Is there evidence-based guidance for timing of soft tissue coverage of grade III B tibia fractures?

The treatment of soft tissue damage associated with severe complicated tibia fractures is a clinical challenge. A recent study of grade III B/C open tibia fractures treated by delayed soft tissue coverage resulted in 20% of patients having osteomyelitis, with a mean follow-up of only 10 months. This study prompted us to review the literature on the association of timing of soft tissue closure in complicated grade III B tibia fractures and the incidence of infections and bone union. A Medline literature search was performed focusing on evidence-based medicine with regard to the timing of soft tissue closure and patients developing bony union and complications such as osteomyelitis. It was difficult to analyze publications with rigor. It appears that the time of surgery has little influence on free-flap failure but that early aggressive debridement followed by soft tissue cover within 3 to 5 days reduces osteomyelitis and delayed bone union. A need for better designed studies is also indicated.