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Reconstructive: Lower Extremity: Original Articles

Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm

Lee, Z-Hye M.D.; Stranix, John T. M.D.; Rifkin, William J. B.A.; Daar, David A. M.D.; Anzai, Lavinia M.D.; Ceradini, Daniel J. M.D.; Thanik, Vishal M.D.; Saadeh, Pierre B. M.D.; Levine, Jamie P. M.D.

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Plastic and Reconstructive Surgery: September 2019 - Volume 144 - Issue 3 - p 759-767
doi: 10.1097/PRS.0000000000005955
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In 1986, Marko Godina’s landmark article “Early Microsurgical Reconstruction of Complex Trauma of the Extremities” provided evidence for the benefits of free flap coverage within 72 hours after initial injury.1 His large series of over 500 patients demonstrated lower rates of flap failure and postoperative infection in the early group compared with flaps performed after 72 hours. The tenet of early reconstruction in lower extremity trauma came to be accepted as the relative gold standard as subsequent studies provided further corroboration.

The introduction of negative-pressure wound therapy in the late 1990s transformed the management of large traumatic wounds by allowing for granulation tissue formation and reduction of tissue edema until definitive coverage was possible.2 Although the basic principles of adequate débridement and bony stabilization have remained the cornerstones for successful limb salvage after lower extremity injuries, the advent of negative-pressure wound therapy and growing microsurgical expertise have challenged the notion of early flap reconstruction. In particular, several recent studies demonstrated that flaps could be performed in the subacute period within 1 week to as late as several months after injury with comparable rates of flap success.3

Although much has changed in the three decades since Godina’s original work, there are few large series detailing outcomes after lower extremity trauma by timing. Multiple authors have more recently highlighted advances in wound management and microsurgical practices that may result in higher rates of success and more favorable outcomes.4,5 Similarly, we hypothesized that the ideal time window for free flap coverage could potentially be extended beyond the initial 72-hour window. In this study, our aim was to examine reconstructive outcomes according to the periods set forth by Godina and to provide an update to his paradigm for timing of microsurgical reconstruction.


Free tissue transfers performed at our institution are entered into a prospectively maintained registry, along with patient information, operative details, and perioperative outcomes. Between 1979 and 2016, 2898 free flaps were performed among three affiliated hospitals: a private university hospital; a Veterans Health Administration Hospital; and a large, public hospital serving as a Level I trauma center for the city. After institutional review board approval, query of the institutional registry was conducted and 806 free tissue transfers performed for lower extremity reconstruction were identified. To reduce heterogeneity among lower extremity trauma patients, only patients with trauma below the knee who underwent soft-tissue flap coverage within 1 year of injury were included in this study. Vascularized bone flaps, injuries extending above the knee, flaps performed more than 1 year after initial injury, and patients with incomplete records were excluded.

These parameters honed our cohort down to 358 soft-tissue free flaps for lower extremity trauma reconstruction that met inclusion criteria (Table 1). Data collection included patient demographics, time between injury and reconstruction, the era of reconstruction, sublocation of injury, free flap type, flap size, operative time, limb vascular status, and perioperative complications. The patient cohort was stratified by era of reconstruction to control for any “learning curve” over time that may have resulted in a selection bias. In addition, the second era of our cohort coincided with the introduction of routine use of negative-pressure wound therapy within our institution, allowing us to indirectly control for its use. Major complications were defined as events involving flap compromise and included take-backs, partial flap failures, and total flap failure. Partial flap failures were defined as those requiring an additional surgical procedure related to wound breakdown or need for flap débridement during the first 3 months after free flap coverage. Total flap failure was defined as flap compromise requiring complete débridement during the index hospitalization. Take-backs were defined as emergent return to the operating room because of suspected flap vascular compromise. Arterial injury was defined as the disruption of continuous flow on preoperative angiography and/or intraoperative identification of significant arterial trauma. In cases of synchronous or metachronous reconstruction with multiple flaps, each flap was treated as a separate entry within our data set and analyzed individually.

