective chart review was performed.
Of the 14 cases included, 5 were open fractures at the time of the initial injury, and 9 were closed. The management of the exposed hardware was determined after examining the bony union status and device loosening. Anterolateral thigh free flap, posterior tibial artery perforator-based propeller flap, and peroneal artery perforator-based propeller flap were performed. All flaps survived without major complications. There were three cases of persistent infections that required the removal of the hardware again and repeated debridement. All three cases involved hardware that had been exchanged during the flap surgery because of loosening.
We achieved positive results by treating exposed hardware with fasciocutaneous perforator flaps and maintaining the original hardware, except in the cases where it had loosened. In cases with device loosening, there is possibility of progression to persistent infection and osteomyelitis even after properly treated with device exchange and soft tissue reconstruction.


Lower extremity; Orthopedic fixation devices; Wounds and injuries; Perforator flap

MeSH Terms

Fractures, Open
Free Tissue Flaps
Lower Extremity*
Orthopedic Fixation Devices
Perforator Flap*
Retrospective Studies
Tibial Arteries
Wounds and Injuries


  • Fig.1. A treatment algorithm of our hospital for treating hardware exposure after lower extremity fracture operation.

  • Fig.2. (A, B) The hardware was exposed through a 1.5×1.5 cm skin and soft tissue defect on the medial malleolus. (C) After a meticulous debridement, we left the hardware intact and covered the defect with a posterior tibial artery perforator-based propeller flap. (D) The surgical site remained closed and asymptomatic 6 months after the surgery.

  • Fig.3. (A) The hardware was exposed through a 3×3 cm skin and soft tissue defect on the dorsum of the foot. (B) We left the hardware intact and covered the defect with a free anterolateral thigh fasciocutaneous flap. (C) The surgical site remained closed and asymptomatic 6 months after surgery.

  • Fig.4. (A) After removal of the hardware, a 14×4 cm sized skin and soft tissue defect was noted on the antetibial area of the patient's left leg. (B) After hardware removal and intramedullary nailing of the tibia fracture, the soft tissue defect was covered using an anterolateral thigh free flap. (C) The surgical site remained closed and asymptomatic 28 months after surgery.


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