• Andreas E Steiert, Andreas Gohritz, Thomas C Schreiber, Christian Krettek, and Peter M Vogt.
• Department of Plastic and Reconstructive Surgery, Hannover Medical School, Hannover, Germany. steiert.andreas@mh-hannover.de
• J Plast Reconstr Aesthet Surg. 2009 May 1; 62 (5): 675-83.

BackgroundControversy remains regarding timing in the management of complex traumatic lower extremity defects. Many authors recommend a definitive bony and soft tissue reconstruction within a critical period of 72 h, yet in many patients this may be impossible due to concomitant injuries or delayed referral. However, little data are available on the results of delayed flap reconstruction of complex traumatic extremity defects, especially using new technologies of wound coverage such as vacuum-assisted closure (VAC((R))) therapy which may reduce the disadvantages of conventional open wound therapy prior to a subsequent flap reconstruction.MethodsWe retrospectively analysed the soft tissue reconstructions in 43 open extremity fractures during a 4-year period with special regard to complications, overall flap loss and wound infection.ResultsA total of 29 male and 13 female patients with 33 open fractures of the lower and 10 of the upper extremity were included. All patients had been referred from a trauma centre at a mean interval of 19 days (range 1-96 days) after the trauma event with temporary VAC((R)) of their wounds after initial fracture fixation and initial debridement of necrotic tissue. Flap reconstruction was thus only possible later than 72 h and definitive wound closure was achieved at a mean time of 28 days (range 3-106 days). Overall, three pedicled flaps were lost and one of 38 microsurgical free flaps (2.6%) underwent necrosis, the cause of which was unrelated to treatment delay.ConclusionsAccording to this study, the flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days, as reported in the literature. This strategy is in accordance with the principles of 'Damage Control Orthopaedics (DCO)' and may reduce the importance of emergency reconstructions, especially in poly-traumatised patients.

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