Table 1. - Patient Demographics and Flap Characteristics
Characteristic Early (≤3 days) (%) Delayed (4–90 days) (%) Late (>90 days) (%) p *
Total no. of patients 77 (21.5) 233 (65.1) 48 (13.4)
Time to coverage, days
 Mean 1.7 26.3 192.1
 Range 0–3 4–85 96–365
 Mean age ± SD, yr 32.1 ± 14.4 37.1 ± 15.6 37.6 ± 15.7 0.043
 Male 60 (77.9) 177 (76.0) 36 (75.0) 0.918
Timing within cohort
 First era (1976–1996) 46 (59.7) 91 (39.1) 36 (75.0) <0.001
 Second era (1997–2016) 31 (40.3) 142 (60.9) 12 (25.0)
Injury factors
 Leg injuries 57 (74.0) 145 (62.2) 33 (68.8)
 Foot injuries 20 (26.0) 88 (37.8) 15 (31.3) 0.149
 Arterial injury 34 (44.2) 83 (35.6) 23 (47.9) 0.167
 Exposed hardware 3 (3.9) 26 (11.2) 3 (6.3) 0.120
Operative and flap characteristics
 Muscle 67 (87.0) 174 (74.7) 38 (79.2) 0.075
 Fasciocutaneous 10 (13.0) 59 (25.3) 10 (20.8)
 1 vs. 2 venous anastomoses 66 (85.7) 162 (69.5) 38 (79.2) 0.013
 End-to-end vs. end-to-side arterial anastomosis 38 (52.1) 107 (49.8) 17 (39.5) 0.394
 Mean flap size, cm2 344.3 276.4 258.8 0.084
 Mean operative time, hr 8.3 8.4 8.3 0.991
*Determined using one-way analysis of variance or χ2 test.
Statistically significant.

Using the original timing groups set forth by Godina, patients were stratified based on time from injury to free flap coverage: less than or equal to 3 days (early), 4 to 90 days (delayed), and more than 90 days (late). A receiver operating characteristic curve was generated, and the Youden index was used to determine the optimal time of reconstruction for predicting flap success. Based on this, the 4- to 90-day group was further divided into two groups (4 to 9 days and 10 to 90 days); outcomes were compared using these three new cohorts: 0 to 3 days, 4 to 9 days, and 10 to 90 days.

The large sample size validated the central limit theorem for a normal distribution of our variables. Categorical variables were compared with chi-square with Fisher’s exact test, and continuous numerical variables were compared by means of a two-tailed t test or one-way analysis of variance. Logistic regression controlling for relevant variables was performed where appropriate. Statistical analysis was performed using IBM SPSS Version 23 (IBM Corp., Armonk, N.Y.). Values of p < 0.05 were considered significant.


There were a total of 358 patients that met inclusion criteria (Table 1). The breakdown of timing from injury to coverage was as follows: less than or equal to 3 days, n = 77 (21.5 percent); 4 to 90 days, n = 233 (65.1 percent); and more than 90 days, n = 48 (13.4 percent). The majority of patients were male [n = 273 (76.3 percent)]. Lower leg injuries [n = 235 (65.6 percent)] requiring flap coverage were more common than those of the foot/ankle [n = 123 (34.4 percent)]. Muscle-based free flaps predominated [n = 279 (77.9 percent)] over fasciocutaneous flaps [n = 79 (22.1 percent)], which was consistent across all periods (p = 0.075). Arterial injury was present in 140 patients, and there was no significant difference between timing groups (p = 0.167). Flaps were divided into cohort eras depending on when they were performed (1976 to 1996 versus 1997 to 2016): flap coverage within 3 days [n = 46 (59.7 percent)] and after 90 days [n = 36 (75.0 percent)] was more common in the initial era, whereas flaps performed within 4 to 90 days [n = 142 (60.9 percent)] were more commonly performed during the second era (p < 0.001).

Major complications occurred in 110 flaps (30.7 percent), with 38 partial flap losses (10.6 percent) and 31 total flap losses (8.7 percent). Unplanned return to the operating room for suspected vascular compromise occurred in 57 flaps (15.9 percent). On univariate analysis (Table 2), there was no significant difference in outcomes between timing groups, including any flap failure (p = 0.237), total flap failure (p = 0.443), partial flap failure (p = 0.112), take-backs (p = 0.786), or major complications (p = 0.138). There was no difference in salvage rate after return to the operating room between timing groups (p = 0.974). Within our entire cohort, 17 flaps (17.6 percent) required use of a vein graft for the artery, whereas six flaps (2.7 percent) required a vein graft for the vein. Failed flaps had significantly higher rates of use of a vein graft for both the artery (23.8 percent versus 5.9 percent; p = 0.003) and the vein (9.5 percent versus 2.0 percent; p = 0.042). There was no difference in the rate of use of vein grafts for either artery or vein between timing groups (p = 0.891 and p = 0.11, respectively).

