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

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 January 10, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies (MINORS) instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, re-operation, 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 flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, take-back 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. Conclusions: The rate of total flap failure, re-operation, 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.

Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter?

“…This is supported by a recent metaanalysis suggesting no difference in complication rates between muscle and fasciocutaneous flaps used for lower extremity reconstruction. 13 Our results demonstrate that the surgical approach to secondary bone grafting does not influence complications, but instead supports the individual surgeon's decision-making as to the best approach. In some cases, secondary surgery is anticipated, and this can influence the choice of flap used in primary soft tissue reconstruction.…”

“…This is supported by a recent meta-analysis suggesting no difference in complication rates between muscle and fasciocutaneous flaps used for lower extremity reconstruction. 13…”

“…A direct flap elevation approach to bone grafting requires consideration of the timing of flap elevation, the anatomy and inset of the flap, and who should perform the elevation. 6,[9][10][11] Although previous literature suggests delayed bone grafting until full wound epithelialization with cessation of drainage, 10 similar rates of nonunion between muscle and free flaps, 9,12,13 preference of timing of secondary flap elevation at 3 months after inset, 14 and employment of an integrative orthoplastic strategy for complex limb reconstruction, 15 limited guidance exists on the ideal surgical approach for secondary procedures, specifically for secondary bone grafting. 16,17 As postoperative complications after flap inset are significantly associated with secondary amputation, evaluation of com-plications associated with approach is critical to limb salvage planning.…”

Current Concepts of Fracture-Related Infection

“…In a 2019 systematic review, Bezstarosti et al [ 66 ] summarized methods to repair the defect of soft tissue, and outcomes showed that free flaps (39%), skin grafts (21%), and rotational flaps (11%) were the more frequently selected strategies. In a recent systematic review and meta-analysis, Dow et al [ 101 ] compared the efficacy of free muscle flaps with free fasciocutaneous flaps for reconstruction defects in the lower limbs following trauma. Outcomes showed similar efficacy regarding the incidences of total flap failure, reoperation, and limb salvage between the two methods.…”

Muscle versus Fascia Free Tissue Transfer for Treatment of Chronic Osteomyelitis in the Comorbid Population

“…19 However, this study consisted of a limited traumatic patient population, and notably did not report on the efficacy of the two flap types in achieving limb salvage, ambulation, or osteomyelitis recurrence rates. Additional studies looking at the traumatic patient population showed that there were no significant differences in between muscle and fasciocutaneous free flaps.. 14,20 In contrast to the chronic wound population, patients with traumatic wounds have heightened risks for polymicrobial and recurrent infection that are unique due to mechanism and energy of trauma. 21 Patients with diabetic foot wounds extending to bone or recurrent wounds conferred a 20 times higher risk of osteomyelitis.…”