Clinical Outcomes and Flap Survival of Freestyle Perforator Flaps for Lower-Limb Traumatic Reconstruction: A Systematic Review and Mapping of the Available Evidence

Freestyle perforator flaps—propeller and perforator-based V-Y advancement flaps raised on an intraoperatively or radiologically identified perforator—are increasingly used for post-traumatic lower-limb reconstruction, but their consolidated outcome profile is unmapped. Following PRISMA 2020 and prospective PROSPERO registration CRD420261422030, Data Search was conducted in PubMed, the Cochrane Library, Embase, Web of Science, MEDLINE, and Scopus abasesusing a predefined PICOS framework. Human studies (≥5 patients) of freestyle/pedicled perforator flaps for traumatic lower-limb defects reporting flap survival or complications were eligible; synthesis was narrative. Of 1,000 records, 40 underwent full-text review and 7 were included. None studied freestyle perforator flaps in lower-limb trauma directly; all were secondary syntheses of adjacent techniques. Reported survival/success ranged from 78.8% (reverse sural flap) to 98% with 0% total loss (Color-Doppler-guided pedicled perforator flaps); free flaps achieved 92–94% versus 86–90% for local flaps. Overall complications were 14.8–21.2%; venous congestion predominated, and coverage within 72 hours reduced osteomyelitis (RR 0.28, 95% CI 0.16–0.49). This systematic review provides the first consolidated map of perforator-based flap survival relevant to traumatic lower-limb reconstruction and delivers clinically actionable findings. Across the closest available evidence, perforator-based and comparator flaps achieved consistently high survival—up to 98% reconstructive success with 0% total flap loss for preoperatively mapped (Color-Doppler-guided)