Timing for Free-Flap Reconstruction for Gustilo Type III Lower Limb Fractures: Systematic Review and Meta-analysis

Despite improvements in surgical techniques, the optimal timing for free-flap reconstruction in Gustilo type III lower limb fractures remains controversial. Although existing interventions have shown positive outcomes, comprehensive data assessing the effect of timing on flap failure and infection rates are still limited. This systematic review and meta-analysis evaluated the impact of timing on the success of free-flap reconstructions in patients with Gustilo type III lower limb fractures. The included studies categorized reconstruction timing into 4 groups: immediate (within 72 h), early (72 h to 1 wk), delayed (1 wk to 42 d), and late (beyond 42 d). Outcomes of interest were infection and flap failure rates. A proportional meta-analysis was conducted to synthesize these outcomes, and meta-regression was used to detect significant differences across timing groups. A total of 26 studies involving 451 flap reconstructions were analyzed. No statistically significant differences were found in infection rates among the timing groups (P = 0.3331). Similarly, timing did not significantly influence flap failure rates (P = 0.0772). However, within the delayed reconstruction group, patients who received negative pressure wound therapy (NPWT) had a significantly lower flap failure rate (3%, 95% confidence interval: 1%-15%) compared with those who did not receive NPWT (13%, 95% confidence interval: 7%-23%; P = 0.0324). In conclusion, free-flap reconstructions for Gustilo type III fractures are safe and effective regardless of timing, with no significant differences in infection or failure rates. The findings also highlight the benefits of NPWT in delayed reconstructions, supporting its use to improve surgical outcomes.