BACKGROUND: Chronic foot wounds often require bony resection, however altering the tripod of the foot carries a risk of new ulcer development nearing 70%. Resulting defects often require free tissue transfer (FTT) reconstruction; outcomes data for various bony resection and FTT options may guide clinical decision-making regarding bone and soft tissue management. We hypothesize that alteration of the bony tripod will increase risk of new lesion development following FTT reconstruction. METHODS: A single-center retrospective cohort analysis of FTT patients from 2011-2019 with bony resection and soft tissue defects of the foot was performed. Data collected included demographics, comorbidities, wound locations, and FTT characteristics. Primary outcomes were recurrent lesion(RL) and new lesion(NL) development. Multivariate logistic regression and cox hazards regression were used to produce adjusted odds ratios(OR) and hazard ratios(HR). RESULTS: Sixty-four patients(mean age 55.9 years) that underwent bony resection and FTT were included. Mean Charlson Comorbidity Index(CCI) was 4.1(standard deviation 2.0) and median follow up was 14.6 months(range 7.5-34.6). Wounds developed post-FTT in 42(67.1%)(RL 39.1%, NL 40.6%). Median time to NL development was 3.7 months(range 0.47-9.1). First metatarsal defect(OR 4.8, 95% CI 1.5-15.7) and flap with cutaneous component(OR 0.24, 95% CI 0.07-0.8) increased and decreased odds of NL development, respectively. CONCLUSION: First metatarsal defects significantly increase NL risk following FTT. The majority of ulcerations heal with minor procedures but require long-term follow up. While soft tissue reconstruction with FTT achieves success in the short-term, NL and RL occur at high rates in the months to years following initial healing.