Breathing Room Between ORIF and Flap Coverage for IIIB Open Tibia Fractures Is About 48 Hours

No increase in deep infection risk if flap coverage is delayed up to 2 days after definitive fixation of open tibial fractures

What’s the Claim?

Among patients with open tibial fractures whose soft tissue loss was severe enough to warrant flap coverage, there was no increase in the risk of deep infection when that flap was applied within two days of fixation, compared to patients who had soft tissue coverage performed at the time of fracture fixation. However, when flap coverage was delayed more than two days or more than five days, the risk of infection increased noticeably (relative risk 1.55 and 1.64, respectively). The authors propose a “safe” window of up to two days between definitive fracture fixation and flap coverage in patients with Gustilo-Anderson IIIB open tibial fractures.

How’s It Stack Up?

In the past, time to initial debridement of the open fracture had been the parameter most surgeons focused on, but more recently that has changed to time from definitive fixation to flap coverage, and the pressure has been mounting on surgeons to get soft tissue coverage done at the time of ORIF (the "fix and flap" approach). But as you'd imagine, it's difficult to control for many of the variables that matter to studies like these, like timing of antibiotic delivery, interaction between antibiotic timing and debridement timing, age, sex, injury severity score, and fixation approach. In addition, specific analytic approaches need to be performed — as well as getting enough patients into the study — if one wants to make a convincing case for a “safe” window. This study of nearly 400 patients (21% of whom developed infections) managed to pull all of these things off as well as is likely to be done for patients with this diagnosis.

What’s Our Take?

This study is important and helpful to call-taking surgeons. Not all of us have a plastic surgeon on-demand, and it provides peace of mind (as well as some medicolegal cover) to know that if it takes a day or two — but not more — to get the wound covered, we’re not increasing the risk of a devastating deep infection. Amazingly, this study had almost no loss to follow-up, it was a 15-center project, and patients whose coverage was delayed likely were “tougher cases” in ways that went unmeasured (which makes the findings even stronger); the analytical approach was robust as well, so we can be confident in these findings. It is worth remembering, though, that there’s no switch that flips at 48 hours in biologic systems, so don’t dawdle— find coverage for these wounds as soon as you reasonably can.


Al-Hourani K, Foote CJ, Duckworth AD, et al. What Is the Safe Window From Definitive Fixation to Flap Coverage in Type 3B Open Tibia Fractures? Supporting Plastics and Orthopaedics Alliance in Reducing Trauma Adverse Events (SPARTA). J Orthop Trauma. 2023;37:103-108.