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J Reconstr Microsurg 2021; 37(09): 764-773
DOI: 10.1055/s-0041-1726398
Original Article

The Need to Improve Patient-Centered Outcome Reporting Following Lower Extremity Flap Reconstruction: A Systematic Review and Meta-analysis

Kevin G. Kim 
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Abigail R. Tirrell
2   Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
,
Paige K. Dekker
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Zoe Haffner
2   Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia
,
Christopher E. Attinger
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Kenneth L. Fan
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
,
Karen K. Evans
1   Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Abstract

Introduction Research in lower extremity (LE) wound management involving flap reconstruction has primarily focused on surgeon-driven metrics. There has been a paucity in research that evaluates patient-centered outcomes (PCO). This systematic review and meta-analysis examines articles published between 2012 and 2020 to assess whether reporting of functional and quality of life (QOL) outcomes have increased in frequency and cohesiveness, compared with the previous two decades.

Methods PubMed and Ovid were queried with appropriate Medical Subject Heading (MeSH) terms for studies published between June 2012 and July 2020. For inclusion, each study had to report any outcome of any tissue transfer procedure to the LE in comorbid patients, including complication rates, ambulation rates, flap success rates, and/or QOL measures. The PCO reporting prevalence was compared with a previous systematic review by Economides et al which analyzed papers published between 1990 and June 2012, using a Pearson's Chi-squared test.

Results The literature search yielded 40 articles for inclusion. The proportion of studies reporting PCO was greater for literature published between 1990 and 2012 compared with literature published between 2012 and 2020 (86.0 vs. 50.0%, p < 0.001). Functional outcomes were more commonly reported between 1990 and 2012 (78.0 vs. 47.5%, p = 0.003); similarly, ambulatory status was reported more often in the previous review (70.0 vs. 40.0%, p = 0.004). This study solely examined the rate at which PCO were reported in the literature; the individual importance and effect on medical outcomes of each PCO was not evaluated.

Conclusion Less than 50% of the literature report functional outcomes in comorbid patients undergoing LE flap reconstruction. Surprisingly, PCO reporting has seen a downward trend in the past 8 years relative to the preceding two decades. Standardized inclusion of PCO in research regarding this patient population should be established, especially as health care and governmental priorities shift toward patient-centered care.

Keywords

patient outcome assessment - patient-centered outcomes research - functional outcomes research - surgical flaps - free tissue flaps - lower extremity

