Download PDF
J Reconstr Microsurg 2023; 39(07): 526-539
DOI: 10.1055/a-2003-8789
Original Article

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis

Todd Dow 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
,
Rawan ElAbd
2   Division of Plastic & Reconstructive Surgery, McGill University, Montreal, Canada
3   Division of Plastic & Reconstructive Surgery, Jaber Al Ahmed Al Jaber Al Sabah Hospital, Surra, Kuwait
,
Connor McGuire
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
,
Joseph Corkum
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
,
Sarah Al Youha
3   Division of Plastic & Reconstructive Surgery, Jaber Al Ahmed Al Jaber Al Sabah Hospital, Surra, Kuwait
,
Osama Samargandi 
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
4   Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
,
Jason Williams
1   Division of Plastic and Reconstructive Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate.

Methods A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates.

Results Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality.

Conclusion The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Keywords

free muscle flap - free fasciocutaneous flap - surgical outcomes - lower limb - trauma

Note

This article conforms to the guidelines set forth by the Helsinki Declaration in 1975. This article also conforms to the PRISMA guidelines.


Authors' Contributions

T.D.: Contributed to study design, data acquisition, data extraction, analysis of results, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.


R.E.A.: Contributed to data acquisition, data extraction, analysis of results, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.


C.M.: Contributed to data acquisition, data extraction, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.


J.C.: Contributed to study design, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.


S.A.Y.: Contributed to study design, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.


O.S.: Contributed to study design, data acquisition, data extraction, analysis of results, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.


J.W.: Contributed to study design, drafting of the manuscript, final approval of the manuscript, and agrees to be held accountable for all aspects of the work.




