A systematic review and meta-analysis of the morbidity of the donor-site of flaps harvested based on the first intermetatarsal artery

TL;DR

This study reviews and analyzes the complications at the donor site after foot flap surgery, finding low but variable rates of objective and subjective issues.

Contribution

The paper provides the first systematic review and meta-analysis on donor-site morbidity for foot-based free flaps in reconstructive surgery.

Findings

Objective donor-site morbidity occurred in 2.99% of cases, with wound dehiscence and delayed healing being most common.

Subjective donor-site morbidity occurred in 3.32% of cases, with daily life disturbance and pain being most frequent.

The study found substantial heterogeneity across studies, limiting the strength of the conclusions.

Abstract

Free tissue flaps from the foot have become an increasingly reliable tool in modern reconstructive surgery; however, the field lacks an empirical analysis focused on donor-site morbidity. This systematic review and meta-analysis aimed to evaluate the incidence of donor-site morbidity following dorsalis pedis and free toe flap harvest.

This systematic review and meta-analysis was performed according to the PRISMA guidelines. A systematic search of PubMed, Embase, CENTRAL, and clinicaltrials.gov was performed on March 3, 2025, to identify eligible studies involving adults who underwent free flap harvest from the toes or dorsum of the foot and reported postoperative donor-site morbidity outcomes. Eligible designs included case series (≥5 patients), observational studies, randomized controlled trials, and controlled clinical trials published in English. Letters, reviews, editorials, conference abstracts, and animal and cadaveric studies were excluded. Two reviewers independently screened studies, extracted data, and assessed bias.

We included 394 cases of free flap harvest (three studies on dorsalis pedis flaps and 11 on toe flaps) across 14 studies published between 2000 and 2025. The percentage of patients experiencing objective and subjective donor-site morbidity was 2.99% and 3.32% respectively. Wound dehiscence, delayed healing, and hematoma were the most common objective complications, while daily life disturbance, pain, and numbness occurred most frequently in the subjective morbidity domain.

The occurrence of donor-site morbidity is relatively low, although substantial heterogeneity limits the strength of these results. This review offers comprehensive insights into donor-site morbidity of foot free flaps, aiming to improve patient and physician awareness.

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