Mohamed EHH, Ahmad S. Early orthoplastic soft-tissue coverage in open tibial fractures reduces infection, nonunion, and amputation. World J Meta-Anal 2026; 14(1): 116322 [DOI: 10.13105/wjma.v14.i1.116322]
Corresponding Author of This Article
Shabbir Ahmad, Academic Fellow, Department of General Surgery, Nangarhar University, Kabul-Jalalabad Highway, Daronta (Darunta), Jalalabad 260101, Nangarhār, Afghanistan. shabbirahmadnoir@gmail.com
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Orthopedics
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Systematic Reviews
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Mar 18, 2026 (publication date) through Mar 10, 2026
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Publication Name
World Journal of Meta-Analysis
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2308-3840
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Mohamed EHH, Ahmad S. Early orthoplastic soft-tissue coverage in open tibial fractures reduces infection, nonunion, and amputation. World J Meta-Anal 2026; 14(1): 116322 [DOI: 10.13105/wjma.v14.i1.116322]
World J Meta-Anal. Mar 18, 2026; 14(1): 116322 Published online Mar 18, 2026. doi: 10.13105/wjma.v14.i1.116322
Early orthoplastic soft-tissue coverage in open tibial fractures reduces infection, nonunion, and amputation
Ebrahem Hesham Hashem Mohamed, Shabbir Ahmad
Ebrahem Hesham Hashem Mohamed, Department of General Surgery, James Paget University Hospital NHS Foundation Trust, Great Yarmouth NR31 6LA, Norfolk, United Kingdom
Shabbir Ahmad, Department of General Surgery, Nangarhar University, Jalalabad 260101, Nangarhār, Afghanistan
Author contributions: Mohamed EHH and Ahmad S made substantial and equal contributions to this work in accordance with the International Committee of Medical Journal Editors guidelines. Both authors contributed to the conception and design of the study, literature search, data extraction, analysis, and interpretation of data. They jointly drafted the manuscript, critically revised it for important intellectual content, and approved the final version to be published. Both authors agree to be accountable for all aspects of the work, ensuring the accuracy and integrity of any part of the study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Shabbir Ahmad, Academic Fellow, Department of General Surgery, Nangarhar University, Kabul-Jalalabad Highway, Daronta (Darunta), Jalalabad 260101, Nangarhār, Afghanistan. shabbirahmadnoir@gmail.com
Received: November 11, 2025 Revised: December 4, 2025 Accepted: December 23, 2025 Published online: March 18, 2026 Processing time: 122 Days and 17.6 Hours
Abstract
BACKGROUND
Open tibial fractures with extensive soft-tissue loss represent one of the most challenging orthopedic emergencies. Delays in definitive soft-tissue coverage significantly increase the risk of deep infection, nonunion, and amputation. Although early coverage has been advocated, the precise timing for optimal outcomes remains debated. This systematic review evaluates current evidence comparing early and delayed flap coverage in Gustilo-Anderson type IIIB and IIIC open tibial fractures. We hypothesized that early orthoplastic intervention within the first week of injury would lead to lower infection and complication rates, while improving union and limb salvage outcomes.
AIM
To determine the impact of early vs delayed soft-tissue coverage on infection, union, flap survival, and limb salvage.
METHODS
A systematic review was performed using PubMed, Scopus, Web of Science, and Google Scholar for studies published from January 2000 to October 2025. Eligible studies included adults (≥ 18 years) with Gustilo-Anderson type IIIB or IIIC open tibial fractures comparing early (≤ 72 hours or ≤ 7-12 days) and delayed flap coverage. Outcomes analyzed were infection, nonunion, flap failure, and amputation. Study quality was assessed using the Newcastle-Ottawa Scale and the Risk of Bias in Non-Randomized Studies of Interventions risk-of-bias tool.
RESULTS
Nine retrospective cohort studies comprising 900 patients were included. Early flap coverage significantly reduced deep infection rates (0%-23% vs up to 72%) and lowered reoperation frequency compared with delayed coverage. Union and limb salvage rates exceeded 90% in early coverage groups, with no increase in flap failure risk. Studies consistently highlighted improved outcomes when early coverage was performed by coordinated orthoplastic teams within specialized trauma centers. The overall methodological quality ranged from moderate to low risk of bias, supporting the clinical value of timely, multidisciplinary management.
CONCLUSION
Early orthoplastic soft-tissue coverage within the first week after fixation reduces infection and nonunion, improves limb salvage, and represents best practice for severe open tibial fractures.
Core Tip: Early orthoplastic management of open tibial fractures remains crucial for reducing complications and preserving limb function. This systematic review synthesizes current evidence comparing early vs delayed soft-tissue coverage in Gustilo-Anderson type IIIB and IIIC fractures. Early flap coverage, ideally within the first week after fixation, markedly decreases deep infection and nonunion rates, improves union and limb salvage, and does not increase flap failure risk. The findings reinforce the importance of coordinated orthoplastic collaboration and timely multidisciplinary care in achieving optimal outcomes for complex lower-limb trauma.
