PURPOSE: Treatment of open fractures is complex and controversial. The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned whether early flap coverage improved the clinical outcome and whether we could improve our antibiotic treatment of open fractures.

METHODS: From 2002 to 2013 we treated 56 patients with an open tibial fracture covered with a free flap. We reviewed patient records and databases for type of trauma, smoking, time to tissue cover, infection, amputations, flap loss and union of fracture. We identified factors that increase the risk of complications. We analysed the organisms cultured from open fractures to propose the optimal antibiotic prophylaxis. Follow-up was a minimum of one year. Primary outcome was infection, bacterial sensitivity pattern, amputation, flap failure and union of the fracture.

RESULTS: When soft tissue cover was delayed beyond seven days, infection rate increased from 27 to 60 % (p < 0.04). High-energy trauma patients had a higher risk of amputation, infection, flap failure and non-union. Smokers had a higher risk of non-union and flap failure. The bacteria found were often resistant to Cefuroxime, aminoglycosides or amoxicillin, but sensitive to vancomycin or meropenem.

CONCLUSION: Flap cover within one week is essential to avoid infection. High-energy trauma and smoking are important predictors of complications. We suggest antibiotic prophylaxis with vancomycin and meropenem until the wound is covered in these complex injuries.