Publication History

Received: 16 April 2022

Accepted: 30 November 2022

Accepted Manuscript online:
28 December 2022

Article published online:
27 January 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
    CrossrefPubMedSearch in Google Scholar
  • 2 Karir A, Stein MJ, Shiga S, Zhang J. Reconstruction of lower extremity defects using the serratus anterior free flap: a systematic review and retrospective case series. J Reconstr Microsurg 2020; 36 (02) 116-126
    Thieme ConnectPubMedSearch in Google Scholar
  • 3 Shipkov H, Traikova N, Voinov P, Boucher F, Braye F, Mojallal A. Vascularloops in reconstructive microsurgery: a review of the literature [in French]. Ann Chir Plast Esthet 2014; 59 (01) 1-8
    PubMedSearch in Google Scholar
  • 4 Tu YK, Yen CY, Ma CH. et al. Soft-tissue injury management and flap reconstruction for mangled lower extremities. Injury 2008; 39 (Suppl. 04) 75-95
    PubMedSearch in Google Scholar
  • 5 Klifto KM, Azoury SC, Othman S, Klifto CS, Levin LS, Kovach SJ. The value of an orthoplastic approach to management of lower extremity trauma: systematic review and meta-analysis. Plast Reconstr Surg Glob Open 2021; 9 (03) e3494
    CrossrefPubMedSearch in Google Scholar
  • 6 Byrd HS, Spicer TE, Cierney III G. Management of open tibial fractures. Plast Reconstr Surg 1985; 76 (05) 719-730
    CrossrefPubMedSearch in Google Scholar
  • 7 Chan JKK, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps. Plast Reconstr Surg 2012; 130 (02) 284e-295e
    CrossrefPubMedSearch in Google Scholar
  • 8 Harry LE, Sandison A, Paleolog EM, Hansen U, Pearse MF, Nanchahal J. Comparison of the healing of open tibial fractures covered with either muscle or fasciocutaneous tissue in a murine model. J Orthop Res 2008; 26 (09) 1238-1244
    CrossrefPubMedSearch in Google Scholar
  • 9 Utvåg SE, Iversen KB, Grundnes O, Reikerås O. Poor muscle coverage delays fracture healing in rats. Acta Orthop Scand 2002; 73 (04) 471-474
    CrossrefPubMedSearch in Google Scholar
  • 10 Guzman-Stein G, Fix RJ, Vasconez LO. Muscle flap coverage for the lower extremity. Clin Plast Surg 1991; 18 (03) 545-552
    CrossrefPubMedSearch in Google Scholar
  • 11 Fox CM, Beem HM, Wiper J, Rozen WM, Wagels M, Leong JC. Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis. J Reconstr Microsurg 2015; 31 (01) 59-66
    Thieme ConnectPubMedSearch in Google Scholar
  • 12 Ohjimi H, Taniguchi Y, Kawano K, Kinoshita K, Manabe T. A comparison of thinning and conventional free-flap transfers to the lower extremity. Plast Reconstr Surg 2000; 105 (02) 558-566
    CrossrefPubMedSearch in Google Scholar
  • 13 Sabino J, Polfer E, Tintle S. et al. A decade of conflict: flap coverage options and outcomes in traumatic war-related extremity reconstruction. Plast Reconstr Surg 2015; 135 (03) 895-902
    CrossrefPubMedSearch in Google Scholar
  • 14 Koepple C, Kallenberger AK, Pollmann L. et al. Comparison of fasciocutaneous and muscle-based free flaps for soft tissue reconstruction of the upper extremity. Plast Reconstr Surg Glob Open 2019; 7 (12) e2543
    CrossrefPubMedSearch in Google Scholar
  • 15 Song MSH, Baldwin AJ, Wormald JCR, Coleman C, Chan JKK. Outcomes of free flap reconstruction for chronic venous ulceration in the lower limb: a systematic review. Ann Plast Surg 2022; 89 (03) 331-335
    CrossrefPubMedSearch in Google Scholar
  • 16 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
    CrossrefPubMedSearch in Google Scholar
  • 17 Nguyen A, Mahabir RC. An update on the level of evidence for plastic surgery research published in plastic and reconstructive surgery. Plast Reconstr Surg Glob Open 2016; 4 (07) e798
    CrossrefPubMedSearch in Google Scholar
  • 18 Lundh A, Gøtzsche PC. Recommendations by Cochrane Review Groups for assessment of the risk of bias in studies. BMC Med Res Methodol 2008; 8: 22-88