Table 2. - Univariate Analysis of Flap Outcomes (Entire Cohort)
Outcome Early (≤3 days) (%) Delayed (4–90 days) (%) Late (>90 days) (%) p *
Any flap failure 19 (24.7) 44 (18.9) 6 (12.5) 0.237
Total failure 9 (11.7) 17 (7.3) 5 (10.4) 0.443
Partial failure 10 (13.0) 27 (11.6) 1 (2.1) 0.112
Operative take-backs 13 (16.9) 35 (15.0) 9 (18.8) 0.786
Salvage 4 (30.8) 12 (34.3) 3 (33.3) 0.974
Major complication 30 (39.0) 69 (29.6) 11 (22.9) 0.138
*Determined using one-way analysis of variance, χ2 test, with Fisher’s exact test (when n < 5).

Multivariate regression analysis controlling for age, timing, presence of arterial injury, and flap type demonstrated that flaps performed within 3 days compared to within 4 to 90 days demonstrated lower rates of major complications (relative risk, 0.40; p = 0.035) and a trend toward decreased partial flap failures (relative risk, 0.13; p = 0.059), as shown in Table 3. Arterial injury was significantly associated with higher total flap failure (relative risk, 2.60; p = 0.022), partial flap failure (relative risk, 2.43; p = 0.019), and take-back (relative risk, 2.00; p = 0.029). Flaps performed in the initial era compared with the later era were also associated with more major complications (relative risk, 1.71; p = 0.03) and take-backs (relative risk, 2.01; p = 0.026).

Table 3. - Multivariate Analysis of Flap Outcomes (Entire Cohort)
Any Flap Failure Total Flap Failure Partial Flap Failure Take-Back Major Complications
OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p
Age 0.99 (0.98–1.01) 0.51 0.98 (0.96–1.01) 0.25 1.00 (0.98–1.03) 0.76 1.00 (0.98–1.02) 0.98 1.00 (0.98–1.01) 0.75
Timing (first vs. second era) 1.42 (0.80–2.52) 0.24 2.25 (0.97–5.22) 0.059 1.06 (0.51–2.21) 0.94 2.01 (1.09–3.86) 0.026* 1.71 (1.05–2.78) 0.03*
Arterial Injury 2.73 (1.53–4.88) 0.001* 2.60 (1.15–5.88) 0.022* 2.43 (1.16–5.10) 0.019* 2.00 (1.08–3.72) 0.029* 0.74 (0.45–1.20) 0.22
Flap type (muscle vs. FC) 1.42 (0.69–2.96) 0.34 1.066 (0.40–2.84) 0.90 1.69 (0.61–4.65) 0.31 0.41 (0.21–0.78) 0.007* 0.65 (0.38–1.13) 0.65
≤3 days (vs. 4–90 days) 0.41 (0.14–1.19) 0.10 0.84 (0.24–2.92) 0.79 0.13 (0.02–1.08) 0.059* 0.94 (0.35–2.54) 0.90 0.40 (0.17–0.94) 0.035*
≤3 days (vs. >90 days) 0.44 (0.17–1.17) 0.10 1.02 (0.33–3.10) 0.98 0.12 (0.02–0.99) 0.049* 0.97 (0.41–2.31) 0.95 0.56 (0.26–1.21) 0.14
FC, fasciocutaneous.
*Statistically significant.

Timing from injury to flap coverage was found to demonstrate a time cutoff of 10 days after injury to be associated with decreased flap success on receiver operating characteristic curve analysis, as shown in Figure 1 (area under the receiver operating characteristic curve, 0.56). Based on this time cutoff, flaps were stratified according to new reconstructive timing groups: within 3 days from injury [n = 77 (24.8 percent)], between 4 and 9 days [n = 72 (23.2 percent)], and between 10 and 90 days [n = 161 (51.9 percent)]. Univariate analysis of flap outcomes for this cohort is shown in Table 4. Multivariate analysis using these new timing cohorts demonstrated no difference in total flap failures (p = 0.35), partial flap failures (p = 0.92), take-backs (p = 0.77), or overall complications (p = 0.08) for flaps performed within 3 days compared to those performed 4 to 9 days after injury. However, flaps performed within 4 to 9 days of injury compared to those performed within 10 to 90 days were associated with significantly lower total flap failure (relative risk, 0.29; p = 0.025) and major complication rates (relative risk, 0.37; p = 0.002) as demonstrated in Table 5. Overall, flaps performed within 10 days after injury compared to those performed 10 to 90 days after injury were associated with decreased rates of major complications (relative risk, 0.49; p = 0.007).