Supplementary Material



Publication History

Received: 23 November 2020

Accepted: 27 January 2021

Article published online:
14 April 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Molnar JA, Vlad LG, Gumus T. Nutrition and chronic wounds: Improving clinical outcomes. Plast Reconstr Surg 2016; 138 (3, suppl): 71S-81S
    CrossrefPubMedGoogle Scholar
  • 2 Nussbaum SR, Carter MJ, Fife CE. et al. An economic evaluation of the impact, cost, and medicare policy implications of chronic nonhealing wounds. 2018; 21 (Suppl. 01) 27-32
    PubMedGoogle Scholar
  • 3 Olsson M, Järbrink K, Divakar U. et al. The humanistic and economic burden of chronic wounds: a systematic review. Wound Repair Regen 2019; 27 (01) 114-125
    CrossrefPubMedGoogle Scholar
  • 4 Oh TS, Lee HS, Hong JP. Diabetic foot reconstruction using free flaps increases 5-year-survival rate. J Plast Reconstr Aesthet Surg 2013; 66 (02) 243-250
    CrossrefPubMedGoogle Scholar
  • 5 Gregg EW, Li Y, Wang J. et al. Changes in diabetes-related complications in the United States, 1990-2010. N Engl J Med 2014; 370 (16) 1514-1523
    CrossrefPubMedGoogle Scholar
  • 6 Kim PJ, Attinger CE, Steinberg JS. et al. Building a multidisciplinary hospital-based wound care center: nuts and bolts. Plast Reconstr Surg 2016; 138 (3, suppl): 241S-247S
    CrossrefPubMedGoogle Scholar
  • 7 Kim PJ, Attinger CE, Orgill D. et al. Complex lower extremity wound in the complex host: results from a multicenter registry. Plast Reconstr Surg Glob Open 2019; 7 (04) e2129
    CrossrefPubMedGoogle Scholar
  • 8 Hasenstein TA, Greene T, Van JC, Meyr AJ. Soft tissue reconstruction with diabetic foot tissue loss. Clin Podiatr Med Surg 2019; 36 (03) 425-440
    CrossrefPubMedGoogle Scholar
  • 9 Mathes SJ, Nahai F. Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis, MO: Mosby; 1982
    Google Scholar
  • 10 Miller EA, Friedrich J. Soft tissue coverage of the hand and upper extremity: the reconstructive elevator. J Hand Surg Am 2016; 41 (07) 782-792
    CrossrefPubMedGoogle Scholar
  • 11 Black CK, Kotha VS, Fan KL, Ragothaman K, Attinger CE, Evans KK. Pedicled and free tissue transfers. Clin Podiatr Med Surg 2019; 36 (03) 441-455
    CrossrefPubMedGoogle Scholar
  • 12 Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg 2011; 127 (Suppl. 01) 228S-238S
    CrossrefPubMedGoogle Scholar
  • 13 Sato T, Yana Y, Ichioka S. Free flap reconstruction for diabetic foot limb salvage. J Plast Surg Hand Surg 2017; 51 (06) 399-404
    CrossrefPubMedGoogle Scholar
  • 14 Lu J, DeFazio MV, Lakhiani C. et al. Limb salvage and functional outcomes following free tissue transfer for the treatment of recalcitrant diabetic foot ulcers. J Reconstr Microsurg 2019; 35 (02) 117-123
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Ducic I, Attinger CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg 2011; 128 (01) 173-180
    CrossrefPubMedGoogle Scholar
  • 16 Economides JM, Patel KM, Evans KK, Marshall E, Attinger CE. Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients. J Reconstr Microsurg 2013; 29 (05) 307-316
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Abdelfattah U, Power HA, Song S, Min K, Suh HP, Hong JP. Algorithm for free perforator flap selection in lower extremity reconstruction based on 563 cases. Plast Reconstr Surg 2019; 144 (05) 1202-1213
    CrossrefPubMedGoogle Scholar
  • 18 Tevis SE, Kennedy GD. Postoperative complications and implications on patient-centered outcomes. J Surg Res 2013; 181 (01) 106-113
    CrossrefPubMedGoogle Scholar
  • 19 Stewart AL, Greenfield S, Hays RD. et al. Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. JAMA 1989; 262 (07) 907-913
    CrossrefPubMedGoogle Scholar
  • 20 Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine. J Gen Intern Med 2007; 22 (08) 1206-1211
    CrossrefPubMedGoogle Scholar
  • 21 O'Toole RV, Castillo RC, Pollak AN, MacKenzie EJ, Bosse MJ. LEAP Study Group. Determinants of patient satisfaction after severe lower-extremity injuries. J Bone Joint Surg Am 2008; 90 (06) 1206-1211
    CrossrefPubMedGoogle Scholar
  • 22 Fioravanti M, Maman P, Curvale G, Rochwerger A, Mattei JC. Amputation versus conservative treatment in severe open lower-limb fracture: a functional and quality-of-life study. Orthop Traumatol Surg Res 2018; 104 (02) 277-281
