Introduction:
Hematoma can adversely affect a flap in several ways, leading to flap compromise. The impact of hematoma on free flap is more complex than previously understood. Free flap compromise due to hematoma most commonly occurs during the early postoperative period.

Aim:
This article highlights the late compromise of the free fibula flap and the significance of flap monitoring after a secondary procedure.

Case study:
We present a case of late free fibula osteocutaneous flap compromise on postoperative day 13 due to hematoma. A 21-year-old woman with left tibia osteofibrous dysplasia underwent wide resection and left tibia reconstruction using the modified Capanna technique. Postoperatively, she developed a deep surgical site infection with implant exposure, secondary to partial thickness necrosis of the skin paddle caused by hematoma-induced ischemia-reperfusion injury. She was treated with antibiotics, dressings, and debridement. Implant removal was performed at postoperative month 5 following bone union.

Results and discussion:
Hematoma can exert pressure on surrounding tissues, leading to vascular pedicle compression and thrombosis. The time dependency of flap salvage rates is associated with the progression of irreversible ischemia-reperfusion injury. Complications such as surgical site infection with implant exposure may occur. Data on timing of implant removal remain limited. Conventional management involves debridement, antibiotics, and hardware removal. The implant may be preserved until bony healing is achieved, provided there is no implant failure, prolonged exposure, or active infection.

Conclusions:
Early recognition and prompt re-exploration are crucial for flap salvageability in the presence of hematoma. The removal of an exposed implant is controversial, as clear guidelines are still lacking.