Chellamuthu Abiramie, Jayaraman Sathish Kumar, A Ramesh B
Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India.
Indian J Plast Surg. 2023 Jan 8;56(1):13-21. doi: 10.1055/s-0042-1760093. eCollection 2023 Feb.
Choosing the components of free flap (fasciocutaneous or muscle) is one of the crucial but controversial decisions in heel reconstruction. This meta-analysis aims to provide an up-to-date comparison of fasciocutaneous flaps (FCFs) and muscle flaps (MFs) for heel reconstruction and to ascertain if one flap has an advantage over the other. Following the Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed identifying studies on heel reconstruction with FCF and MF. Primary outcomes were survival, time of ambulation, sensation, ulceration, gait, need for specialized footwear, revision procedures, and shear. Meta-analyses and Trial Sequential Analysis (TSA) were performed to estimate the pooled risk ratios (RRs) and standardized mean difference (SMD) with fixed effects and random effects models, respectively. Of 757 publications identified, 20 were reviewed including 255 patients with 263 free flaps. The meta-analysis showed no statistically significant difference between MF and FCF in terms of survival (RR, 1; 95% confidence interval [CI], 0.83, 1.21), gait abnormality (RR, 0.55; 95% CI, 0.19, 1.59), ulcerations (RR, 0.65; 95% CI, 0.27, 1.54), footwear modification (RR, 0.52; 95% CI, 0.26, 1.09), and revision procedures (RR, 1.67; 95% CI, 0.84, 3.32). FCF had superior perception of deep pressure (RR, 1.99; 95% CI, 1.32, 3.00), light touch, and pain (RR, 5.17; 95% CI, 2.02, 13.22) compared with MF. Time to full weight-bearing (SMD, -3.03; 95% CI, -4.25, -1.80) was longer for MF compared with FCF. TSA showed inconclusive results for comparison of the survival of flaps, gait assessment, and rates of ulceration. Patients reconstructed with FCF had superior sensory recovery and early weight bearing on their reconstructed heels, hence faster return to daily activities compared with MFs. In terms of other outcomes such as footwear modification and revision procedure, both flaps had no statistically significant difference. The results were inconclusive regarding the survival of flaps, gait assessment, and rates of ulceration. Future studies are required to investigate the role of shear on the stability of the reconstructed heels.
选择游离皮瓣（筋膜皮瓣或肌皮瓣）的组成部分是足跟重建中关键但存在争议的决策之一。本荟萃分析旨在对用于足跟重建的筋膜皮瓣（FCF）和肌皮瓣（MF）进行最新比较，并确定一种皮瓣是否比另一种具有优势。
按照系统评价和荟萃分析的首选报告项目指南，进行了一项系统文献综述，以确定关于使用FCF和MF进行足跟重建的研究。主要结局包括皮瓣存活、行走时间、感觉、溃疡形成、步态、对特殊鞋类的需求、翻修手术以及剪切力。分别采用固定效应模型和随机效应模型进行荟萃分析和试验序贯分析（TSA），以估计合并风险比（RRs）和标准化均差（SMD）。
在识别出的757篇出版物中，对20篇进行了综述，包括255例患者的263个游离皮瓣。荟萃分析显示，MF和FCF在皮瓣存活（RR，1；95%置信区间[CI]，0.83，1.21）、步态异常（RR，0.55；95%CI，0.19，1.59）、溃疡形成（RR，0.65；95%CI，0.27，1.54）、鞋类修改（RR，0.52；95%CI，0.26，1.09）和翻修手术（RR，1.67；95%CI，0.84，3.32）方面无统计学显著差异。与MF相比，FCF对深部压力（RR，1.99；95%CI，1.32，3.00）、轻触觉和疼痛（RR，5.17；95%CI，2.02，13.22）的感觉更佳。与FCF相比，MF达到完全负重的时间（SMD，-3.03；95%CI，-4.25，-1.80）更长。TSA显示皮瓣存活、步态评估和溃疡形成率比较的结果尚无定论。
与MF相比，接受FCF重建的患者在重建足跟处感觉恢复更佳且能早期负重，因此能更快恢复日常活动。在鞋类修改和翻修手术等其他结局方面，两种皮瓣无统计学显著差异。关于皮瓣存活、步态评估和溃疡形成率的结果尚无定论。未来需要研究剪切力对重建足跟稳定性的作用。