    CrossrefPubMedGoogle Scholar
  • 23 Hsu CY, Tsai YS, Yau CS, Shie HH, Wu CM. Differences in gait and trunk movement between patients after ankle fracture and healthy subjects. Biomed Eng Online 2019; 18 (01) 26
    CrossrefPubMedGoogle Scholar
  • 24 Mackenzie EJ, Rivara FP, Jurkovich GJ. et al. The impact of trauma-center care on functional outcomes following major lower-limb trauma. J Bone Joint Surg Am 2008; 90 (01) 101-109
    CrossrefPubMedGoogle Scholar
  • 25 Binkley JM, Stratford PW, Lott SA, Riddle DL. North American Orthopaedic Rehabilitation Research Network. The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999; 79 (04) 371-383
    PubMedGoogle Scholar
  • 26 Borden WB, Chiang YP, Kronick R. Bringing patient-centered outcomes research to life. Value Health 2015; 18 (04) 355-357
    CrossrefPubMedGoogle Scholar
  • 27 Squitieri L, Chung KC. Measuring provider performance for physicians participating in the merit-based incentive payment system. Plast Reconstr Surg 2017; 140 (01) 217e-226e
    CrossrefPubMedGoogle Scholar
  • 28 MIPS Explore Measures&Activities. How to use this tool. Accessed October 29, 2020 at: https://qpp.cms.gov/mips/explore-measures?tab=qualityMeasures&py=2020#measures
    Google Scholar
  • 29 Georgescu AV, Matei IR, Capota IM. The use of propeller perforator flaps for diabetic limb salvage: a retrospective review of 25 cases. Diabet Foot Ankle 2012;3
    Google Scholar
  • 30 Patel KM, Seruya M, Franklin B, Attinger CE, Ducic I. Factors associated with failed hardware salvage in high-risk patients after microsurgical lower extremity reconstruction. Ann Plast Surg 2012; 69 (04) 399-402
    CrossrefPubMedGoogle Scholar
  • 31 Kolbenschlag J, Hellmich S, Germann G, Megerle K. Free tissue transfer in patients with severe peripheral arterial disease: functional outcome in reconstruction of chronic lower extremity defects. J Reconstr Microsurg 2013; 29 (09) 607-614
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Li CC, Chang SC, Fu JP. et al. Comparison of hatchet-shaped tensor fascia lata flap and pedicle anterior lateral thigh flap for treatment of trochanteric sores: a retrospective analysis of 48 patients. Ann Plast Surg 2013; 71 (06) 659-663
    CrossrefPubMedGoogle Scholar
  • 33 Park JS, Roh SG, Lee NH, Yang KM. Versatility of the distally-based sural artery fasciocutaneous flap on the lower leg and foot in patients with chronic disease. Arch Plast Surg 2013; 40 (03) 220-225
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Horch RE, Lang W, Arkudas A. et al. Nutrient free flaps with vascular bypasses for extremity salvage in patients with chronic limb ischemia. J Cardiovasc Surg (Torino) 2014; 55 (02, Suppl 1): 265-272
    PubMedGoogle Scholar
  • 35 Huang CC, Chang CH, Hsu H. et al. Endovascular revascularization and free tissue transfer for lower limb salvage. J Plast Reconstr Aesthet Surg 2014; 67 (10) 1407-1414
    CrossrefPubMedGoogle Scholar
  • 36 Lee YK, Park KY, Koo YT. et al. Analysis of multiple risk factors affecting the result of free flap transfer for necrotising soft tissue defects of the lower extremities in patients with type 2 diabetes mellitus. J Plast Reconstr Aesthet Surg 2014; 67 (05) 624-628
    CrossrefPubMedGoogle Scholar
  • 37 Patel KM, Economides JM, Franklin B, Sosin M, Attinger C, Ducic I. Correlating patient-reported outcomes and ambulation success following microsurgical lower extremity reconstruction in comorbid patients. Microsurgery 2014; 34 (01) 1-4
    CrossrefPubMedGoogle Scholar
  • 38 Wink JD, Nelson JA, Fischer JP, Cleveland EC, Kovach III SJ. Free tissue transfer for complex reconstruction of the lower extremity: experience of a young microsurgeon. J Reconstr Microsurg 2014; 30 (05) 349-358
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Akhtar S, Ahmad I, Khan AH, Khurram MF. Modalities of soft-tissue coverage in diabetic foot ulcers. Adv Skin Wound Care 2015; 28 (04) 157-162
    CrossrefPubMedGoogle Scholar
  • 40 Kallio M, Vikatmaa P, Kantonen I, Lepäntalo M, Venermo M, Tukiainen E. Strategies for free flap transfer and revascularisation with long-term outcome in the treatment of large diabetic foot lesions. Eur J Vasc Endovasc Surg 2015; 50 (02) 223-230
    CrossrefPubMedGoogle Scholar