Table 4. - Univariate Analysis of Flap Outcomes (0–90 Days Only)
Outcome ≤3 Days (%) 4–9 Days (%) 10–90 Days (%) p *
Any flap failure 19 (24.7) 18 (25.0) 26 (16.1) 0.089
Total failure 9 (11.7) 9 (12.5) 8 (5.0) 0.048
Partial failure 10 (13.0) 9 (12.5) 18 (11.2) 0.671
Operative take-backs 13 (16.9) 11 (15.3) 24 (14.9) 0.706
Salvage 4 (30.8) 2 (18.2) 10 (41.7) 0.382
Major complication 30 (39.0) 31 (43.1) 38 (23.6) 0.006
*Determined using one-way analysis of variance, χ2 test, with Fisher’s exact test (when n < 5).

Table 5. - Multivariate Analysis of Flap Outcomes (0–90 Days Only)
Characteristic Any Flap Failure Total Flap Failure Partial Flap Failure Take-Back Major Complications
OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p
Age 0.99 (0.97–1.01) 0.31 0.98 (0.95–1.01) 0.13 1.00 (0.97–1.03) 0.97 0.99 (0.98–1.02) 0.95 0.99 (0.97–1.01) 0.33
Timing (first vs. second era) 1.32 (0.71–2.43) 0.38 2.33 (0.93–5.88) 0.072 0.86 (0.41–1.83) 0.70 2.04 (1.06–3.93) 0.033* 2.07 (1.22–3.53) 0.007*
Arterial injury 2.91 (1.51–5.60) 0.001* 1.90 (0.70–5.15) 0.21 3.11 (1.41–6.84) 0.005* 0.63 (0.33–1.22) 0.17 1.21 (0.69–2.14) 0.83
Flap type (muscle vs. FC) 0.44 (0.19–1.07) 0.07 0.55 (0.15–2.00) 0.36 0.44 (0.14–1.33) 0.15 2.49 (1.23–5.03) 0.011* 1.56 (0.84–2.94) 0.16
≤3 days (vs. 4–9 days) 0.83 (0.39–1.74) 0.62 0.58 (0.19–1.81) 0.35 1.05 (0.43–2.58) 0.92 0.89 (0.40–1.99) 0.77 0.57 (0.30–1.07) 0.081
4–9 days (vs. 10–90 days) 0.53 (0.26–1.10) 0.087 0.29 (0.10–0.86) 0.025* 0.90 (0.37–2.20) 0.82 0.78 (0.36–1.70) 0.17 0.37 (0.20–0.70) 0.002*
≤3 days (vs. 10–90 days) 0.74 (0.36–1.54) 0.42 0.52 (0.18–1.54) 0.24 0.97 (0.40–2.36) 0.95 0.87 (0.39–1.94) 0.73 0.49 (0.26–0.91) 0.024*
<10 days (vs. 10–90 days) 0.65 (0.36–1.18) 0.16 0.43 (0.17–1.07) 0.07 0.93 (0.45–1.93) 0.85 0.93 (0.45–1.93) 0.85 0.49 (0.29–0.82) 0.007*
FC, fasciocutaneous.
*Statistically significant.

Fig. 1.
Fig. 1.:
Receiver operating characteristic curve for timing of reconstruction for predicting flap success. The Youden index was calculated, and in our data set, flap coverage at postinjury day 10 was the most consistent time point at which flap success decreased and therefore was used as a cutoff.


Although Godina’s original work established some of the guiding principles for free flap reconstruction in lower extremity trauma, there were some limitations. Most notably, his analysis did not control for the learning curve that occurred over time: his first 100 cases had a flap failure rate of 26 percent, compared with only 4 percent in his last 100 cases, and the majority of his initial 100 cases were performed in a delayed fashion. Despite this confounding factor, the concept of early coverage within 3 days of injury became widely accepted as the gold standard, especially given the rationale of less scarring and fibrosis in the immediate stages after injury. Furthermore, it has been well documented that the onset of significant inflammation in the delayed period after injury can affect all tissue types of the lower extremity—from the skin and muscle, to the neurovascular structures—resulting in compromised outcomes after free flap reconstruction.

