A Survey of U.K. Units and a Suggested Protocol for Free Flap Reconstruction of the Lower Limb: Follow-up and Management in the First Postoperative Week

O’Neill, Jennifer; Greenwood, Amy; Khan, Umraz

doi:10.1055/s-0030-1267384

Cited by 25 publications

(19 citation statements)

References 8 publications

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“…Three surveys examined postoperative management protocols for free tissue transfer to the lower extremity from both the United States and United Kingdom. [8][9][10] These surveys looked at initiation, timing, advancement, and conclusion of dangle protocols, as well as flap monitoring, compressive wrapping, and time to weight bearing (►Figs. 2 and 3).…”

Section: Resultsmentioning

confidence: 99%

“…2 and 3). 6,8,9 Initiation of dangle on postoperative day two was safely performed in one study of fasciocutaneous flaps with traditional anastomotic techniques, suggesting that perhaps this may be safe in a carefully selected patient population. 19 In terms of flap monitoring, the majority of surgeons agree that clinical examination of the flap is necessary and reliable.…”

Section: Effect Of Dangle Protocols On Flap Physiologymentioning

confidence: 99%

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Untitled

2019

J reconstr Microsurg

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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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Section: Resultsmentioning

confidence: 99%

Section: Effect Of Dangle Protocols On Flap Physiologymentioning

confidence: 99%

Untitled

2019

J reconstr Microsurg

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“…The starting point, frequency, and duration vary widely; whereas some start the dangling protocol as early as on the second postoperative day (POD), others wait until the fourth postoperative week [1–3]. Some report not to use dangling as a standard procedure at all [1], and some use it only in select cases [2]. In general, the dangling protocol is performed in a hospital setting.…”

Section: Introductionmentioning

confidence: 99%

Is dangling of the lower leg after a free flap reconstruction necessary? Study protocol for a large multicenter randomized controlled study

Krijgh

Teunis

Schellekens

et al. 2019

Trials

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Background Within the field of plastic surgery, free tissue transfer is common practice for knee and lower leg defects. Usually, after such free flap reconstruction, patients undergo a dangling protocol in the postoperative phase. A dangling protocol is designed to gradually subject the free flap to increased venous pressure resulting from gravitational forces. Worldwide there are multiple variations of dangling protocols. However, there is no evidence available in the literature that supports the use of a dangling protocol. Methods This is a multicenter randomized controlled trial that includes patients with a free flap lower leg reconstruction. The primary outcome is to assess whether a no-dangling protocol is not inferior to a dangling protocol, in terms of proportion of partial flap loss, 6 months after surgery. Secondary objectives are to identify differences in major and minor complications, length of stay, and costs, and to objectify blood gaseous changes during dangling. Furthermore, at 2 years we will assess difference in physical function, infection rates, and osseous union rates. Discussion The primary outcome of this study will give a more decisive answer to the question of whether a dangling protocol is necessary after a free flap reconstruction of the lower leg. The secondary outcomes of this study will provide a better insight into the physical functions, infection rates, and union rates in these patients. Trial registration Central Committee on Research Involving Human Subjects (CCMO), NL63146.041.17. Registered on 11 July 2018. Netherlands Trial Register, NTR7545. Registered on 10 October 2018.

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“…whereas some start the dangling protocol as early as on the second postoperative day, others wait until the fourth postoperative week [1][2][3] . Some report not to use dangling as a standard procedure at all 1 , or only in select cases 2 . In general, the dangling protocol is performed in a hospital setting.…”

mentioning

confidence: 99%

Is dangling of the lower leg after a free flap reconstruction necessary? A large multicenter randomized controlled study.

Krijgh

Teunis

Schellekens

et al. 2019

Preprint

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Background: Within the field of plastic surgery free tissue transfer is common practice for knee and lower leg defects. Usually, after such free flap reconstruction patients undergo a dangling protocol in the postoperative phase. A dangling protocol is designed to gradually subject the free flap to increased venous pressure resulting from gravitational forces. Worldwide there are multiple variations of dangling protocols. However, there is no evidence available in the literature that supports the use of a dangling protocol. Methods: This is a multicenter randomized controlled trial that includes patients with a free flap lower leg reconstruction. The primary outcome is to assess whether a nodangling protocol is not inferior to a dangling protocol in terms of proportion of partial flap loss, six months after surgery. Secondary objectives are to identify differences in major and minor complications, length of stay, costs, and to objectify blood gaseous changes during dangling.Furthermore, at 2 years we will assess difference in physical function, infection rates and osseous union rates. Discussion: The primary outcome of this study will give a more decisive answer to the question whether a dangling protocol is necessary after a free flap reconstruction of the lower leg.The secondary outcomes of this study will provide a better insight into the physical functions, infection rates and union rates in these patients. Trial registration: Registered at the CCMO (Dutch Medical Research Ethics Commission) in the Netherlands on 11 July 2018: NL63146.041.17.Registered with the Dutch Trial Register (registration number NTR 7545).

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A Survey of U.K. Units and a Suggested Protocol for Free Flap Reconstruction of the Lower Limb: Follow-up and Management in the First Postoperative Week

Cited by 25 publications

References 8 publications

Untitled

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Is dangling of the lower leg after a free flap reconstruction necessary? Study protocol for a large multicenter randomized controlled study

Is dangling of the lower leg after a free flap reconstruction necessary? A large multicenter randomized controlled study.

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