  • 41 DeFazio MV, Hung RW, Han KD, Bunting HA, Evans KK. Lower extremity flap salvage in thrombophilic patients: managing expectations in the setting of microvascular thrombosis. J Reconstr Microsurg 2016; 32 (06) 431-444
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Lee YB, Kim DH, Jung JH, Park JY. Chronic open infective lateral malleolus bursitis management using local rotational flap. BioMed Res Int 2017; 2017: 2728092
    PubMedGoogle Scholar
  • 43 Sidon E, Shemesh S, Rosenthal Y, Heller S, Velkes S, Burg A. Medial forefoot fillet flap for primary closure of transmetatarsal amputation: A series of four cases. Foot 2017; 33: 53-56
    CrossrefPubMedGoogle Scholar
  • 44 Wu H, Shen J, Yu X. et al. Two stage management of Cierny-Mader type IV chronic osteomyelitis of the long bones. Injury 2017; 48 (02) 511-518
    CrossrefPubMedGoogle Scholar
  • 45 de Rezende MR, Saito M, Paulos RG. et al. Reduction of morbidity with a reverse-flow sural flap: a two-stage technique. J Foot Ankle Surg 2018; 57 (04) 821-825
    CrossrefPubMedGoogle Scholar
  • 46 Falola RA, Lakhiani C, Green J. et al. Assessment of function after free tissue transfer to the lower extremity for chronic wounds using the lower extremity functional scale. J Reconstr Microsurg 2018; 34 (05) 327-333
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Ju J, Li L, Zhou R, Hou R. Combined application of latissimus dorsi myocutaneous flap and iliac bone flap in the treatment of chronic osteomyelitis of the lower extremity. J Orthop Surg Res 2018; 13 (01) 117
    CrossrefPubMedGoogle Scholar
  • 48 Kanuri A, O'Kelly ND, Shuck J, Kim P, Evans KK, Attinger CE. The effect of positive postdebridement cultures on local muscle flap reconstruction of the lower extremity. Plast Reconstr Surg Glob Open 2018; 6 (09) e1864
    CrossrefPubMedGoogle Scholar
  • 49 Kim SW, Sung IH, Kim YH. Reconstruction of severe atherosclerotic and obstructive diabetic feet using thoracodorsal artery perforator flaps with long vascular pedicles. Microsurgery 2018; 38 (03) 287-294
    CrossrefPubMedGoogle Scholar
  • 50 Lim SY, Kim GH, Sung IH. et al. Lower extremity salvage with thoracodorsal artery perforator free flap in condition of symmetrical peripheral gangrene. BioMed Res Int 2018; 2018: 6508607
    PubMedGoogle Scholar
  • 51 Schwaiger K, Russe E, Kholosy H. et al. Reconstructive microsurgical approach for the treatment of pyoderma gangrenosum. J Plast Reconstr Aesthet Surg 2018; 71 (01) 44-52
    CrossrefPubMedGoogle Scholar
  • 52 Settembre N, D'oria M, Saba C, Bouziane Z, Malikov S. Negative pressure wound therapy to promote fixation and remodeling of omental flap in patients with revascularized limbs: a case series. Ann Vasc Surg 2018; 52: 313.e5-313.e8
    CrossrefPubMedGoogle Scholar
  • 53 Sung IH, Jang DW, Kim SW, Kim YH, Kim SW. Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps. Microsurgery 2018; 38 (06) 674-681
    CrossrefPubMedGoogle Scholar
  • 54 Yang X, Fang Z, Liu M. et al. Free vascularized fascia flap combined with skin grafting for deep toe ulcer in diabetic patients. J Surg Res 2018; 231: 167-172
    CrossrefPubMedGoogle Scholar
  • 55 Assi C, Samaha C, Chamoun Moussa M, Hayek T, Yammine K. A comparative study of the reverse sural fascio-cutaneous flap outcomes in the management of foot and ankle soft tissue defects in diabetic and trauma patients. Foot Ankle Spec 2019; 12 (05) 432-438
    CrossrefPubMedGoogle Scholar
  • 56 Chang CH, Huang CC, Hsu H, Lin CM, Huang SM. Editor's choice - diabetic limb salvage with endovascular revascularisation and free tissue transfer: long-term follow up. Eur J Vasc Endovasc Surg 2019; 57 (04) 527-536
    CrossrefPubMedGoogle Scholar
  • 57 DeFazio MV, Economides JM, Anghel EL, Tefera EA, Evans KK. Lower extremity free tissue transfer in the setting of thrombophilia: analysis of perioperative anticoagulation protocols and predictors of flap failure. J Reconstr Microsurg 2019; 35 (04) 270-286
    Article in Thieme ConnectPubMedGoogle Scholar
  • 58 Janhofer DE, Lakhiani C, Kim PJ. et al. The utility of preoperative arteriography for free flap planning in patients with chronic lower extremity wounds. Plast Reconstr Surg 2019; 143 (02) 604-613
    CrossrefPubMedGoogle Scholar
  • 59 Lee JT, Cheng LF, Hsu H, Wu MS, Chien SH. Reconstruction of diabetic foot defects with the proximal lateral leg perforator flap. Ann Plast Surg 2019; 82 (05) 546-551
