A Meta-analysis of Timing for Microsurgical Free Flap Reconstruction for Lower Limb Injury: Evaluation of the Godina Principles
Siba Haykal, MD, PhD, FRCSC1, Melissa Roy, MD2, Usamah Simjee, BS1, Ashit Patel, MBChB FACS1.
1Albany Medical Centre, Albany, NY, USA, 2University of Toronto, Toronto, ON, Canada.
Background In 1986 Marko Godina published his seminal work regarding the timing of free flap reconstruction for traumatic extremity defects. Early reconstruction, compared to delayed and late reconstruction resulted in significant decreases in free flap failure rate, postoperative infections, hospitalization time, bone healing time and number of additional anesthesias. The objective of this manuscript was to evaluate whether these principles continue to apply. Methods A meta-analysis was performed analyzing articles from Medline, Embase and Pubmed. Four hundred and ninety-two articles were screened and 142 articles were assessed for eligibility. Following full text review, 43 articles were included in this study. Results The exact timing for free flap reconstruction, free flap failure rate, infection rate and followup was defined in all 43 articles. Early free flap reconstruction was found to have significantly lower rates of free flap failure and infection in comparison to delayed reconstruction (p = 0.008; p = 0.0004). Compared to late reconstruction, early reconstruction was found to have significantly lower infection rates only (p = 0.01) with no difference in free flap failures rates. Early reconstruction was found to lead to fewer additional procedures (p=0.03). No statistical significance was found for bone healing time or hospitalization time. Conclusion Early free flap reconstruction performed within the first 72 hours resulted in a decreased rate of free flap failures, infection and additional procedures with no difference in other parameters. All studies included were of level IV or V evidence with no randomized controlled trials having been performed. The largest majority of free flap cases continue to be performed in the delayed time frame. The results of this study could have a significant impact on our health care system.
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