Since Godina’s original article advocating early reconstruction, several additional studies have examined the impact of timing on outcomes after free flap reconstruction of the lower extremity, with variable conclusions as to optimal timing.6 A recent meta-analysis of studies with evidence levels of IV and V by Haykal et al. confirmed Godina’s findings that lower extremity reconstruction within 3 days of injury resulted in decreased rates of free flap failures compared with those performed within 4 to 90 days.7 Initial analysis in our cohort corroborated these findings by demonstrating significantly lower rates of major complications and a trend toward lower partial flap failures for flaps performed within 3 days of injury. This would imply that if reconstruction cannot be performed within 3 days of injury, it is unsafe to do so until more than 3 months after injury. However, definitive coverage within 72 hours after lower extremity trauma is often not feasible, especially if the patient suffers life-threatening injuries requiring more urgent attention or requires transfer to a tertiary limb-salvage center.

Given these practical limitations and the arbitrary nature of Godina’s original timing groups, we sought to determine a more realistic time cutoff for definitive reconstruction without compromising flap outcomes. Our analysis using the receiver operating characteristic curve demonstrated day 10 to be the time point at which flap success decreases. After subdividing the 4- to 90-day group to 4 to 9 days versus 10 to 90 days and comparing outcomes to the less than or equal to 3-day group, we demonstrated no increase in flap failures or complications for flaps performed 4 to 9 days after reconstruction compared to the less than or equal to 3-day group. However, flaps performed 10 to 90 days after injury did demonstrate increased total flap failures and major complications compared with those performed within 3 days. These findings provide robust evidence that the safe “early” period of reconstruction can be extended to within 10 days of injury. Other studies have compared outcomes according to different periods (Table 6).1,3,8–14 A retrospective review by Francel et al. of 72 patients with Gustilo grade IIIB lower extremity fractures demonstrated fewer major complications and decreased time to bony union when performed within 15 days of injury compared to when performed 15 to 30 days and more than 30 days after injury.9 In contrast, Starnes-Roubaud et al. found no difference in flap failure, osteomyelitis, or bony union between lower extremity free flaps performed within 15 days compared to more than 15 days after injury.10 Other studies that expanded the acute period even further demonstrated no significant difference in flap complications. Kolker et al. compared reconstructions for below-knee lower extremity injuries performed within 21 days versus 22 to 60 days and more than 60 days, with no significant differences in flap complications.11 Similarly, Hill et al. demonstrated no differences for reconstructions performed within 30 days compared to those performed 31 to 90 days and more than 90 days after injury.12 Ultimately, these studies were not only underpowered, they also reflect the relative discrepancy in the literature regarding the definition of “early” reconstruction, encompassing a wide period of up to 30 days.13 Our study is the first to directly compare the timing groups in the context of the original Godina cohorts and to provide a specific and practical modification to his paradigm with the potential to impact the decision on timing of reconstruction.

Table 6. - Articles on Timing in Lower Extremity Reconstruction
Reference Study Design No. of Patients Outcomes Assessed Reconstruction Criteria Timing Windows Conclusion
Byrd et al., 19858 Prospective 191 Flap failure, amputation rate, osteomyelitis, time to bony union, length of stay, time to closure Open tibial fractures (type I–IV) Acute, 1–5 days; subacute, 1–6 wk; chronic, >6 wk Acute best for all outcomes
Godina, 19861 Retrospective 532 Flap failure, infections, time to bony union, length of stay Lower extremity trauma Early, <72 hr; delayed, 72 hr–3 mo; late, >3 mo Acute best for all outcomes
Francel et al., 19929 Retrospective 72 Flap failure, reoperations, osteomyelitis, SSI, length of stay, time to bony union Gustilo grade IIIB injuries <15 days, 15–30 days, >30 days <15-day group: fewer flap failures and reoperations, decreased LOS and time to bony union
Kolker et al., 199711 Retrospective 451 Flap failure, reoperation Below-knee injuries Acute, <22 days; subacute, 22–60 days; chronic, >60 days No difference in outcomes
Karanas et al., 20083 Retrospective 14 Flap failure, osteomyelitis Lower extremity trauma All >72 hr No flap loss in 14 patients
Hill et al., 201312 Retrospective 60 Flap failure, reoperation, SSI Lower extremity trauma <30 days; 31–90 days; >91 days No significant difference in outcomes; trend toward lower rates of failure among >91-day group
Raju et al., 201414 Retrospective 50 Flap failure, reoperation, infection Lower extremity trauma (all received débridement, fracture stabilization, NPWT before flap) 1, 2, 3, 4, 5, 6, and 7 wk
No difference in outcomes
Bellidenty et al., 201413 Retrospective 89 Flap failure, osteomyelitis Lower extremity trauma (emergency Gustilo grade IIIB injuries vs. delayed cases referred to center for coverage) Emergency; delayed Lower failure and infection rates in “emergency” group, increased in delayed group
Starnes-Roubaud et al., 201510 Retrospective 51 Flap failure, osteomyelitis, bony union, ambulation Lower extremity trauma <15 days, >15 days No difference in outcomes
SSI, surgical-site infection; LOS, length of stay; NPWT, negative-pressure wound therapy.