    CrossrefPubMedGoogle Scholar
  • 60 Nguyen T, Rodriguez-Collazo ER. Healing heel ulcers in high-risk patients: distally based peroneus brevis muscle flap case series. J Foot Ankle Surg 2019; 58 (02) 341-346
    CrossrefPubMedGoogle Scholar
  • 61 Black C, Fan KL, Defazio MV. et al. Limb salvage rates and functional outcomes using a longitudinal slit arteriotomy end-to-side anastomosis for limb-threatening defects in a high-risk patient population. Plast Reconstr Surg 2020; 145 (05) 1302-1312
    CrossrefPubMedGoogle Scholar
  • 62 Black CK, Zolper EG, Ormiston LD. et al. Free anterolateral thigh versus vastus lateralis muscle flaps for coverage of lower extremity defects in chronic wounds. Ann Plast Surg 2020; 85 (S1): (Suppl. 01) S54-S59
    CrossrefPubMedGoogle Scholar
  • 63 Janhofer DE, Lakhiani C, Kim PJ. et al. The utility of preoperative venous testing for lower extremity flap planning in patients with lower extremity wounds. Plast Reconstr Surg 2020; 145 (01) 164e-171e
    CrossrefPubMedGoogle Scholar
  • 64 Kim SW. Perforator free flap coverage of chronic lower extremity ulcers in patients with autoimmune diseases under immunosuppression. Int J Low Extrem Wounds 2020; (e-pub ahead of print). DOI: 10.1177/1534734620919611.
    CrossrefPubMedGoogle Scholar
  • 65 Lee ZH, Daar DA, Stranix JT. et al. Free-flap reconstruction for diabetic lower extremity limb salvage. J Surg Res 2020; 248: 165-170
    CrossrefPubMedGoogle Scholar
  • 66 Spatz ES, Spertus JA. Shared decision making: a path toward improved patient-centered outcomes. Circ Cardiovasc Qual Outcomes 2012; 5 (06) e75-e77
    CrossrefPubMedGoogle Scholar
  • 67 Rathert C, Wyrwich MD, Boren SA. Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev 2013; 70 (04) 351-379
    CrossrefPubMedGoogle Scholar
  • 68 Poitras ME, Maltais ME, Bestard-Denommé L, Stewart M, Fortin M. What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC Health Serv Res 2018; 18 (01) 446
    CrossrefPubMedGoogle Scholar
  • 69 Vyas KS, Johnson K, Mardini S. The role of patient-centered outcomes research in plastic surgery. Ann Plast Surg 2016; 77 (06) 585-586
    CrossrefPubMedGoogle Scholar
  • 70 Ho AL, Klassen AF, Cano S, Scott AM, Pusic AL. Optimizing patient-centered care in breast reconstruction: the importance of preoperative information and patient-physician communication. Plast Reconstr Surg 2013; 132 (02) 212e-220e
    CrossrefPubMedGoogle Scholar
  • 71 Dingemans SA, Kleipool SC, Mulders MAM. et al. Normative data for the lower extremity functional scale (LEFS). Acta Orthop 2017; 88 (04) 422-426
    CrossrefPubMedGoogle Scholar
  • 72 Egeler SA, de Jong T, Luijsterburg AJM, Mureau MAM. Long-term patient-reported outcomes following free flap lower extremity reconstruction for traumatic injuries. Plast Reconstr Surg 2018; 141 (03) 773-783
    CrossrefPubMedGoogle Scholar
  • 73 Vielgut I, Gregori M, Holzer LA, Glehr M, Hashemi S, Platzer P. Limb salvage and functional outcomes among patients with traumatic popliteal artery injury: a review of 64 cases. Wien Klin Wochenschr 2015; 127 (13-14): 561-566
    CrossrefPubMedGoogle Scholar
  • 74 Estoque RC, Togawa T, Ooba M. et al. A review of quality of life (QOL) assessments and indicators: Towards a “QOL-Climate” assessment framework. Ambio 2019; 48 (06) 619-638
    CrossrefPubMedGoogle Scholar
  • 75 Ruggieri P, Mavrogenis AF, Mercuri M. Quality of life following limb-salvage surgery for bone sarcomas. Expert Rev Pharmacoecon Outcomes Res 2011; 11 (01) 59-73
    CrossrefPubMedGoogle Scholar
  • 76 Spanos K, Saleptsis V, Athanasoulas A. et al. Factors associated with ulcer healing and quality of life in patients with diabetic foot ulcer. Angiology 2017; 68 (03) 242-250
    CrossrefPubMedGoogle Scholar
  • 77 MacArthur IR, McInnes CW, Dalke KR. et al. Patient reported outcomes following lower extremity soft tissue sarcoma resection with microsurgical preservation of ambulation. J Reconstr Microsurg 2019; 35 (03) 168-175
    Article in Thieme ConnectPubMedGoogle Scholar
  • 78 Mundy LR, Klassen A, Sergesketter AR. et al. Content validity of the LIMB-Q: A patient-reported outcome instrument for lower extremity trauma patients. J Reconstr Microsurg 2020; 36 (09) 625-633
    Article in Thieme ConnectPubMedGoogle Scholar