    CrossrefPubMedSearch in Google Scholar
  • 19 Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (MINORS): development and validation of a new instrument. ANZ J Surg 2003; 73 (09) 712-716
    CrossrefPubMedSearch in Google Scholar
  • 20 Gagnier JJ, Morgenstern H, Altman DG. et al; Ann Arbor Clinical Heterogeneity Consensus Group. Consensus-based recommendations for investigating clinical heterogeneity in systematic reviews. BMC Med Res Methodol 2013; 13: 106-288
    CrossrefPubMedSearch in Google Scholar
  • 21 Lee ZH, Abdou SA, Ramly EP. et al. Larger free flap size is associated with increased complications in lower extremity trauma reconstruction. Microsurgery 2020; 40 (04) 473-478
    CrossrefPubMedSearch in Google Scholar
  • 22 Lee ZH, Daar DA, Stranix JT. et al. Risk factors for microvascular free flaps in pediatric lower extremity trauma. Microsurgery 2020; 40 (01) 44-50
    CrossrefPubMedSearch in Google Scholar
  • 23 Lee ZH, Abdou SA, Daar DA. et al. Comparing outcomes for fasciocutaneous versus muscle flaps in foot and ankle free flap reconstruction. J Reconstr Microsurg 2019; 35 (09) 646-651
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Abdou SA, Stranix JT, Daar DA. et al. Free tissue transfer with distraction osteogenesis and masquelet technique is effective for limb salvage in patients with gustilo type IIIB open fractures. Plast Reconstr Surg 2020; 145 (04) 1071-1076
    CrossrefPubMedSearch in Google Scholar
  • 25 Stranix JT, Lee ZH, Anzai L. et al. Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: are two veins better than one?. Microsurgery 2018; 38 (07) 745-751
    CrossrefPubMedSearch in Google Scholar
  • 26 Heidekrueger PI, Ehrl D, Prantl L. et al. Microsurgical reconstruction of the plantar foot: Long-term functional outcomes and quality of life. J Reconstr Microsurg 2019; 35 (05) 379-388
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Broer PN, Moellhoff N, Mayer JM, Heidekrueger PI, Ninkovic M, Ehrl D. Comparison of outcomes of end-to-end versus end-to-side anastomoses in lower extremity free flap reconstructions. J Reconstr Microsurg 2020; 36 (06) 432-437
    Thieme ConnectPubMedSearch in Google Scholar
  • 28 Stranix JT, Lee ZH, Jacoby A. et al. Forty years of lower extremity take-backs: flap type influences salvage outcomes. Plast Reconstr Surg 2018; 141 (05) 1282-1287
    CrossrefPubMedSearch in Google Scholar
  • 29 Kuran I, Turgut G, Bas L, Ozkan T, Bayri O, Gulgonen A. Comparison between sensitive and nonsensitive free flaps in reconstruction of the heel and plantar area. Plast Reconstr Surg 2000; 105 (02) 574-580
    CrossrefPubMedSearch in Google Scholar
  • 30 Cho EH, Shammas RL, Carney MJ. et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
    CrossrefPubMedSearch in Google Scholar
  • 31 Sofiadellis F, Liu DS, Webb A, Macgill K, Rozen WM, Ashton MW. Fasciocutaneous free flaps are more reliable than muscle free flaps in lower limb trauma reconstruction: experience in a single trauma center. J Reconstr Microsurg 2012; 28 (05) 333-340
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Noever G, Brüser P, Köhler L. Reconstruction of heel and sole defects by free flaps. Plast Reconstr Surg 1986; 78 (03) 345-352
    CrossrefPubMedSearch in Google Scholar
  • 33 Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006; 117 (07) 2468-2475 , discussion 2476–2477
    CrossrefPubMedSearch in Google Scholar
  • 34 Karşıdağ S, Akçal A, Turgut G, Uğurlu K, Baş L. Lower extremity soft tissue reconstruction with free flap based on subscapular artery. Acta Orthop Traumatol Turc 2011; 45 (02) 100-108
    CrossrefPubMedSearch in Google Scholar
  • 35 Han Y, Han Y, Song B, Guo L, Tao R, Chai M. Free medial plantar flap versus free dorsal myocutaneous flap for the reconstruction of traumatic foot sole defects. Ann Plast Surg 2020; 84 (5S, Suppl 3): S178-S185
