title: Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis.
abstract: BACKGROUND
  Management of soft tissue injuries of the heel is challenging and the composition of free tissue transfer that provides optimal aesthetic and functional outcomes in heel reconstruction is not clear. While fasciocutaneous flaps may result in shear planes that cause instability with mobilization, insensate muscle flaps may not be able to withstand the pressures of weight bearing and thus ulcerate.
  
  
  METHODS
  A systematic literature search was performed using Medline and PubMed databases. Primary outcome measures were time to mobilize, ulceration, revision or debulking surgery, and the requirement for specialized footwear. Analysis of pooled outcomes was undertaken using fixed-effects meta-analysis, calculating the incidence rate ratio for included articles.
  
  
  RESULTS
  Overall 576 articles were identified; out of which 11 articles met the final inclusion criteria, detailing 168 free tissue transfers in 163 patients. The study size ranged from 4 to 72 cases. There was a trend toward higher rates of ulceration (17 vs. 26%), requirement for revision (23 vs. 31%), and the requirement for specialized footwear (35 vs. 56%) in muscle flaps, but these differences were not statistically significant.
  
  
  CONCLUSIONS
  The current review provided a summary of reported outcomes of free heel reconstruction in the literature till date. With the current evidence largely limited to small cohort studies (level IV evidence), there were no significant differences found between reconstructive options. These findings serve as a call to action for more reconstructive surgeons to collaborate on multi-institutional prospective studies with robust outcomes assessment. As such, an ideal flap for reconstruction of the weight-bearing heel has not yet been made clear.
authors.affiliation: Department of Surgery, Monash University, Clayton, Victoria, Australia.
authors.forename: Carly M
authors.initials: CM
authors.lastname: Fox
authors.affiliation: Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
authors.forename: Henry M
authors.initials: HM
authors.lastname: Beem
authors.affiliation: Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Wiper
authors.affiliation: Department of Surgery, Monash University, Clayton, Victoria, Australia.
authors.forename: Warren M
authors.initials: WM
authors.lastname: Rozen
authors.affiliation: Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
authors.forename: Michael
authors.initials: M
authors.lastname: Wagels
authors.affiliation: Department of Surgery, Monash University, Clayton, Victoria, Australia.
authors.forename: James C
authors.initials: JC
authors.lastname: Leong
mesh_terms: D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply*; D006085:Graft Survival; D006365:Heel / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008866:Microsurgery; D019651:Plastic Surgery Procedures; D017695:Soft Tissue Injuries / Q000601:surgery*; D013524:Surgical Flaps; D016896:Treatment Outcome; D016474:Weight-Bearing; D014945:Wound Healing