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Patterson et al. Plast Aesthet Res 2022;9:23 https://dx.doi.org/10.20517/2347-9264.2021.117 Page 5 of 11

Early intervention to prevent infection
The path to a functional outcome begins with prevention of infection. The risk of infection in open
[33]
fractures correlates with injury severity and is modifiable . Intravenous antibiotics tailored to severity,
mechanism, and exposure should be administered as soon as possible, along with updated tetanus
prophylaxis. For less severe fractures (Gustilo Anderson type I and II), current recommendations suggest
using a first-generation cephalosporin; for more severe fractures (Gustilo Anderson type III), gram-negative
coverage is indicated through fluoroquinolones and monobactams .
[34]
Following thorough debridement, wounds must be clean before definitive skeletal or soft tissue
reconstruction to minimize the risk of infection. Soft tissue coverage should be performed once the wound
is sufficiently stable for coverage and definitive bony stabilization has been performed by orthopedic
colleagues. Godina advocated for aggressive and early debridement of all contaminant material and
[35]
nonviable tissue followed by soft tissue coverage within 72 h of injury. However, delayed coverage beyond
this time frame may also be reasonable, with various guidelines published by international groups stressing
that coverage be performed within 5 to 7 days of injury [36-39] .

Antibiotic bead pouches and negative pressure wound therapy (NPWT) have emerged as alternatives to soft
dressings during the interval between debridement and soft tissue reconstruction. Antibiotic bead pouches
seal the soft tissue defect with a semipermeable membrane over an antibiotic drug delivery depot. Negative
pressure wound therapy provides a sealed environment and improves local blood flow. While utilization of
NPWT has increased over time, the therapeutic efficacy of NPWT for open fracture management has come
into question. Li et al. found NPWT was associated with reduced surgical site infections in meta-analysis
[40]
of 45 randomized-control trials compared with soft dressings. However, the WOLFF study, a multicenter
randomized trial in patients with severe open lower limb fractures, did not identify differences in the rate of
infection or self-rated disability compared to standard dressings . Recent literature comparing NPWT to
[41]
antibiotic bead pouches suggests that NPWT may be overutilized, provide inferior results, and cost more
than antibiotic bead pouches in the management of open fractures pending soft tissue reconstruction .
[42]
How “functional” would the best possible outcome be for the patient?
The orthoplastic team should weigh the potential outcomes of their surgical interventions. Surgeons should
consider the best functional outcome, the most likely outcome, and if those outcomes would meet the needs
of the patient. Many methods have been developed to predict limb outcomes, including scoring systems and
psychosocial assessments as described in LEAP and METALS. The Gustilo-Anderson classification, which
categorizes the severity of soft tissue damage and contamination in open fractures, can be prognostic of
inferior outcomes . Understanding predictive factors of functionality can inform discussions with patients
[43]
about reasonable expectations.

The objectives of orthopedic trauma reconstruction include a stable, pain-free limb that can bear weight,
achieve functional ranges of motion, and safely interact with the environment. For the lower extremity,
functional outcomes may be considered as a hierarchy from the ability to support weight, transfer between
the bed and the wheelchair, stance and ambulation with a device, ambulation without an assistive device,
and higher-level activities. For the upper extremity, this gradation spans instrumental activities of daily
living like independent facial and perineal hygiene to complex occupational tasks. Restoration of limb
segment length, alignment, rotation symmetric to the uninjured state or contralateral limb; full joint range
of motion; full strength; full sensation; and return to high-demand occupational and recreational activities
are goals but may not always be attainable. Normal and functional ranges of joint motion are shown in
Table 1.