QUESTION 2 : What is the appropriate timing for fl ap coverage of open fractures and traumatic wound defects ?

The timing of soft tissue coverage has long been recognized as one of the most critical determinants of the length of in-hospital stay, most of the early postoperative complications and ultimate outcomes [1]. Early coverage has been associated with higher union rates, and lower complication and infection rates compared to those reconstructed after 5-7 days [2–5]. Furthermore, early reconstruction improves fl ap survival, as microsurgical free fl ap integration becomes more challenging with a delay due to an increased prothrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated ortho-plastic trauma service are likely to receive defi nitive treatment of a severe open tibia fracture with tissue loss within the established parameters of good practice [6]. “Fix and fl ap” has sometimes been recommended for specialist hospitals where the expertise is available. Antibiotic bead pouches to decrease infection rates have long been advocated when there is segmental tissue loss, gross contamination or established infection as pre-fl ap tissue infection seems to be an independent predictor of adverse fl ap and skeletal reconstruction outcomes [7,8]. Level IV series of free tissue transfer to address open traumatic wounds with accompanying fractures have been published since the fi rst free tissue transfer for soft tissue coverage by Buncke in 1970 [9]. In 1986, Godina advocated early soft tissue coverage on a review of 532 patients based on an increased rate of fl ap failure in those wounds open > 72 hours [10]. However, during that time period, infection management and particularly the care and treatment of osteomyelitis were poorly understood, and dogma existed that simply the placement of a free tissue transfer over infection in the form of infected hardware or osteomyelitis was enough to treat and cure the infection. It took a great deal of time to break this dogma. Various series advocate the need for early soft tissue coverage in these cases, due to exposed soft tissue as well as the results of higher fl ap failure and often accompanying late infection rate [11-13]. These studies are found to be fl awed in multiple respects, which include the lack of expertise and knowledge in the diagnosis and treatment of existing infection [12], low volume with resultant lack of expertise [11,13] and the inaccurate conclusion that time of fl ap placement could in any way aff ect the probability of successful bony union. Many good studies have appeared confi rming what the experienced non-union surgeon and microsurgeon know: that fl ap survival depends upon a decolonized and “living wound. ” Harrison et al. performed a thorough literature review of articles published from 1995–2011, and performed meta-analysis of 15 articles meeting inclusion criteria. They reported no diff erence in outcome between when free tissue transfer was performed and survival of the fl ap or eventual outcome [14]. Theodorakopoulou et al. reported a systematic review of 11 studies of war-related high energy extremity injuries treated with free tissue transfer in the subacute period (9 days to 3 years post-injury). There was no direct association to time of fl ap placement with a 95.5% free fl ap success rate in this particularly complex patient population [15]. Since 2000, numerous independent case series by experienced microsurgeons have also shown no diff erence in outcome in regard to timing of free fl ap placement [16-20]. These represent wellexecuted tissue transfers except for one series with a higher overall but uniform fl ap failure rate [19]. The consistent fi nding was that timing of free tissue transfer was not a direct cause of failure of fl ap survival. The original work of Godina seems now to be outdated and not applicable to current surgical practice as it relates to timing of free tissue transfer of traumatic wounds.