Background The decision between local and free tissue coverage for distal lower leg defects has long been dictated by the location and size of defects. Recent reports of distal defects treated successfully with pedicled perforator flaps demonstrate equivalent clinical outcomes; however, the complication rate can be high. The goal of this study was to evaluate the cost equivalence of free versus pedicled perforator flap to assist decision-making and guide clinical care.

Methods The institutional database was searched for patients with acute injury over the distal lower extremity requiring free or pedicled perforator flap. Demographic, clinical, and total resource cost was gathered. Patients were matched to Gustilo–Anderson or Arbeitsgemeinschaft fur Osteosynthesefragen classification as well as size of defect and outcomes, and cost compared.

Results We have included 108 free flaps and 22 pedicled perforator flaps in the study. There was no difference in complication rate between groups. Free flaps had significantly more reoperations, required longer operative time, and had longer intensive care unit (ICU) care with higher cost of surgery and overall cost than pedicled flaps. When controlling for size of defect, surgical cost remained significantly different between groups (p = 0.013), but overall cost did not. Multivariable regression analysis indicated flap type to be the primary driver of cost of surgery, while body mass index elevated the total cost.

Conclusion Pedicled perforator flap coverage for small to medium-sized defects (< 70 cm2) is a viable and cost-effective option for distal lower leg soft tissue reconstruction after acute traumatic injury with similar clinical outcomes and shorter operative duration and ICU stay.

Presented at: The 9th Congress of World Society for Reconstructive Microsurgery in Seoul, Korea, June 17, 2017.

J.C.H.: Experimental design, data gathering, analysis, and draft of the manuscript.

N.A.Z.: Data interpretation, analysis, and wrote the primary draft of the manuscript.

Y.J.T.: Statistical management, data analysis, and reviewed the manuscript.

C.C.H.: Data gathering, initial data analysis, and reviewed the manuscript.

S.H.C.: Data gathering, initial data analysis, and reviewed the manuscript.

Chih-H.L.: Data gathering and reviewed the manuscript.

Cheng-H.L.: Experimental design, data gathering, data interpretation, advised in initial draft of manuscript, and reviewed the final manuscript.

This study was approved by our institutional review board under protocol number 201508108B0.

*These authors contributed equally to this work.

Received: 31 January 2022

Accepted: 05 October 2022

Article published online:
03 December 2022

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