Top

BMC Musculoskeletal Disorders

Published in:

Open Access 01-12-2024 | Osteomyelitis | Research

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study

Authors: Mitsutoshi Ota, Makoto Motomiya, Naoya Watanabe, Kohei Shimoda, Norimasa Iwasaki

Published in: BMC Musculoskeletal Disorders | Issue 1/2024

Abstract

Background

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction.

Methods

We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis.

Results

The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases.

Conclusions

Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction.

Data access statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am. 1991;73(9):1316–22.CrossRefPubMed

Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285–92. https://doi.org/10.1097/00006534-198609000-00001.CrossRefPubMed

Lese I, Grobbelaar AO, Sabau D, Georgescu AV, Constantinescu MA, Olariu R. The propeller flap for traumatic distal lower-Limb reconstruction: risk factors, pitfalls, and recommendations. J Bone Joint Surg Am. 2020;102(6):510–8. https://doi.org/10.2106/jbjs.19.00648.CrossRefPubMed

Noaman HH, Mohamed MA, Faisal A, Soroor YO. Different surgical procedures for reconstruction of soft-tissue defects around the ankle. Injury. 2022;53(7):2657–65. https://doi.org/10.1016/j.injury.2022.03.066.CrossRefPubMed

El-Sabbagh AH. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg. 2011;27(9):511–23. https://doi.org/10.1055/s-0031-1284238.CrossRefPubMed

Gooden MA, Gentile AT, Mills JL, Berman SS, Demas CP, Reinke KR, Hunter GC, Westerband A, Greenwald D. Free tissue transfer to extend the limits of limb salvage for lower extremity tissue loss. Am J Surg. 1997;174(6):644–8. https://doi.org/10.1016/s0002-9610(97)00175-x. discussion 648–9.CrossRefPubMed

Hasegawa M, Torii S, Katoh H, Esaki S. The distally based superficial sural artery flap. Plast Reconstr Surg. 1994;93(5):1012–20. https://doi.org/10.1097/00006534-199404001-00016.CrossRefPubMed

Vathulya M, Dhingra M, Nongdamba H, Chattopadhyay D, Kapoor A, Dhingra VK, Mago V, Kandwal P. Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center. Arch Plast Surg. 2021;48(4):417–26. https://doi.org/10.5999/aps.2020.02089.CrossRefPubMedPubMedCentral

Culliford ATt, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: a single institution’s experience over 25 years. Ann Plast Surg. 2007;59(1):18–21. https://doi.org/10.1097/01.sap.0000262740.34106.1b. discussion 21–12.CrossRefPubMed

10.

Guillier D, Sapino G, Schaffer C, Borens O, Thein E, Bramhall RJ, di Summa PG. Lower limb reconstruction involving osteosynthesis material: a retrospective study on propeller flaps outcomes. Injury. 2021;52(10):3117–23. https://doi.org/10.1016/j.injury.2021.04.003.CrossRefPubMed

11.

Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg. 1991;44(1):53–4. https://doi.org/10.1016/0007-1226(91)90179-n.CrossRefPubMed

12.

Bekara F, Herlin C, Somda S, de Runz A, Grolleau JL, Chaput B. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: what is the safest coverage? A meta-analysis Microsurgery. 2016;38(1):109–19. https://doi.org/10.1002/micr.30047.CrossRefPubMed

13.

Gupta S, Gupta P, Khichar P, Mohammad A, Escandón JM, Kalra S. Perforator propeller flaps for lower extremity soft-tissue defect reconstruction: Shortening the learning curve. J Clin Orthop Trauma. 2022;27: 101831. https://doi.org/10.1016/j.jcot.2022.101831.CrossRefPubMedPubMedCentral

14.

Innocenti M, Menichini G, Baldrighi C, Delcroix L, Vignini L, Tos P. Are there risk factors for complications of perforator-based propeller flaps for lower-extremity reconstruction? Clin Orthop Relat Res. 2014;472(7):2276–86. https://doi.org/10.1007/s11999-014-3537-6.CrossRefPubMedPubMedCentral

15.

Nelson JA, Fischer JP, Brazio PS, Kovach SJ, Rosson GD, Rad AN. A review of propeller flaps for distal lower extremity soft tissue reconstruction: is flap loss too high? Microsurgery. 2013;33(7):578–86. https://doi.org/10.1002/micr.22134.CrossRefPubMed

16.

Cajozzo M, Jiga LP, Jandali Z, Muradov M, Pignatti M, Cordova A, D’Arpa S. Complications and Solutions in Propeller Flap Surgery. Semin Plast Surg. 2020;34(3):210–20. https://doi.org/10.1055/s-0040-1714087.CrossRefPubMedPubMedCentral

17.

Innocenti M, Dell’Acqua I, Famiglietti M, Vignini L, Menichini G, Ghezzi S. Free perforator flaps vs propeller flaps in lower limb reconstruction: a cost/effectiveness analysis on a series of 179 cases. Injury. 2019;50(Suppl 5):s11–6. https://doi.org/10.1016/j.injury.2019.10.039.CrossRefPubMed

18.

Koh K, Goh TLH, Song CT, Suh HS, Rovito PV, Hong JP, Hallock GG. Free versus pedicled perforator flaps for lower extremity reconstruction: a multicenter comparison of institutional practices and outcomes. J Reconstr Microsurg. 2018;34(8):572–80. https://doi.org/10.1055/s-0038-1639576.CrossRefPubMed

19.

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg. 2009;250(2):187–96. https://doi.org/10.1097/SLA.0b013e3181b13ca2.CrossRefPubMed

20.

