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So, we performed a systematic review with meta\u2010analysis comparing free flaps (perforator\u2010based or not) and pedicled\u2010propeller flaps to respond to the question \u201cwhat is the safest coverage for distal third of the lower limb?\u201d<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE\u00ae, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta\u2010analysis. The homogeneity Q statistic and the <jats:italic>I<\/jats:italic><jats:sup>2<\/jats:sup> index were computed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled\u2010propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6\u20135.3] for free flaps and 2.77% [95%CI:0.0\u20135.6] for pedicled\u2010propeller flaps (<jats:italic>P<\/jats:italic>\u2009=\u20090.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled\u2010propeller flaps (<jats:italic>P<\/jats:italic>\u2009=\u20090.37). In more detail, we noted for free flaps versus pedicled\u2010propeller flaps: partial necrosis (2.70 vs. 6.88%, <jats:italic>P<\/jats:italic>\u2009=\u20090.001%), wound dehiscence (2.38 vs. 0.26%, <jats:italic>P<\/jats:italic>\u2009=\u20090.018), infection (4.45 vs. 1.22%, <jats:italic>P<\/jats:italic>\u2009=\u20090.009). The coverage failure rate was 5.24% [95%CI:3.68\u20136.81] versus 2.99% [95%CI:0.38\u20135.60] without significant difference (<jats:italic>P<\/jats:italic>\u2009=\u20090.016).<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta\u2010analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled\u2010propeller flaps than free flaps, in reality the success of coverage appears similar. \u00a9 2016 Wiley Periodicals, Inc. 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