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Patterson et al. Plast Aesthet Res 2022;9:23 https://dx.doi.org/10.20517/2347-9264.2021.117 Page 7 of 11

Provisional restoration of alignment by percutaneous pinning or external fixation can maintain limb
[53]
structure if the soft tissues are not initially amenable to definitive limb fixation . The choice of definitive
skeletal reconstruction is influenced by fracture features, location, fragmentation, bone health, patient age,
and other system wide pathologies [54,55] . Plans for soft tissue reconstruction and staged bone grafting for
critical-sized bone defects also influence fixation preferences [54,55] . For extremity injuries, the decision is most
often between intramedullary nailing and open reduction internal fixation with plates [56,57] . External fixation
or ring fixation can also be powerful tools in the context of severe soft tissue injury [58,59] .

In general, definitive skeletal reconstruction should be undertaken in conjunction with or as close as
possible to soft tissue reconstruction to optimize outcomes. Effective and timely (within 5-7 days) soft tissue
[52]
coverage decreases the incidence of fracture nonunion and infection . Articular fractures with cartilage
injury are associated with joint instability and the development of post-traumatic osteoarthritis and may
require protected weight bearing for extended periods [60,61] . If definitive fixation is performed at a later date,
mal- or non-union can occur when a bone heals in an abnormal position or does not completely fuse [62,63] .
Autologous bone grafting or reduction revision are effective treatments for post-traumatic nonunion but
may require flap elevation for access .
[64]

Segmental bone defects require special coordination of orthoplastic care. Resulting from high-energy
traumas, these injuries include massive soft tissue injury with a completely devitalized or absent bone
fragment that is separated by at least two distinct fracture lines [65,66] . Segmental defects often require a staged
reconstruction approach with debridement, antibiotic spacer placement, and staged bone grafting or bone
transport [67,68] . Coordination and discussion among the orthoplastic team regarding flap choices, expected
time to flap maturation, and pedicle selection are advised. Any immediate or future planned surgical
approaches should be considered in order to inform timing, surgical tactics, and reduce the risk of future
neurovascular injury or flap loss.

Monitored rehabilitation to optimize outcome
Postoperative rehabilitation is a critical counterpart to surgical intervention for extremity injuries. The
outcome of limb reconstruction is powerfully affected by the prescription, oversight, and delivery of
physical or occupational therapy in the post-operative period. Postoperative rehabilitation requires effective
and consistent communication with the patient and allows clinical follow-up to monitor compliance and
confirm the efficacy of continued therapy.

The orthoplastics approach continues after surgical coordination with a balancing act between
postoperative restrictions such as flap dangling and restrictions on weight bearing or joint motion with the
goals of early mobilization to decrease mortality and functional morbidity. Immobilization of limbs and
joints is not benign. For example, gracilis free flap protocols typically require bedrest with strict dangling
protocols that will gradually increase as the flap matures. These restrictions can conflict with the orthopedic
surgeon’s prescription for early active and active assisted joint motion to prevent joint contractures, tendon
adhesions, and edema, as well as patient mobilization to prevent venous thromboembolism, decubitus
ulcers, pneumonia, and mortality. Specifically, elderly patients are more likely to develop stiff joints
following fracture fixation due to immobilization of soft tissue.

Rehabilitation progresses in a stepwise manner starting with early protective activity and mobilization with
the progression of weight bearing to later strengthening and conditioning supervised by physical and
occupational therapists . Communication between orthopedic and plastic surgery providers about
[69]
rehabilitation priorities should continue after discharge while monitoring soft tissue healing and flap