Bekara F, Herlin C, De Runz A, Boccara D, Chaput B. Free or perforator-pedicled propeller flaps in lower extremity reconstruction: defining the coverage failure. J Reconstr Microsurg. 2017;33(S01):e2–3. https://doi.org/10.1055/s-0038-1641725.CrossRefPubMed

21.

Abdelrahman I, Moghazy A, Abbas A, Elmasry M, Adly O, Elbadawy M, Steinvall I, Sjoberg F. A prospective randomized cost billing comparison of local fasciocutaneous perforator versus free Gracilis flap reconstruction for lower limb in a developing economy. J Plast Reconstr Aesthet Surg. 2016;69(8):1121–7. https://doi.org/10.1016/j.bjps.2016.04.013.CrossRefPubMed

22.

Soteropulos CE, Shulzhenko NO, Nayar HS, Poore SO. The effect of perforator skeletonization on pedicled fasciocutaneous flaps of the lower extremity: a systematic review. J Reconstr Microsurg. 2020;36(9):634–44. https://doi.org/10.1055/s-0040-1713598.CrossRefPubMed

23.

Bekara F, Herlin C, Mojallal A, Sinna R, Ayestaray B, Letois F, Chavoin JP, Garrido I, Grolleau JL, Chaput B. A systematic review and meta-analysis of perforator-pedicled propeller flaps in lower extremity defects: identification of risk factors for complications. Plast Reconstr Surg. 2016;137(1):314–31. https://doi.org/10.1097/PRS.0000000000001891.CrossRefPubMed

24.

Scampa M, Megevand V, Suva D, Kalbermatten DF, Oranges CM. Free versus pedicled flaps for lower limb reconstruction: a meta-analysis of comparative studies. J Clin Med. 2022;11(13):3672. https://doi.org/10.3390/jcm11133672.CrossRefPubMedPubMedCentral

25.

Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am. 2000;82(12):1681–91.CrossRefPubMed

26.

Li X, Cui J, Maharjan S, Lu L, Gong X. Reconstruction of the foot and ankle using pedicled or free flaps: perioperative flap survival analysis. PLoS ONE. 2016;11(12): e0167827. https://doi.org/10.1371/journal.pone.0167827.CrossRefPubMedPubMedCentral

27.

Liette MD, Rodriguez P, Bibbo C, Masadeh S, Ellabban MA. Propeller flaps of the lower extremity. Clin Podiatr Med Surg. 2020;37(4):727–42. https://doi.org/10.1016/j.cpm.2020.06.001.CrossRefPubMed

28.

Blough JT, Saint-Cyr MH. Propeller flaps in lower extremity reconstruction. Clin Plast Surg. 2021;48(2):173–81. https://doi.org/10.1016/j.cps.2021.01.002.CrossRefPubMed

29.

Kim K, Kim J, Jeong W, Jo T, Park SW, Choi J. Outcome of distal lower leg reconstruction with the propeller perforator flap in diabetic patients. J Plast Surg Hand Surg. 2021;55(4):242–8. https://doi.org/10.1080/2000656x.2020.1858843.CrossRefPubMed

30.

Patzakis MJ, Zalavras CG. Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. J Am Acad Orthop Surg. 2005;13(6):417–27. https://doi.org/10.5435/00124635-200510000-00006.CrossRefPubMed

31.

Prada C, Bengoa F, Bhandari M. The management of fracture related infections: what practices can be supported by high-level evidence? J Orthop Surg (Hong Kong). 2022;30(3):10225536221119580. https://doi.org/10.1177/10225536221119580.CrossRefPubMed

32.

Khouri RK. Avoiding free flap failure. Clin Plast Surg. 1992;19(4):773–81.CrossRefPubMed

33.

Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience. Plast Reconstr Surg. 2007;120(4):952–9. https://doi.org/10.1097/01.prs.0000255175.92201.c7.CrossRefPubMed

34.

Godina M. Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg. 1979;64(5):673–82.CrossRefPubMed

35.

Artiaco S, Battiston B, Colzani G, Bianchi P, Scaravilli G, Boux E, Tos P. Perforator based propeller flaps in limb reconstructive surgery: clinical application and literature review. Biomed Res Int. 2014;2014:690649.CrossRefPubMedPubMedCentral

36.

Iida T, Yoshimatsu H, Koshima I. Reconstruction of Anterolateral Thigh Defects Using Perforator-Based Propeller Flaps. Ann Plast Sur. 2017;79(4):385–9. https://doi.org/10.1097/sap.0000000000001175.CrossRef

Title: Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study
Authors: Mitsutoshi Ota
Makoto Motomiya
Naoya Watanabe
Kohei Shimoda
Norimasa Iwasaki
Publication date: 01-12-2024
Publisher: BioMed Central
Keyword: Osteomyelitis
Published in: BMC Musculoskeletal Disorders / Issue 1/2024
Electronic ISSN: 1471-2474
DOI: https://doi.org/10.1186/s12891-024-07433-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study

Abstract

Background

Methods

Results

Conclusions

Data access statement

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Data access statement

Please log in to get access to this content

Other articles of this Issue 1/2024

The learning curve for minimally invasive Achilles repair using the “lumbar puncture needle and oval forceps” technique

The influence of gender and sport on popliteal angle and dorsiflexion in junior high school students

Correction: Arthrodesis of the interphalangeal joints of the hand by two-dimensional intraosseous wiring

Exploring patient perspectives on EQ-5D-5L data visualization within an individualized decision aid for total knee arthroplasty (TKA) in Alberta, Canada

Comparison of radiological and clinical outcomes of cervical laminoplasty versus lateral mass screw fixation in patients with ossification of the posterior longitudinal ligament

Does interferential current provide additional benefit to orthopedic rehabilitation for the patients with proximal humeral fractures? A randomized controlled study