Does an Early and Aggressive Combined Wrapping and Dangling Procedure Affect the Clinical Outcome of Lower Extremity Free Flaps?—A Randomized Controlled Prospective Study Using Microdialysis Monitoring

Abstract

Background The ideal starting point for flap training (FT) with the combined wrapping and dangling procedure is still a question of debate. Most units follow their own established protocols and currently evidence of flap compromise due to FT is still lacking. The aim of this study was to prove if an early and "aggressive" wrapping and dangling protocol could lead to metabolic changes, measured by microdialysis, indicating ischemia resulting in compromised flap perfusion. Methods Between 2010 and 2014, 49 patients with microvascular free flap reconstruction of the lower limb were included in this study. Patients were randomized into two groups. Group I started FT on the 7th postoperative day, and group II started on day 3. FT consisted of a combined wrapping and dangling procedure doubling its duration daily and ending at day 5. Flaps were monitored clinically and by microdialysis for ischemia-induced changes and metabolic parameters in the flap tissue in respect to different starting points of FT. Results All 49 patients in both groups were able to complete the postoperative FT without complications. Noninferiority of the early group could be proven and microdialysis results showed no differences between both groups. Conclusion We could prove by microdialysis that an early start of FT does not lead to compromised flap perfusion. Moreover, an early start of FT can lead to a reduced length of hospital stay. Furthermore, a reduced risk for deep vein thrombosis, pulmonary embolism, and pneumonia due to earlier mobilization might be an appreciated side effect.

Safety and effectiveness of early compression of free flaps following lower limb reconstruction: A systematic review

“…Early flap compression, defined as interventions commenced within the first postoperative week, was reported in 7 studies that included a total of 253 patients. All of these used elastic bandages to achieve compression at this stage, starting as early as post-operative day 1 8,9,[14][15][16][17][18] . Out of these, 4 complete flap failures were reported, resulting in an overall flap failure rate of 1.6% for early flap compression.…”

Use of Adipose-Derived Stem Cells to Support Topical Skin Adhesive for Wound Closure: A Preliminary Report from Animal In Vivo Study

“…A month and a half, halfway through the experiment, allowed us also to obtain important knowledge about the flow of the wound healing process and correspond it to standard clinical practice to detect early complications or address when a patient reports any inconvenience or dissatisfaction [ 24 ]. At this point in the study, no differences between first assessment and final results were reported in all groups that could be related to the rare clinical occurrence of deterioration when no early complications were detected [ 25 ].…”

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

“…Jokuszies et al [4] and Neubert et al [5] performed the only two known randomized controlled trials in this patient group. They compared an early start of the dangling protocol on POD 3 to the more standard starting point on POD 7.…”

“…It must be noted that the patients included in these studies were for the most part the same group of patients. Furthermore, the numbers of patients in both studies were small (31 and 49), resulting in an underpowered study [4, 5]. McGhee et al published a systematic review comparing an early dangling protocol to a late dangling protocol [6].…”

“…McGhee et al published a systematic review comparing an early dangling protocol to a late dangling protocol [6]. They found eight relevant articles, including the studies performed by Jokuszies et al [4] and Neubert et al [5]. Based on the currently available literature, they concluded that an early dangling protocol can be safely used.…”