Similar to Godina’s landmark study, our free flap outcomes demonstrated a learning curve, with significantly higher rates of major complication for those performed within the first two decades compared with those performed in the latter two decades, and thus our multivariate analysis was designed to control for this potentially confounding variable. In addition, these two eras of reconstruction also roughly coincided with the introduction of negative-pressure wound therapy at our institution in 1997. Several studies have highlighted the potentially beneficial role of negative-pressure wound therapy in improving the safety of delayed reconstruction.14–17 Given the well-delineated benefits of negative-pressure wound therapy on wound management, we can potentially refer its use in our cohort as a contributing factor for prolonging the initial safe period of reconstruction from 3 days to 10 days.18–20 However, unfortunately, the use of negative-pressure wound therapy on perioperative flap outcomes was unable to be directly examined in our study because of inconsistent documentation of its use; instead, we were forced to use era of reconstruction as a proxy to control for its possible confounding nature. Although it is possible that negative-pressure wound therapy can temporize lower extremity wounds and allow for reliable flap coverage after the 10-day window, we provide definitive evidence for this time cutoff irrespective of negative-pressure wound therapy use.

There may be several benefits to extending this acute period from 3 days to 10 days. In managing any traumatic wound, adequate débridement to a clean, healthy wound bed is essential before reconstruction.21,22 Thus, with an extra week, reconstructive surgeons can afford to stage reconstruction and perform serial débridement before flap coverage, if necessary, particularly in the setting of a highly contaminated wound. One consideration when critically evaluating our results is that there may be some element of selection bias within our cohort, with more severe injuries (i.e., those with higher degrees of contamination) being repaired in the delayed fashion to allow for adequate preoperative débridement. In addition, although vascular intervention at the time of lower extremity free flap transfer has been shown to be safely performed in the peripheral vascular disease and diabetic population, there are few data regarding timing in the trauma population (i.e., in patients with Gustilo grade IIIC fracture).23 Given the risks of significant tissue edema and reperfusion injury after revascularization, delaying free flap reconstruction beyond the 72-hour window is likely safest and preferred in this group.24

As such, in a multiteam approach to treatment of traumatic lower extremity injuries, lengthening the time before safe soft-tissue coverage can facilitate a comprehensive treatment plan and ensure the availability of all team members with individual expertise (e.g., microsurgical, orthopedic, vascular). Nonetheless, increased costs attributable to extended hospital stay must be balanced with timing of safe coverage, although patients can be discharged with negative-pressure wound therapy and readmitted for definitive reconstruction if necessary.

Because of the retrospective nature of this study, there are inherent limitations. In particular, our data were limited to the perioperative period and free flap outcomes during the index hospitalization. Unfortunately, documentation related to long-term outcomes was not consistently available, and we were unable to determine the incidence of postoperative infection, bony union, and limb loss. In addition, the clinical factors resulting in the observed time-to-coverage period for each patient were not reliably discernible and preclude further insight into the reconstructive timing decision. Additional factors such as the presence of infection at the time of reconstruction were also not available, and the impact of these variables on reconstructive outcomes would likely prove helpful in guiding surgical decision-making moving forward.


Based on Marko Godina’s original work, microsurgical reconstruction within 3 days of lower extremity trauma has long been advocated as the gold standard. Our results build on his findings and provide evidence that the safe period of early soft-tissue coverage can be extended to within 10 days of injury. Given that immediate free flap coverage may not be feasible in every clinical scenario, this extended cutoff provides a more realistic period to undertake reconstruction.


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3. Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008;28:632–634.
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18. Hou Z, Irgit K, Strohecker KA, et al. Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture. J Trauma 2011;71:1705–1708.
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