Closure of a free osteofasciocutaneous fibula flap donor site using local skin grafts or flaps: A systematic review and meta-analysis

Background In free osteofasciocutaneous fibula flaps, secondary donor sites are avoided using one of three local closure methods: full-thickness skin grafts (FTSGs), split-thickness skin grafts (STSGs), or flaps. This systemic review aimed to evaluate the differences in outcomes among the three groups of closure methods used for free fibula flap defects. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, we systematically searched the PubMed and Web of Science medical databases from inception to January 2021 for articles focused on closure of the free fibula flap donor site using the lower leg area-local skin graft or flap-that mentioned the free fibula flap defect size, and/or complications of the donor site. Study characteristics, free fibula flap size, and short-term complication rates were extracted for analysis. The pooled complication rates and confidence intervals were calculated based on the random-effects model. Results Eleven studies were included in the qualitative synthesis, and ten studies were included in the quantitative synthesis (meta-analysis). The FTSG (n = 79, 52.3%) was the most widely used method, while both STSG (n = 36, 23.8%) and flap (n = 36, 23.8%) were the least commonly used methods. The mean free fibula flap length and width were largest for the flap method (11.5 +/- 2.5 cm and 6.0 +/- 1.8 cm), and all closure methods were used for free fibula flap widths >= 3 cm. Rates of partial and complete necrosis were highest for the FTSG method (20.3%, p = .95, I-2 = 0%) and lowest for the flap method (12.7%, p = .95, I-2 = 0%). Conclusion This systemic review indicated that any closure method could be adapted for a free fibula flap width ranging from 3 to 9 cm, and the flap method was associated with the lowest rate of short-term complications.