Assessing predictors and outcomes of secondary debulking procedures in lower limb trauma reconstruction: A retrospective cohort study.

The goal of flap design in orthoplastic trauma is to provide stable, vascularized coverage for fractures, prevent infection and enable fracture union. This study aimed to improve orthoplastic trauma outcomes by identifying factors that predict the need for secondary flap debulking in severe open lower limb fractures. A retrospective cohort of 893 patients treated at a UK major trauma center was analyzed, with 126 patients (14.1%) requiring secondary debulking post-fracture union. Logistic regression evaluated the impact of sex, age, injury location and flap type on debulking likelihood. Our results showed that men were significantly less likely to request and undergo debulking (OR = 0.33, p < 0.001), whereas younger patients had higher odds (OR = 0.97, p < 0.001). The requests for debulking of flaps around the ankle (OR = 4.93, p < 0.001) and dorsum of the foot (OR = 5.28, p < 0.05) were significantly higher compared to midshaft to distal third of the tibia and plantar foot flaps. Medial plantar local fasciocutaneous and gracilis free flaps had significantly lower debulking rates (p < 0.001). Functional outcomes improved after debulking, with Enneking scores increasing from 28.0 (70.0%) to 33.0 (82.5%) (V = 200.5, p < 0.001). Post-debulking complications affected 16.8% of cases, mostly minor, with no total flap loss. This predictive model highlights how factors such as sex, age, injury zone and flap choice can guide surgical planning to enhance function, aesthetics and quality of life in limb reconstruction.