Title : Effect of timing on outcomes of free flap reconstruction following traumatic injury to the extremity: A systematic review
Abstract:
Background: Immediate free flap reconstruction within 72 hours has traditionally been recommended for traumatic extremity defects; however, modern wound management and microsurgical advances have challenged whether this timing threshold should remain absolute. The optimal timing of reconstruction, particularly beyond the initial 72-hour window, remains unclear.
Purpose: To evaluate the relationship between timing of free flap reconstruction after traumatic extremity injury and postoperative outcomes, and to determine whether specific intervals beyond the initial 72-hour window are associated with worse outcomes.
Study Design/Level of Evidence: Systematic review; Level IV evidence.
Methods: A systematic literature search was conducted using the following databases from their inception to December 2023: PubMed, OVID Databases, Web of Science, and Scopus. Of the 805 identified articles, 100 full-length articles were assessed, and 27 articles (1,757 flaps) were included. Rates of flap failure, bone nonunion, reoperation, and complications were compared across time frames using two classification systems for time to surgery: 1) ≤72 hours or >72 hours; 2) 72 hours to ≤7 days, >7 days to ≤30 days, or >30 days.
Results and Conclusion: The flap failure rate for the first classification system was 3.7% for ≤72 hours and 8.9% for >72 hours (P = <0.001). Of note, the infection rate was higher at 8.2% vs. 6.7% (P= 0.305), and the complication rate was lower at 15.5% vs. 20.8% (RR=0.743; P=0.015) for ≤72 hours compared to >72 hours. The flap failure rate was 5.2% for 72 hours to ≤7 days, 6.0% for >7 to ≤30 days, and 8.8% for >30 days (P= 0.250) for the second classification system. This review suggests that immediate reconstruction within 72 hours continues to be most effective. However, our findings suggest that the window of time beyond 72 hours is more nuanced, and that flap failure should not be viewed as directly proportional to time beyond the initial 72 hours.
