Reconstruction of the Foot and Ankle Using Pedicled or Free Flaps: Perioperative Flap Survival Analysis

Abstract

ObjectiveThe purpose of this study is to determine the correlation between non-technical risk factors and the perioperative flap survival rate and to evaluate the choice of skin flap for the reconstruction of foot and ankle.MethodsThis was a clinical retrospective study. Nine variables were identified. The Kaplan-Meier method coupled with a log-rank test and a Cox regression model was used to predict the risk factors that influence the perioperative flap survival rate. The relationship between postoperative wound infection and risk factors was also analyzed using a logistic regression model.ResultsThe overall flap survival rate was 85.42%. The necrosis rates of free flaps and pedicled flaps were 5.26% and 20.69%, respectively. According to the Cox regression model, flap type (hazard ratio [HR] = 2.592; 95% confidence interval [CI] (1.606, 4.184); P < 0.001) and postoperative wound infection (HR = 0.266; 95% CI (0.134, 0.529); P < 0.001) were found to be statistically significant risk factors associated with flap necrosis. Based on the logistic regression model, preoperative wound bed inflammation (odds ratio [OR] = 11.371,95% CI (3.117, 41.478), P < 0.001) was a statistically significant risk factor for postoperative wound infection.ConclusionFlap type and postoperative wound infection were both independent risk factors influencing the flap survival rate in the foot and ankle. However, postoperative wound infection was a risk factor for the pedicled flap but not for the free flap. Microvascular anastomosis is a major cause of free flap necrosis. To reconstruct complex or wide soft tissue defects of the foot or ankle, free flaps are safer and more reliable than pedicled flaps and should thus be the primary choice.

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

“…The free ALT flap was reviewed in 72 patients who underwent reconstruction with defects ( Table 4) at the heel, foot and ankle region. We reviewed the ALT flap in three separate studies: for the effectiveness of free flaps in plantar ulcers of the insensate foot, for analysis of perioperative flap survival in reconstruction of the foot and ankle, and to evaluate the relationship between free flap success and postoperative ambulation in diabetic foot limb salvage [9,12,17]. Twenty-five patients underwent reconstruction with 26 free flaps for plantar ulcers of the insensate foot using the ALT (n = 18), RAF (n = 4) and GM (n = 4).…”

“…In this study, the ALT flap was regarded as the first choice for reconstruction of plantar ulcers due to having a dual advantage of both a fasciocutaneous and muscle flap providing a stable walking surface while the RAF is preferred for defects at the metatarsal heads and forefoot and GM flaps for defects where obliteration of the dead space is necessary such as in cases of osteomyelitis [9]. In a study of 144 patients, 14 different flaps ( Table 4) were reviewed to determine the correlation between nontechnical risk factors and the perioperative flap survival rate in regards to evaluating the choice of free or pedicled flaps for reconstruction of the foot and ankle [12]. The perioperative period was defined as within 2 weeks after flap transfer.…”

“…With numerous options existing for surgical reconstruction by way of flap transfer for the management of complex soft tissue defects of the lower extremity such as reconstruction using free flaps or vascularized perforator pedicle flaps, there is a need for greater data regarding flap selection based on flap outcomes to better improve patient care. It is also necessary to take into consideration several factors when selecting the most suitable flap transfer for each individual patient with regards to the location and size of the soft tissue defect, defect etiology, presence of existing comorbidities and the vascular condition at the recipient site [12,14,18,19].…”

Risk factors for pedicled flap necrosis in hand soft tissue reconstruction: a multivariate logistic regression analysis

“…However, partial or total flap necrosis remains the main complication and has a relatively high incidence . Most studies regarding risk factors of flap necrosis have focused on the risk factors of pedicled flaps of the lower extremities and free flaps . Gir et al .…”

“…17 Most studies regarding risk factors of flap necrosis have focused on the risk factors of pedicled flaps of the lower extremities and free flaps. [18][19][20][21][22][23][24][25][26] Gir et al found that age, gender, aetiology or location of the defect, and type or size of the flap were not statistically significant risk factors associated with complications of pedicled perforator flaps in the lower extremities, 24 whereas Bekara et al found that age older than 60 years, diabetes and arteriopathy are significant risk factors for perforator-pedicled flap complications in the lower extremities. 21 In addition, de Blacam et al stated that venous insufficiency and increasing age were both risk factors for pedicled flap complications.…”