    CrossrefPubMedSearch in Google Scholar
  • 36 Wyble EJ, Yakuboff KP, Clark RG, Neale HW. Use of free fasciocutaneous and muscle flaps for reconstruction of the foot. Ann Plast Surg 1990; 24 (02) 101-108
    CrossrefPubMedSearch in Google Scholar
  • 37 Philandrianos C, Moullot P, Gay AM. et al. Soft tissue coverage in distal lower extremity open fractures: comparison of free anterolateral thigh and free latissimus dorsi flaps. J Reconstr Microsurg 2018; 34 (02) 121-129
    Thieme ConnectPubMedSearch in Google Scholar
  • 38 Rodriguez ED, Bluebond-Langner R, Copeland C, Grim TN, Singh NK, Scalea T. Functional outcomes of posttraumatic lower limb salvage: a pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma 2009; 66 (05) 1311-1314
    PubMedSearch in Google Scholar
  • 39 Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg 2013; 40 (05) 575-583
    Thieme ConnectPubMedSearch in Google Scholar
  • 40 Lo SJ, Lee YC, Hsu J, Hsu CC, Lin CH, Lin CH. Does muscle improve validated outcome measures in open tibial fractures? New insights from a cohort study of the anterolateral thigh flap (ALT) versus ALT-Vastus lateralis flaps. J Plast Reconstr Aesthet Surg 2021; 74 (02) 268-276
    CrossrefPubMedSearch in Google Scholar
  • 41 Seyidova N, Anderson K, Abood A. Comparison of patients satisfaction with aesthetic outcomes following lower extremity reconstruction: muscle vs. fasciocutaneous free flaps. J Plast Reconstr Aesthet Surg 2021; 74 (01) 65-70
    CrossrefPubMedSearch in Google Scholar
  • 42 Elbatawy A, Elgammal M, Zayid T. et al. Pediatric microsurgery in the reconstruction of complex posttraumatic foot and ankle defects: a long-term follow-up with a comprehensive review of the literature. J Reconstr Microsurg 2021; 37 (03) 193-200
    Thieme ConnectPubMedSearch in Google Scholar
  • 43 Parikh RP, Ha A, Tung T. Free flap reconstruction of traumatic pediatric foot and ankle defects: an analysis of clinical and functional outcomes. J Reconstr Microsurg 2021; 37 (09) 783-790
    Thieme ConnectPubMedSearch in Google Scholar
  • 44 Kim PH, Leopold SS. In brief: Gustilo-Anderson classification. [corrected]. Clin Orthop Relat Res 2012; 470 (11) 3270-3274
    CrossrefPubMedSearch in Google Scholar
  • 45 Stranix JT, Lee ZH, Jacoby A. et al. Not all gustilo type IIIb fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg 2017; 140 (05) 1033-1041
    CrossrefPubMedSearch in Google Scholar
  • 46 Ricci JA, Koolen PG, Shah J, Tobias AM, Lee BT, Lin SJ. Comparing the outcomes of different agents to treat vasospasm at microsurgical anastomosis during the papaverine shortage. Plast Reconstr Surg 2016; 138 (03) 401e-408e
    CrossrefPubMedSearch in Google Scholar
  • 47 Stranix JT, Anzai L, Mirrer J. et al. Dual venous outflow improves lower extremity trauma free flap reconstructions. J Surg Res 2016; 202 (02) 235-238
    CrossrefPubMedSearch in Google Scholar
  • 48 Ahmadi I, Herle P, Rozen WM, Leong J. One versus two venous anastomoses in microsurgical free flaps: a meta-analysis. J Reconstr Microsurg 2014; 30 (06) 413-418
    Thieme ConnectPubMedSearch in Google Scholar
  • 49 Riot S, Herlin C, Mojallal A. et al. A systematic review and meta-analysis of double venous anastomosis in free flaps. Plast Reconstr Surg 2015; 136 (06) 1299-1311
    CrossrefPubMedSearch in Google Scholar
  • 50 Lorenzo AR, Lin CH, Lin CH. et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
    CrossrefPubMedSearch in Google Scholar
  • 51 Hong JP, Shin HW, Kim JJ, Wei FC, Chung YK. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 2005; 115 (01) 142-147
    CrossrefPubMedSearch in Google Scholar
  • 52 Salgado CJ, Mardini S, Jamali AA, Ortiz J, Gonzales R, Chen HC. Muscle versus nonmuscle flaps in the reconstruction of chronic osteomyelitis defects. Plast Reconstr Surg 2006; 118 (06) 1401-1411
