SLR - March 2020 - Ashmi H. Patel
The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations
Reference: Lese I, Grobbelaar A, Sabau D, Georgescu A, Constantinescu M, Olariu R. The Propeller Flap for Traumatic Distal Lower-Limb Reconstruction: Risk Factors, Pitfalls, and Recommendations. J Bone Joint Surg Am. 2019 Dec; 00:1-9.
Scientific Literature Review
Reviewed By: Ashmi H. Patel, DPM
Residency Program: Kaiser Permanente North Bay Consortium – Vallejo, CA
Podiatric Relevance: Commonly, lower extremity trauma that result in large soft tissue deficits are managed with free flaps. In these cases, soft tissue coverage over fractures can be complicated by extensive soft tissue loss or the need for multiple incisions required for internal fixation. To mitigate these problems, the propeller flap was first described in 1991 and later became popular for its notable advantages including shorter operative time, reduced cost and lack of a distant donor site. The main disadvantages have been venous congestion and partial flap necrosis.
Methods: All patients who had been treated with a propeller flap from 2014 to 2017 were included in this single-center study. Indications to use the propeller flap rather than a free flap included traumatic defects in the distal third of the leg requiring flap coverage of an area measuring <5 centimeters in diameter, dopplerable signal of the perforating artery, and comorbidities that were unsuitable for a complex microvascular procedure. Patients with a Guistilo 3C injury were excluded and managed with a free flap. Surgical data was recorded, including details regarding the flap and perforator, donor-site closure, the duration of surgery, the source vessel of the perforator, and complications.
Results: A total of 26 patients met the inclusion criteria and the average age was 60. Nine patients experienced postoperative complications, but only three needed revision surgery. One patient had partial flap necrosis and infection and subsequently underwent partial defect coverage with a small bipedicled skin flap. A second patient with extensive partial flap necrosis was managed with a free flap for coverage. A third patient with complete flap necrosis was managed with a dermal substitute and skin graft. All other complications were treated nonoperatively. The average time to healing was 5.9 weeks. There was a significant association between complications and the source artery of the propeller flap with propeller flaps based on the peroneal artery being strongly associated with postoperative complications (p=0.015). There were no significant differences between patients with and without complications in terms of age, wound area, flap area, the flap arc of rotation or the timing of reconstruction (p > 0.05).
Conclusions: Free flaps are considered the gold standard for lower limb reconstructions; however, propeller flaps have become increasingly popular. Their texture, color, and thickness are more suitable because of the proximity of the donor area and the operative time is much shorter. The main advantage of propeller flaps is that that no microvascular anastomosis is required. The mean duration of surgery is 115 minutes. Another advantage is the preservation of all three vascular axes of the distal part of the leg which reduces the donor site morbidity. However, if the area of crush injury is close to the flap, it could compromise the flap. Even though the distal third leg are considered to be at risk when local flaps are used, authors have suggested that propeller flaps based on single perforator arising from the posterior tibial or peroneal artery can be safely employed, even in patients with comorbidities.