OBJECTIVES: Osteocutaneous free flap reconstruction can be complicated by hardware failure. The present study investigates the frequency and predictors of hardware failure in head and neck osteocutaneous reconstruction. METHODS: Patients who underwent osteocutaneous head and neck free flap reconstruction between the years of 2014 and 2022 were identified at our institution. Hardware failure was defined as hardware infection, screw plate loosening, exposed hardware, migration, deformation, or fracture. RESULTS: We identified 47 patients who met the inclusion criteria for this study. Common indications for intervention included squamous cell carcinoma (35, 74%) and osteoradionecrosis (8, 17%). Most operations used fibular flaps (31, 66%) or osteocutaneous radial forearm flaps (12, 26%). The median age at the time of reconstruction was 66 years (IQR: 59 to 72). In total, 17 (36%) patients experienced hardware failure in the postoperative period. On univariable analysis, estimated blood loss (P=0.01) and early postoperative infectious complication (P=0.03) were the only significant predictors of hardware failure. On multivariable analysis, these factors retained significance. Estimated blood loss had an OR of 1.004 (95% CI: 1.001-1.008
P=0.01), and infectious complication had an OR of 5.22 (95% CI: 1.28-24.84
P=0.03). CONCLUSION: The incidence of hardware failure among patients who undergo head and neck osteocutaenous free flap reconstruction is high (36%). Patients with infectious complications and high estimated blood loss may be more likely to develop hardware failure. LEVEL OF EVIDENCE: Level III.