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

Abstract

Introduction: Early postoperative compression of free flaps for lower limb reconstruction remains controversial. It may reduce venous congestion and promote resolution of oedema. However, concerns remain regarding inadvertent pedicle compression, which may lead to flap failure. The aim of this systematic review was to determine the safety and effectiveness of this intervention. Methods: A systematic review was designed in compliance with PRISMA. MEDLINE and EMBASE databases were searched. Parallel screening, selection of eligible studies and data gathering was carried out by two independent authors. A formal risk of bias assessment was included along with appraisal of outcomes.Results: A total of 847 abstracts were retrieved and 262 free flaps for lower limb reconstruction were identified in 10 eligible articles. The overall flap failure rate for patients that underwent early postoperative compression was 1.6%. Apart from flap failure rates, there were no other outcomes consistently reported and none of the studies included a no-compression group for comparison. Discussion: All the included studies had methodological flaws, resulting in a high risk of bias.Nevertheless, there was consistent reporting of flap failure as a postoperative outcome. Compression of free flaps in the context of lower limb reconstruction does not appear to be associated with a higher flap failure rate compared with other series. Compression bandages may reduce the pain associated with dangling regimes. However, there is no evidence to support that free flap compression in the context of lower limb reconstruction is associated with any other clinical benefit.

Timing of Unplanned Reoperation After Lower Extremity Free Flap Reconstruction

“…First, after free flap reconstruction, patients undergo a period of extensive immobilization, which may facilitate the development of a prothrombotic state, particularly after surgery 27 . In addition, after these reconstructions, the vascular pedicle or anastomosis of the flap may be compromised by a number of intrinsic and extrinsic factors 28 . Among the potential internal factors, compression may be caused by postoperative edema, metal implants, and bony prominences.…”

“…27 In addition, after these reconstructions, the vascular pedicle or anastomosis of the flap may be compromised by a number of intrinsic and extrinsic factors. 28 Among the potential internal factors, compression may be caused by postoperative edema, metal implants, and bony prominences. Externally, vascular pedicles and the integrity of the anastomosis may be jeopardized by circumferential dressings, compressive splints/wraps, or compression on surrounding objects in physical space (ie, hospital bed, pillows, leg elevating structures).…”

Comparison of the Efficacy of Two Elastic Bandages for Forearm Hematoma After Transradial Coronary Intervention

“…In a study involving a total of 38 patients with forearm hematoma following coronary intervention, Berner et al compared the results of injecting dehydrating agents in the hand dorsal vein between the affected and the non-affected sides. They found that injection in the hand dorsal vein of the affected side could relieve pain faster, promote better edema regression, and reduce the occurrence of tension blisters ( 15 ). Jonker et al compared the curative effects of tension hematoma on the anterior wall following coronary intervention of hand compression, elastic bandage compression alone, and bandage compression combined with dehydration.…”

Intraoperative Invasive Blood Pressure Monitoring in Flap-Based Lower Extremity Reconstruction

“…With advances in the field of microvascular surgery, success rates of FTT have continued to increase, estimated to be more than 95% and as high as 98% to 99% in some case series. [6][7][8][9][10] The most common causes of flap failure are hematoma and/or thrombus formation, both of which can hinder subsequent revascularization attempts and may ultimately compromise flap salvageability. [11][12][13] Because of this, the surgical team must strike a careful balance to achieve an arterial pressure that is conducive to adequate tissue perfusion but not so high that it hinders adequate homostasis.…”

“…Free tissue transfer (FTT) is a reconstructive modality that allows for limb salvage in patients who might otherwise be subject to amputation. With advances in the field of microvascular surgery, success rates of FTT have continued to increase, estimated to be more than 95% and as high as 98% to 99% in some case series 6–10 . The most common causes of flap failure are hematoma and/or thrombus formation, both of which can hinder subsequent revascularization attempts and may ultimately compromise flap salvageability 11–13 .…”