Early Flap Coverage Improves Outcomes in Open Lower-Limb Fractures: study

Open tibial fractures remain the most prevalent open fracture, necessitating orthoplastic management with flap reconstruction. Early soft tissue coverage, ideally within 72 hours, is widely regarded as the gold standard for reducing infection, promoting bone healing, and improving limb salvage. However, injury severity, patient comorbidities, and pre-theater coordination pose challenges to the recommended management window, thereby increasing the number of patient-reported complications.

A systematic review and meta-analysis were conducted by Sina Dehnadi et al in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search of six databases identified comparative studies evaluating flap reconstruction performed within 72 hours versus beyond 72 hours following injury. The primary outcome addressed operative complications. Risk of bias was assessed using ROBINS-I (Cochrane Collaboration, London, UK) and RoB2 (Cochrane Collaboration, London, UK), while evidence quality and methodology review were evaluated using GRADE and AMSTAR-2. The article has been published in ‘Cureus’ journal.

The key findings of the study were:

• From 2010 to 2025, 14 articles met the inclusion criteria among 21 potentially eligible studies, comprising 2652 patients (1859 males and 793 females).

• 10 were conducted retrospectively and 4 prospectively, with varying levels of evidence: II (n = 3), III (n = 7), and IV (n = 4).

• Early reconstruction within 72 hours was associated with fewer complications compared with delayed reconstruction.

• Meta-analysis demonstrated lower risks of infection, osteomyelitis, and amputation (risk ratios of 0.69, 0.28, and 0.55; confidence intervals of 0.47-1.02, 0.16- 0.49, and 0.27-1.12, respectively), with a statistically significant reduction in osteomyelitis.

• Prior reviews had critical methodological flaws, whereas this study achieved a high confidence rating.

The authors concluded - “The findings within this study reinforce prior reviews and guidelines, encouraging early flap coverage (within 72 hours) due to its association with fewer complications. However, due to heterogeneity and the predominance of retrospective studies, the overall quality remains limited. Additionally, evidence indicates that timing alone does not dictate outcome, and patient-specific factors can influence the results. These findings collectively provide modern evidence to support refining existing orthoplastic guidelines toward a more evidence-based approach to flap timing in lower-limb reconstruction.”

For further details on the article refer to:

Dehnadi S, Pérez R, Zien Yu M, et al. (April 19, 2026) Timing of Flap Coverage in Open Fractures: A Systematic Review and Meta-Analysis.

Cureus 18(4): e107338. DOI 10.7759/cureus.107338