1. Early definitive soft tissue cover is associated with better outcomes, including reduced deep infection rates.
2. Definitive soft tissue cover should be performed either at the same time as wound excision or within 72 hours of injury.
3. Free flap reconstruction is best performed on scheduled lists by experienced, dedicated senior surgical teams following adequate preparation of the patient. This must include optimum physiology and planning. CT scanning with an angiogram may help with planning of osteo-synthese as well as the free flap. This should be undertaken in a specialist centre offering the full spectrum of orthoplastic services.
4. If internal fixation is used, definitive soft tissue cover should be performed at the same time.
Soft tissue cover of a meticulously and comprehensively excised (debrided) wound is the cornerstone of achieving infection-free fracture union (1, 2, 3). Before the significance of the soft tissue structures surrounding the fractured bone was recognised, reconstruction of the soft tissue defect was consigned to the ‘delayed’ phase (4). Early ‘open wound’ management methods were associated with extremely high rates of complications, for example, 40% develop osteomyelitis and 30% non-union (5). Early soft tissue cover may reduce the risk of bacterial contamination and biofilm development. The role of early coverage of open tibial fractures using muscle flaps to prevent deep infection was recognised as early as 1977 (6) and this paradigm was developed subsequently using free flaps (7).
Current National Institute for Health and Care Excellence (NICE) Guidelines advocate definitive coverage within 72 hours if this cannot be performed at the time of primary wound excision (8). Provided comprehensive wound excision has been achieved, early definitive soft tissue coverage of open fractures is associated with reduced free flap failure and deep infection rates. Moreover, delay leads to tissue oedema, peri-vascular fibrosis, and an increased risk of venous thrombosis, making the surgery more challenging technically.
A number of studies have investigated the effect of timing of soft tissue coverage. Whilst the definition of early and delayed wound closure varied between studies, the literature suggests that the best outcomes are achieved when the wounds are covered at the earliest opportunity.
Various historic studies found that lengthy delays were associated with dramatically poorer outcomes. A retrospective series of over 500 cases demonstrated that free tissue transfer performed within 3 days, rather than 3 days to 3 months of injury, was associated with improved flap survival (0.75 vs 12%) and reduced infection rates (1.5 vs 17.5%) (7). A review of muscle flaps in grade IIIB open tibial fractures found that patients with flap cover within 10 days spent less time in hospital and had a deep infection rate of 18% compared with 69% in the delayed groups combined (9).
A group reviewing their outcome of 83 flap reconstructions in 64 patients found that the rate of deep infection associated with metal implants was significantly lower in the early coverage group (<5 days) compared with the delayed group, as were the rates of free flap failure and local flap partial necrosis (10). Another study of 105 patients who underwent free muscle flap reconstruction for open tibial fractures found that flaps performed between 1 and 7 days post-injury were associated with a lower overall complication rate of 31% compared with 39% in the >42 days group and 47% in the 8–42 days group, whilst the time to fracture union was 2.4 compared with 6.5 versus 6.2 months, respectively (11). Early coverage with fasciocutaneous flaps has also been found to be beneficial. In a study of 38 patients with Gustilo–Anderson IIIB fractures in whom fasciocutaneous flaps was the predominant reconstructive option, the infection rate was found to be significantly lower in patients who had coverage within 7 days of injury (12.5%) compared with coverage at 7 or more days (53%); furthermore, there was no evidence of a relationship between flap type and infection rate (12) Similar improved outcomes for patients undergoing definitive soft tissue reconstruction within 1 week have been reported by other groups (13, 14, 15, 16, 17).
Further studies that attempted to assess the risk of delay suggest that wounds should be covered at the earliest opportunity. Using multivariate analysis, a study of 69 tibial fractures found that the odds of flap-related complications and infection increased by 11% and 16%, respectively, for each day after 7 days post-injury (18). A retrospective study of 137 type III fractures also used multivariate analysis and found that a delay of more than 5 days to wound coverage was an independent predictor of infection, with an odds ratio of 7.39 (19).
The effect of even shorter delays was reported in a review of 105 consecutive free flap reconstructions for severe open lower limb trauma in 103 patients (20). The outcomes of patients reconstructed within 3 days of injury were compared with those beyond 7 days. The latter group had significantly increased rates of wound infection prior to free flap reconstruction, flap re-operation, deep metal infection (4.2 vs 28.6%, p < 0.05) and osteomyelitis (4.2 vs 21.4%, p < 0.05). In cases of exposed metalwork, free flap transfer beyond 1 day significantly increased the flap failure rate (0 vs 50%) and was associated with a greater overall number of surgical procedures as well as a longer hospital stay.
Immediate versus staged reconstruction
The concept of the ‘fix and flap’ approach where skeletal fixation and soft tissue reconstruction are undertaken in a single stage was introduced with the aim of achieving earlier fracture union and minimising flap failure and deep infection rates (21). A retrospective review of patients with grade IIIB or IIIC fractures compared the effect of timing of reconstruction on deep infection rates (22). In the first group, primary closure was achieved in a single ‘fix and flap’ procedure, comprising wound excision and skeletal stabilisation with a muscle flap. The second and third groups underwent immediate wound excision and internal fixation but soft tissue cover was achieved between 48 and 72 hours, and over 72 hours, respectively. The times to fracture union (28.8, 35.3, and 43.1 weeks, respectively) were shorter in the ‘fix and flap’ group. Another group reviewed grade III fractures in 73 consecutive patients and compared those who underwent definitive fixation and immediate coverage against patients who had staged operations. The deep infection rate in the immediate group was only 4.2% compared with 34.6% in the staged group (23). Similarly, a retrospective study of 89 Gustilo–Anderson IIIB fractures found that delayed soft tissue reconstruction was associated with osteomyelitis in 60% and flap failure in 23% compared with 4% for both in the immediate group (24). A prospective cohort study of 29 consecutive patients with IIIB or IIIC fractures compared immediate with delayed reconstruction (after a mean delay of 4.4 days) with a mean follow up of 47 months. In the delayed group, time to full unprotected weight bearing (9.6 months vs 5 months), time to definitive union (11.6 months vs 5.6 months), the number of operations (3.9 vs 1.6), and the deep infection rate (4/15 vs 0/14) were all significantly higher (25).
It is not possible to be prescriptive as to the exact number of days post-injury that soft tissue cover should be achieved as it depends on the individual circumstances of the injury and patient. For example, in the polytrauma setting, life must come before limb. Whilst immediate soft tissue reconstruction, as implied by the ‘fix and flap’ protocol, may seem to be the ideal, complex surgery, especially those requiring microsurgical free tissue transfer, should be undertaken only once the patient has been stabilised, adequately prepared, and investigated, and should be performed under elective conditions by dedicated senior surgeons working within experienced orthoplastic teams in specialist centres. This is balanced by the increasing risk of deep infection and technical difficulties encountered as the perivascular soft tissues become more oedematous, friable, and eventually fibrotic. Therefore, soft tissue reconstruction should be performed at the earliest safe opportunity to maximise the chances of long-term success. The current NICE guidance (8), based on the available evidence, recommends that if definitive reconstruction is not performed at the time of wound excision, it should be achieved within 72 hours of injury unless patient factors dictate otherwise. Internal fixation should only be performed if definitive soft tissue reconstruction is achieved at the same time.
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