Timing of Dangle Protocol Initiation Following Lower Extremity Free Flap Reconstruction

Although the indications for the dangle protocol following lower extremity free flap reconstruction (LEFFR) are well established, significant heterogeneity in the postoperative day (POD) of protocol initiation is observed in clinical practice. This study aims to evaluate the outcomes associated with different initiation times of the dangle protocol following LEFFR.

A retrospective chart review included adult patients who underwent LEFFR at a level 1 trauma center from January 2016 to December 2022. Patients were grouped according to initiation of extremity dangling: early (POD 4-6) versus late (POD 7-8). The primary outcome was flap failure. Secondary outcomes were postoperative and dangle-related complications, including rate of flap take-back, partial necrosis, venous congestion, ischemia, hematoma, seroma, wound dehiscence, infection, and pulmonary embolism.

A total of 103 patients (mean age, 43.5 ± 14.5 years) were included: 46 in the early group and 57 in the late group. No significant difference in flap failure was observed between groups (4.3% vs 1.8%, P  = 0.585). The early group displayed a significant reduction in average hospital LOS (21.5 vs 25 days, P  = 0.010). The rate of flap take-back, partial necrosis, venous congestion, ischemia, hematoma, seroma, infection, and pulmonary embolism did not differ significantly between groups.

Our results suggest that early initiation of the dangle protocol may decrease hospital LOS without adversely affecting flap outcomes. Future prospective studies are needed to provide additional evidence to determine the optimal timing of dangle protocol initiation.