    CrossrefPubMedSearch in Google Scholar
  • 53 Kovar A, Colakoglu S, Iorio ML. Choosing between muscle and fasciocutaneous free flap reconstruction in the treatment of lower extremity osteomyelitis: available evidence for a function-specific approach. J Reconstr Microsurg 2020; 36 (03) 197-203
    Thieme ConnectPubMedSearch in Google Scholar
  • 54 Zweifel-Schlatter M, Haug M, Schaefer DJ, Wolfinger E, Ochsner P, Pierer G. Free fasciocutaneous flaps in the treatment of chronic osteomyelitis of the tibia: a retrospective study. J Reconstr Microsurg 2006; 22 (01) 41-47
    Thieme ConnectPubMedSearch in Google Scholar
  • 55 Sinha AK, Wood MB, Irons GB. Free tissue transfer for reconstruction of the weight-bearing portion of the foot. Clin Orthop Relat Res 1989; (242) 269-271
    PubMedSearch in Google Scholar
  • 56 Sönmez A, Bayramiçli M, Sönmez B, Numanoğlu A. Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps. Plast Reconstr Surg 2003; 111 (07) 2230-2236
    CrossrefPubMedSearch in Google Scholar
  • 57 May Jr JW, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: a clinical and gait analysis study. Plast Reconstr Surg 1985; 75 (05) 627-641
    CrossrefPubMedSearch in Google Scholar
  • 58 May JW, Lukash FN, Gallico GG. 3rd. Latissimus dorsi free muscle flap in lower-extremity reconstruction. Plast Reconstr Surg 1981; 68 (04) 603-607
    CrossrefPubMedSearch in Google Scholar
  • 59 Gordon L, Buncke HJ, Alpert BS. Free latissimus dorsi muscle flap with split-thickness skin graft cover: a report of 16 cases. Plast Reconstr Surg 1982; 70 (02) 173-178
    CrossrefPubMedSearch in Google Scholar
  • 60 Ducic I, Hung V, Dellon AL. Innervated free flaps for foot reconstruction: a review. J Reconstr Microsurg 2006; 22 (06) 433-442
    Thieme ConnectPubMedSearch in Google Scholar
  • 61 Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical composite tissue transplantation. Clin Plast Surg 1983; 10 (01) 55-72
    CrossrefPubMedSearch in Google Scholar
  • 62 Wood MB, Irons GB, Cooney III WP. Foot reconstruction by free flap transfer. Foot Ankle 1983; 4 (01) 2-7
    CrossrefPubMedSearch in Google Scholar
  • 63 Lister GD. Use of an innervated skin graft to provide sensation to the reconstructed heel. Plast Reconstr Surg 1978; 62 (02) 157-161
    CrossrefPubMedSearch in Google Scholar
  • 64 Rautio J, Kekoni J, Hämäläinen H, Härmä M, Asko-Seljavaara S. Mechanical sensibility in free and island flaps of the foot. J Reconstr Microsurg 1989; 5 (02) 119-125
    Thieme ConnectPubMedSearch in Google Scholar
  • 65 Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg 1986; 77 (05) 785-794
    CrossrefPubMedSearch in Google Scholar
  • 66 Musharafieh R, Atiyeh B, Macari G, Haidar R. Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction: review of 17 cases. J Reconstr Microsurg 2001; 17 (03) 147-150
    Thieme ConnectPubMedSearch in Google Scholar
  • 67 Ulusal BG, Lin YT, Ulusal AE, Lin CH, Yen JT. Reconstruction of foot defects with free lateral arm fasciocutaneous flaps: analysis of fifty patients. Microsurgery 2005; 25 (08) 581-588
    CrossrefPubMedSearch in Google Scholar
  • 68 Claes KE, Roche NA, Opsomer D, De Wolf E J, Sommeling CE. Van Landuyt K. Free flaps for lower limb soft tissue reconstruction in children: systemic review. J Plast Reconstr Aesthet Surg. 2019; 72 (05) 711-728
    PubMedSearch in Google Scholar
  • 69 Cherubino M, Corno M, D'Arpa S. et al. Muscle versus fasciocutaneous flap in lower limb reconstruction: is there a best option?. J Reconstr Microsurg 2017; 33 (S 01): S27-S33
    Thieme ConnectPubMedSearch in Google Scholar
  • 70 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. PLoS Med 2009; 6 (07) e1000097
    Search in Google Scholar