External Fixator Kickstands for Free Soft Tissue Flap Protection: Case Series and Description of Technique

Background: Protected elevation represents a critical component of postoperative care, particularly in posteriorly located flaps, to prevent pressure on the flap’s vascular pedicle and ensure a successful skin graft. Although several short case series and technique papers have described kickstand placement to prevent heel ulcers as an adjuvant to fixator placement for fracture management, there remains a paucity of reports describing external fixator placement solely for extremity elevation and pressure alleviation in the postoperative care of flap coverage procedures. Methods: Patients who underwent lower extremity free flap coverage procedures requiring temporary elevation were included. Age, diagnosis, soft tissue procedures performed, type of external fixator placed, duration of frame placement, mode of removal, and complications related to external fixator placement were documented. Patients requiring external fixator placement for fracture management were excluded. Results: Twelve patients with 13 lower limb soft tissue defects were included in our case series. A thin-wire ring external fixator kickstand was applied in 5 limbs while the rest underwent placement of a uniplanar carbon fiber bar type external fixator kickstands. The average time for removal of the frames was 4 weeks. No complications were reported from kickstand placement. Conclusion: The use of external fixator kickstands is an effective and safe adjuvant to soft tissue flap procedures for the lower extremity. Our case series is the largest in the literature and first to address the technical considerations for frame placement, positioning, and removal for external fixator kickstands placed solely for flap coverage procedures. Level of Evidence: Level IV, retrospective case series.