Meta-analysis of adverse outcomes following soft tissue reconstruction of complex open lower limb fractures

Complex open lower limb fractures are associated with considerable morbidity. Soft tissue reconstruction is fundamental in the management of severe injuries. This systematic review and meta-analysis was conducted to pool data on key adverse outcomes following treatment of these injuries including total flap failure, infection and amputation.

A PRISMA-compliant systematic review and meta-analysis was conducted (PROSPERO CRD420251130703) by searching the MEDLINE, Embase and Cochrane CENTRAL databases from inception to August 2025. Data were extracted in duplicate by 5 reviewers. Risk of bias was assessed using NHLBI Quality Assessment Tools. Meta-analysis of proportions evaluated primary outcomes of total flap failure, amputation, deep infection or osteomyelitis.

The search retrieved 1163 records after deduplication, yielding 188 included studies with 15,551 patients and 10,856 flap reconstructions. Road traffic accidents accounted for 55.6% of the injuries. Most (69.9%) soft tissue reconstructions were free flaps and 30.1% were local flap reconstructions. The pooled total flap failure rate was 8.0% (95% CI 6.9-9.2) across 6071 flaps. Deep infection or osteomyelitis was observed in 12.9% of reconstructed limbs (95% CI 10.6-15.6). Amputation was required in 6.3% (95% CI 5.2-7.6) of 5276 limbs. Risk of bias was low in 21.0% of the studies, moderate in 64.5% and high in 14.5%.

This meta-analysis provides summary statistics for key adverse outcomes following complex open lower limb fracture and soft tissue reconstruction. These data may inform future research in this population.