Functional and clinical outcomes of propeller flaps in lower extremity reconstruction: A systematic review

Soft-tissue reconstruction of the distal leg, ankle, and foot remains challenging due to limited local tissue and compromised vascularity. Propeller perforator flaps have emerged over the past 2 decades as an alternative to free flaps, offering preservation of major vascular axes and reduced donor-site morbidity. However, clinical outcomes remain heterogeneous, and the reliability and functional benefits of PPFs are still debated.

A PRISMA-2020-compliant systematic review (PROSPERO: CRD420251148124) was conducted through August 2025 across PubMed, MEDLINE, Embase, Ovid, and Web of Science. Eligible studies included observational designs, case series, and case reports on PPFs for lower-extremity reconstruction. Primary outcomes included flap survival, necrosis, venous congestion, infection, reoperation, functional recovery, and quality of life. The risk of bias was assessed using the Joanna Briggs Institute tools and the Newcastle-Ottawa Scale.

Fifty-one studies (n = 1474 patients) met the inclusion. Trauma was the leading etiology (88%), with reconstructions most often involving the ankle/malleolar and heel regions. Posterior tibial and peroneal artery perforators were used in 74% of cases. Complete flap survival was reported in 47% of studies; partial necrosis in 28%, and total flap loss in 10%. Venous congestion was common but often self-limiting. Functional outcomes were inconsistently reported and generally favorable in fewer than half of the studies. Methodological quality was moderate to good in most reports.

Propeller perforator flaps are a feasible reconstructive option for lower limb defects, although outcomes remain variable. Further prospective, comparative studies are needed to establish their long-term reliability and functional impact.