A Systematic Review of Free Tissue Transfer in the Management of Non-traumatic Lower Extremity Wounds in Patients with Diabetes

Abstract Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity. Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used. Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01). Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

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Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1667049 ◽

2018 ◽

Vol 35 (01) ◽

pp. 001-007 ◽

Cited By ~ 3

Author(s):

Carol Soteropulos ◽

Jenny Chen ◽

Samuel Poore ◽

Catharine Garland

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Weight Bearing ◽

Free Tissue Transfer ◽

Postoperative Management ◽

Venous Congestion ◽

Evidence Based ◽

Flap Survival ◽

Randomized Controlled ◽

Tissue Transfer

Background Free tissue transfer for lower extremity reconstruction is a safe and reliable option for a wide range of challenging wounds; however, no consensus exists regarding postoperative management. Methods A systematic review of postoperative management of lower extremity free tissue transfer was conducted using Medline, Cochrane Database, and Web of Science. Multicenter surveys, randomized controlled trials, cohort studies, and case series were reviewed. Results Fifteen articles investigating current protocols, flap physiology, and aggressive dangle protocols were reviewed. The following evidence-based conclusions were made: (1) Free tissue transfer to the lower extremity is unique due to altered hemodynamics and dependency during orthostasis. Free flap circulation is dependent on locally mediated responses and deprived of compensatory muscular and neurovascular mechanisms that prevent venous congestion in the normal extremity. (2) Compressive wrapping reduces venous congestion and edema and may induce ischemic conditioning, which can increase blood flow. (3) Dangle protocols vary widely in timing of initiation, frequency, and monitoring. Small volume studies examining aggressive mobilization protocols initiating early dependency have led to earlier ambulation and discharge, with no change in flap survival as compared with conservative protocols. (4) Weight bearing may begin after the completion of dangle protocol if no orthopedic injury is present. Conclusions Early initiation of a dangle protocol does not appear to negatively impact flap survival based on this systematic review. Compressive wrapping may be a useful adjunct. Many surgeons agree that clinical monitoring is sufficient; there is no consensus on the utility of adjunct monitoring techniques. Weight bearing may begin after completion of dangle protocol with close flap monitoring, if not prevented by orthopedic restrictions. By providing additional outflow vasculature to reduce venous congestion, flow-through anastomoses may eliminate the need for a dangle protocol. Further research, including large randomized controlled trials is still needed to establish high-level evidence-based conclusions.

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A Systematic Review of Outcomes and Flap Selection Following Lower Extremity Free Tissue Transfer Versus Vascularized Perforator Pedicle Flap Transfer in Lower Limb Reconstruction

International Journal of Orthoplastic Surgery ◽

10.29337/ijops.15 ◽

2018 ◽

Vol 1 (2) ◽

pp. 1-12 ◽

Cited By ~ 3

Author(s):

Edgardo Rodriguez-Collazo ◽

Arshad Khan ◽

Dominic DiPierro ◽

Isra Khan

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Lower Limb ◽

Free Tissue Transfer ◽

Pedicle Flap ◽

Limb Reconstruction ◽

Flap Transfer ◽

Tissue Transfer ◽

Lower Limb Reconstruction

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Free Tissue Transfer in Pressure Ulcer Reconstruction: A Systematic Review

Journal of Reconstructive Microsurgery Open ◽

10.1055/s-0041-1729640 ◽

2021 ◽

Vol 06 (01) ◽

pp. e35-e39

Author(s):

Chelsi Robertson ◽

Charles Patterson ◽

Hugo St. Hilaire ◽

Frank H. Lau

Keyword(s):

Systematic Review ◽

English Language ◽

Free Tissue Transfer ◽

Free Flaps ◽

Final Analysis ◽

The United States ◽

Local Flap ◽

Recurrence Rates ◽

Tissue Transfer ◽

Cochrane Database

Abstract Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review. Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance. Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications. Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.

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RE: Free-Tissue Transfer for the Reconstruction of War-Related Extremity Injuries: A Systematic Review of Current Practice

Military Medicine ◽

10.7205/milmed-d-16-00027 ◽

2016 ◽

Vol 181 (6) ◽

pp. 511-511

Author(s):

Franck Marie Leclère ◽

Casoli Vincent

Keyword(s):

Systematic Review ◽

Current Practice ◽

Free Tissue Transfer ◽

Tissue Transfer ◽

Extremity Injuries

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Risk Factors for Amputation Following Lower Extremity Free Tissue Transfer in a Chronic Wound Population

Plastic & Reconstructive Surgery Global Open ◽

10.1097/01.gox.0000584700.54496.d3 ◽

2019 ◽

Vol 7 ◽

pp. 84-85

Author(s):

Peter Wirth ◽

Jonathan A. Schwitzer ◽

Vikas S. Kotha ◽

Elliot T. Walters ◽

Karen Kim Evans

Keyword(s):

Risk Factors ◽

Lower Extremity ◽

Chronic Wound ◽

Free Tissue Transfer ◽

Tissue Transfer

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Cross-Leg Flaps for Lower Extremity Salvage: A Scoping Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1679955 ◽

2019 ◽

Vol 35 (07) ◽

pp. 505-515

Author(s):

Melody Scheefer Van Boerum ◽

Thomas Wright ◽

Mary McFarland ◽

Michelle Fiander ◽

Christopher J. Pannucci

Keyword(s):

Lower Extremity ◽

Scoping Review ◽

Free Tissue Transfer ◽

The United States ◽

Posterior Tibial Artery ◽

Tissue Loss ◽

Peroneal Artery ◽

Tissue Transfer ◽

Reconstructive Option ◽

Soft Tissue Loss

Abstract Background Lower extremity trauma with soft tissue loss presents a challenge to the reconstructive surgeon. Cross-leg flaps, first described by Hamilton in 1854, are still used to salvage traumatized lower extremities in patients not suitable for free tissue transfer, or those who are receiving care in locations with limited resources. Methods A scoping review methodology was used to examine the evidence supporting the use of cross-leg flaps in modern healthcare. Results There have been 409 cases of cross-leg flaps reported in the modern literature, with the majority of flap cases occurring outside the United States in Turkey, India, and Japan. The most common indication was trauma, mentioned in 93.2% of patients (n = 353 of 379), and anatomic limitation, including inadequate vasculature, was the main reason for not performing free tissue transfer (52.8% of patients; n = 170 of 322). The majority are cross-leg fasciocutaneous flaps (85.8%, n = 273 of 318), based off the posterior tibial artery (27.5%, n = 50 of 182) and peroneal artery (26.9%, n = 49 of 182) and, covering defects of the distal third of the leg (55.5%, n = 151 of 272), or the foot (27.9%, n = 76 of 272). The pedicles are typically divided at 3 weeks (mean 20.9 days) after external fixation is used as the immobilization method (57.7%, n = 184 of 319). Flap survival was 100% across all publications except one (n = 349 of 350 patients), making cross-leg flaps a robust and reliable reconstructive option. Conclusion In resource-limited environments or in patients who are unsuitable for microvascular free tissue transfer, the cross-leg flap remains an impactful and reliable option for limb salvage.

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