title: Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis.
abstract: BACKGROUND
  Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?"
  
  
  METHODS
  This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I2index were computed.
  
  
  RESULTS
  We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016).
  
  
  CONCLUSIONS
  In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France.
authors.forename: Farid
authors.initials: F
authors.lastname: Bekara
authors.affiliation: Department of Plastic and Reconstructive Surgery, Lapeyronie University Hospital, Montpellier, France.
authors.forename: Christian
authors.initials: C
authors.lastname: Herlin
authors.affiliation: Biostatistic Unit, Institut Universitaire du Cancer Toulouse, Toulouse, France.
authors.forename: Serge
authors.initials: S
authors.lastname: Somda
authors.affiliation: Department of Plastic and Reconstructive Surgery, Nancy University Hospital, Nancy, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: de Runz
authors.affiliation: Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France.
authors.forename: Jean Louis
authors.initials: JL
authors.lastname: Grolleau
authors.affiliation: Department of Plastic and Reconstructive Surgery, Rangueil University Hospital, Toulouse, France.
authors.forename: Benoit
authors.initials: B
authors.lastname: Chaput
mesh_terms: D058752:Free Tissue Flaps; D006801:Humans; D007869:Leg Injuries / Q000601:surgery*; D061525:Perforator Flap; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D019651:Plastic Surgery Procedures / Q000379:methods*; D016896:Treatment Outcome