Use of venous couplers in microsurgical lower extremity reconstruction: A systematic review and meta-analysis

Background Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. Methods Retrospective review (1979–2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. Results More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. Conclusion Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

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Free-Flap Lower Extremity Reconstruction: A Cohort Study and Meta-Analysis of Flap Anastomotic Outcomes between Perforator and Nonperforator Flaps

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1636939 ◽

2018 ◽

Vol 34 (06) ◽

pp. 455-464 ◽

Cited By ~ 2

Author(s):

Christopher Song ◽

Keith Koh ◽

Bien-Keem Tan ◽

Terence Goh

Keyword(s):

Cohort Study ◽

Lower Extremity ◽

Free Flap ◽

Meta Analysis ◽

Relevant Literature ◽

Success Rates ◽

Perforator Flaps ◽

Anastomotic Complications ◽

Lower Extremity Reconstruction ◽

Extremity Reconstruction

Introduction Free-flap outcomes in lower extremity reconstruction carry the lowest anastomotic success rates compared with other anatomical sites. Despite their advantages over traditional nonperforator flaps, free perforator flaps have only recently become established in this area due to the additional challenges faced. It is therefore crucial to assess the anastomotic outcomes of perforator and nonperforator free flaps. Methods We performed a single-center retrospective cohort study and combined this with a meta-analysis of the relevant literature. We evaluated three flap anastomotic outcomes: reexploration, operative salvage, and flap failure rates. Results Between January 2010 and June 2015, our center managed 161 patients who underwent lower extremity free-flap reconstruction, which included 76 perforator flaps and 85 nonperforator flaps. The perforator flaps had higher reexploration rates compared with the nonperforator flaps, but this was not statistically significant (18.4 and 10.6%; p = 0.18). Perforator flaps had a higher flap salvage rate but were not statistically significant (78.6 and 22.2%; p = 0.374). Lastly, although not statistically significant, perforator flaps had a lower rate of complete failure due to anastomotic complications (3.9 and 8.2%; p = 0.336). The meta-analysis included 12 studies (inclusive of the index study) and found no statistical difference in all three outcomes. Conclusion Our meta-analysis is the first reported study and serves as an indication that free perforator flaps in lower extremity are as reliable as their traditional nonperforator counterparts. This does come with the prerequisite appreciation of the anatomical variations, the delicate handling of these flaps, and a low threshold for reexploration.

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Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis

Microsurgery ◽

10.1002/micr.30047 ◽

2016 ◽

Vol 38 (1) ◽

pp. 109-119 ◽

Cited By ~ 41

Author(s):

Farid Bekara ◽

Christian Herlin ◽

Serge Somda ◽

Antoine de Runz ◽

Jean Louis Grolleau ◽

...

Keyword(s):

Lower Extremity ◽

Meta Analysis ◽

Lower Extremity Reconstruction ◽

Extremity Reconstruction

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Reconstruction of Lower Extremity Defects Using the Serratus Anterior Free Flap: A Systematic Review and Retrospective Case Series

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1697920 ◽

2019 ◽

Vol 36 (02) ◽

pp. 116-126 ◽

Cited By ~ 1

Author(s):

Aneesh Karir ◽

Michael J. Stein ◽

Sarah Shiga ◽

Jing Zhang

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Free Flap ◽

Case Series ◽

Free Flaps ◽

Complication Rates ◽

Minor Complication ◽

Serratus Anterior ◽

Lower Extremity Reconstruction ◽

Extremity Reconstruction

Abstract Background Free tissue transfer is the most common modality for distal third lower extremity reconstruction, yet complication rates remain high. The serratus anterior muscle free flap, which can be harvested alone or as a chimeric flap, is a robust and reliable option that remains the primary modality for distal third lower extremity defects at our institution. The objective of this study was to perform a systematic review of lower extremity reconstruction with the serratus anterior free flap and provide a retrospective review of cases at our institution. Methods A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library (PROSPERO CRD42018110692). Articles reporting reconstruction of lower extremity and foot defects using serratus anterior free flaps in adults were included. A retrospective cohort study of serratus anterior free flaps was then performed from 2012 to 2018 at our institution. Results Thirty-seven articles meeting inclusion criteria provided data on 198 flaps: 125 (63%) serratus-only flaps and 73 (37%) chimeric flaps based on the subscapular axis. Among the serratus-only flaps, defects were primarily due to chronic wounds (51%) or acute infections (33%). Flap survival rate was 97%, and the major and minor complication rates were 5 and 9%, respectively. Of the 10 cases included in the case series, flap survival rate was 100%, there were no major complications, and the minor complication rate was 44%. The average time to flap healing was 95 days and average lower extremity functional scale score was 58/80 among five patients. Conclusion Serratus anterior muscle free flaps are a versatile and reliable option for distal third lower extremity reconstruction.

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