Sub-emergency versus emergency or delayed free flap coverage for Gustilo III upper limb fractures: With…

Cohort studyOrthopaedics & traumatology, surgery & research : OTSR· Aug 2026

Sub-emergency versus emergency or delayed free flap coverage for Gustilo III upper limb fractures: With reduced infection, enhanced limb salvage, and improved functional recovery.

Feiya Zhou, Wenjing Jiang, Huachen Liu … Leyi Cai

Microsurgery & FlapsCohort studyTreatmentQ1IF 3.0

Delayed free flap coverage beyond 72 hours linked to higher infection rates.

Sub-emergency versus emergency or delayed free flap coverage for Gustilo III upper limb fractures: With reduced infection, enhanced limb salvage, and improved functional recovery.

Feiya Zhou … Leyi Cai

Orthopaedics & traumatology, surgery & research · Aug 2026 · Q1 in Surgery

Background

Gustilo type III open fractures of the upper extremity present severe soft‑tissue and bony injuries.

Purpose

This study aimed to assess the association between timing of coverage and postoperative infection rates.

Methods

In this observational cohort study, 85 patients with upper limb Gustilo III fractures (2018-2024) were allocated to three groups based on clinical decision: emergency (same anesthetic, n = 25), sub‑emergency (within 72 h, n = 26), or delayed (>72 h, n = 34).

n = 85 patients

Results

Infection rate was 29.4% when flap coverage was delayed beyond 72 hours.

4%

Emergency

3.8%

Sub-emergency

29.4%

Delayed

More results

Baseline characteristics were comparable except for higher Injury Severity Score (Injury Severity Score) in the delayed group (p = 0.001).

Osteomyelitis, flap necrosis, and bone defects occurred almost exclusively in the delayed group.

More results

Multivariable analysis (13 total infections) did not identify timing as an independent predictor (p = 0.831); higher Injury Severity Score, longer operative time, and extended hospital stay showed trends but were not statistically significant.

Functional recovery (QuickDASH, SF‑12 PCS) was superior in both early groups.

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Conclusion · 1 of 2

In this observational study, free flap coverage beyond 72 h was associated with higher unadjusted infection rates; however, this finding cannot be interpreted causally due to severe confounding-by-indication, as the delayed cohort sustained significantly higher baseline trauma severity (Injury Severity Score).

Conclusion · 2 of 2

Emergency and sub-emergency (<72 h) coverage demonstrated comparable favorable outcomes, suggesting that the sub-emergency window represents a safe, logistically advantageous alternative LEVEL OF EVIDENCE: III; Therapeutic.

Sub-emergency versus emergency or delayed free flap coverage for Gustilo III upper limb fractures: With reduced infection, enhanced limb salvage, and improved functional recovery.

Sub-emergency versus emergency or delayed free flap coverage for Gustilo III upper limb fractures: With reduced infection, enhanced limb salvage, and improved functional recovery.

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