title: A systematic review of early versus delayed wound closure in patients with open fractures requiring flap coverage.
abstract: BACKGROUND
  Wound management in open fractures remains an area of controversy. Although numerous protocols for soft tissue coverage and fracture fixation have been proposed, problems with infection, delayed healing, and prolonged disability have remained. The purpose of this systematic review was to critically examine the timing of flap coverage in open fractures and its impact on bone union, infections, complication rates, and duration of hospital stay.
  
  
  METHODS
  We comprehensively searched the literature for relevant studies across CINAHL, EMBASE, MEDLINE, and the Cochrane databases. The Orthopaedic Trauma Association and Canadian Orthopedic Association proceedings were also searched. Two independent reviewers screened and assessed abstracts. Articles were selected using specific inclusion criteria and were categorized as "early," "intermediate," or "late" based on their timing of flap coverage. Methodological quality of included studies was assessed using the Newcastle-Ottawa Scale for Cohort Studies.
  
  
  RESULTS
  Of 83 potentially eligible studies, 20 articles were included in the final analysis (agreement kappa = 0.83). Of these, eight studies evaluated "early" flap coverage, nine studies evaluated "intermediate" flap coverage, and nine studies evaluated "late" flap coverage. Early flap coverage was associated with lower infection rates (p < 0.0001) and lower complications (p = 0.15).
  
  
  CONCLUSIONS
  The results of this systematic review (level III evidence) suggest that any delay in flap coverage may provide suboptimal bone healing, infection, and complication rates. It is recommended that methodologically sound randomized controlled trials be performed comparing "early" flap coverage time points to determine optimal outcomes for bone union, infection, and hospital stay as none exist to date.
authors.affiliation: Division of Orthopedic Surgery, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Thomas
authors.initials: T
authors.lastname: Wood
authors.forename: Mojib
authors.initials: M
authors.lastname: Sameem
authors.forename: Ronen
authors.initials: R
authors.lastname: Avram
authors.forename: Mohit
authors.initials: M
authors.lastname: Bhandari
authors.forename: Bradley
authors.initials: B
authors.lastname: Petrisor
mesh_terms: D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods; D017102:Fracture Healing; D005597:Fractures, Open / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D013524:Surgical Flaps; D013530:Surgical Wound Infection / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome