Timing of Flap Coverage in Open Fractures: A Systematic Review and Meta-Analysis

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 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and were prospectively registered with PROSPERO (CRD420251033412). 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. From 2010 to 2025, 14 articles met the inclusion criteria among 21 potentially eligible studies, comprising 2652 patients (1859 males and 793 females). 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. Flap coverage within 72 hours is associated with improved clinical outcomes and should be prioritized whenever feasible for patients with open fractures of their lower limbs. Despite guideline recommendations, the majority of flap reconstructions are still performed more than 72 hours after injury. This highlights the need for improved multidisciplinary coordination and timely access to specialist orthoplastic care.