Soft tissue reconstruction of combat-related injuries affecting the lower limb: is a time target realistic? A systematic review and meta-analysis

BackgroundMajor extremity trauma forms a considerable proportion of combat-related injuries. Coverage of lower limb soft tissue defects utilises the reconstructive ladder. The 72-h target to definitive reconstruction has been proposed in civilian trauma. The primary aim of this study was to determine whether the time to definitive reconstruction and the number of pre-flap debridements have an impact on flap success in lower limb combat injury reconstructions.MethodsA literature search was conducted on Pubmed, Prospero, Dynamed, DARE, EMBASE, COCHRANE and BMJ databases. A random effects model was used due to significant heterogeneity between the papers and a meta-regression was implemented for the analysis of outcomes.ResultsA total of seven studies had fulfilled the inclusion criteria. The cumulative number of flaps performed was 378 (255 free flaps and 123 non-free flaps). The Latissimus Dorsi free flap was the most common flap performed (n = 153). The proportion of flap success across the studies was 88% (0.88, 95% CI: 0.77-0.94). There was no statistically significant impact of the number of pre-flap debridements on flap success rates (OR of: 1.23 [95% CI: 0.62 to 2.44], p > 0.05). Time to reconstruction had no statistically significant impact on flap success rates (OR of: 0.88 [95% CI: 0.77 to 1.00], p > 0.05).ConclusionsThe choice of flap used in lower limb combat-related injuries is dependent upon the type, extent and location of injury. Onus should be placed on ensuring the wound is adequately debrided prior to definitive coverage to provide a healthy wound bed for reconstruction.Level of Evidence: Not gradable