Silver trauma is a term used to define trauma and injuries occurring in older patients who usually have underlying frailty and polymorbidity. It is recognised that as our population ages there will be an increasing volume of silver trauma in our hospitals. Contemporary data shows there are 12.5 million people aged 65 and older currently living in the United Kingdom (U.K.) [1]. Low energy falls in individuals over 65 years are common, with around one-third of this age group falling each year and 31% of such injuries requiring medical attention [2]. Fractures, especially those of the wrist, forearm, proximal femur and lower limb, are the most common serious injuries resulting from falls in the elderly [3], [4], [5]. These injuries are associated with increased mortality in the older population [6], [7], [8], [9].

The 2017 Trauma Audit Research Network (TARN) report “Major Trauma in Older People” highlighted 54% of severely injured patients in England and Wales are aged 60 and over [4]. It described low level falls (less than 2 m) as being the leading cause of major trauma in this age group [4]. Regional trauma networks have devised silver trauma protocols to address age-related physiological differences compared to younger patients and common comorbidities in the older population [10], [11], [12], [13]. Open lower limb fractures in the elderly can lead to immobility and permanent dependence, negatively impacting quality of life [14], [15], [16], [17], [18], [19], [20], as well as adding a significant financial burden to individuals and health care systems. Individuals above 65 years have 25.7 times higher risk of death compared to individuals aged 15–39 years [15]. Management of open lower limb fractures in the elderly have an estimated median cost of £20,398 per patient [16] vs £13,785 in the general population [17]. In the elderly, osteoporosis and reduced bone healing lead to higher rates of malunion, non-union and lower limb amputations compared to younger patients [21]. Traditionally, free tissue transfer has not been considered suitable for the elderly patient due to the duration of surgical procedure and a higher risk of vascular insufficiency because of age-related comorbidities. With recent advances in microsurgery, post-operative care and detailed knowledge of arterial anatomy, lower limb free flaps have a success rate of 85–96% [22], [23], [24].

Management of open fractures are supported by national guidelines, recommending a shared orthoplastic approach based on British Orthopaedic Society Standards for Trauma and Orthopaedics (BOAST) guidelines [25]. The National Institute for Health and Care Excellence recommends that individuals with open fracture of long bones, the hindfoot or midfoot should have definitive soft tissue cover within 72 h [26]. Free flaps are often required for soft tissue reconstruction following adequate debridement and excision of traumatised tissue [27]. Open lower limb fractures require a radical, multidisciplinary management. The “fix and flap” [28] concept highlighted benefits of a combined orthopaedic and plastic surgical approach to ensure early skeletal stabilisation and early soft tissue cover with an appropriate flap reconstruction. Free flaps are now routinely used in the United Kingdom for lower limb open fractures with significant soft-tissue defects. The overall goal is to restore function, form, and provide a stable soft tissue envelope to allow bony healing in the absence of infection [29].

In the era of Montgomery, accurate information during counselling about the risks and complication profile of limb salvage is key for the patient and clinician alike. In this systematic review we aim to compare the complication profile of free fasciocutaneous flaps with free muscular/myocutaneous flaps in older patients (≥60 years) undergoing reconstruction for lower limb open fractures to aid decision making in this patient cohort.