Local flaps vs. free flaps for complex lower limb fractures: Effect of flap choice on patient-reported outcomes

Abstract

The optimal flap cover for managing open lower limb fractures is debated. Most studies have reported on surgical outcome but clinical outcome is not well recognised. We aimed to determine whether there are differences in patient-reported quality of life (QoL) outcome between local flap versus free flap.All patients admitted with lower limb open fractures were retrospectively reviewed. Patient notes were assessed for demographics, time to fracture union, wound healing and patient-reported QoL with EQ-5D-5L alongside a novel flap assessment tool.A total of 40 patients had flap reconstruction of their lower limb injury; 23 local flap (Group I) and 17 free flap (Group II). Average length of follow-up was 33.8 months. Group I -10 revisions of flaps (43.5%) and 14 surgical complications (60.9%). Fracture union was 171 days and wound healing 130 days. EQ-5D index and EQ-VAS scores were 0.709 and 79.3, respectively. Group II -8 revision of flaps (47.1%) and 12 surgical complications (70.6%). Fracture union was 273 days and wound healing 213 days. EQ-5D index and EQ-VAS scores were 0.525 and 57.2, respectively. Aesthetic appeal -48% Group I vs. 66% Group II. Significant differences were found between the two flap groups with higher scores for daily living in Group I (p = 0.007) compared to higher overall flap ratings in Group II (p = 0.049). Both groups were comparable in terms of complications; while flap congestion and dehiscence were more common with free flaps statistical interrogation did not elicit significance (p > 0.05).Local flap and free flap techniques offer distinct advantages. Local flaps have better surgical outcome and patient-reported QoL in the first few years post soft tissue reconstruction. Differences between local and free reconstructive techniques in terms of patient health and function are ameliorated in the longer term.

Free versus Pedicled Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies

“…Defect aetiology varied greatly between and inside the selected studies including traumatism, neoplasm, infections, scar contractures, and chronic wounds (with peripheral vascular disease, irradiation, and neuropathy). Complete flap necrosis was reported in all 10 articles and the pooled analysis did not find a significant difference between FF and PF (RR 1.35, 95%CI 0.76-2.39, p = 0.31) [12][13][14][15][16][17][18][19][20][21]. (Figure 2) A partial flap failure was reported in eight articles and FF had a significantly lower risk than PF in the pooled analysis (RR 0.45, 95%CI 0.22-0.91, p = 0.03) [12][13][14][15][16][18][19][20] (Figure 3).…”

“…(Figure 2) A partial flap failure was reported in eight articles and FF had a significantly lower risk than PF in the pooled analysis (RR 0.45, 95%CI 0.22-0.91, p = 0.03) [12][13][14][15][16][18][19][20] (Figure 3). Overall complication rates were reported in six studies, and the pooled analysis found no significant difference between FF and PF concerning the overall risk of complications (RR 0.83, 95%CI 0.64-1.07, p = 0.16) [13,15,16,[19][20][21] (Figure 4). For Yuan et al's work, a vascular crisis was not counted as a complication, as it was defined as a clinical sign motivating surgical exploration.…”

“…After being screened by title and abstract, only 19 studies were considered eligible for complete reading. Ten studies met all the selection criteria [12][13][14][15][16][17][18][19][20][21] (Figure 1).…”

Negative Pressure Wound Therapy as an Artificial Leech to Save a Congestive Flap: Case Report

“… 7 Meanwhile, Bhullar et al reported a venous congestion rate of 8.7% in a lower limb reconstructed with local flaps, and of 23.5% in those reconstructed with free flaps. 8 …”

“…7 Meanwhile, Bhullar et al reported a venous congestion rate of 8.7% in a lower limb reconstructed with local flaps, and of 23.5% in those reconstructed with free flaps. 8 Venous congestion has an extrinsic or intrinsic etiology; the first one is related to mechanical causes and the second one, to microcirculatory problems. If the cause is extrinsic, it requires a return to the operating room.…”