A prospective randomized study comparing the results of early with delayed reduction and stabilization of acute femoral fractures in adults was performed over a two-year period in 178 patients. Only patients who were more than sixty-five years old and had a fracture of the hip were excluded. Arterial blood gases, injury-severity score at the time of admission, pulmonary function, days in the hospital, days in the intensive-care unit, and hospital costs were recorded for all patients. The patients were divided into two groups: those who had an isolated fracture of the femur and those who had multiple injuries. When stabilization of the fracture was delayed in the patients who had multiple injuries, the incidence of pulmonary complications (adult respiratory-distress syndrome, fat embolism, and pneumonia) was higher, the hospital stay was longer, and the number of days in the intensive-care unit was increased. The cost of hospital care showed a statistically significant increase for all patients who had delayed treatment of the fracture compared with those who had early stabilization.

Lawrence B. Bone (Fig 1), the author of this classic paper currently serves as Chairman and Program Director of the Department of Orthopaedic Surgery at the State University of New York Buffalo, School of Medicine and Biomedical Sciences. Born and raised in western New York in the family of a rural general surgeon he also earned his MD there. He took a general surgical residency at the same institution during which time general surgeons routinely took Trauma Call. As a result he gained wide experience in the treatment of fractures. This experience led to further training as an AO Fellow in Davos, Switzerland and eventually to an orthopaedic residency in Dallas, Texas at Southwestern and Parkland hospitals. During all of this Dr. Bone came to recognize that the then current wisdom of treating femur fractures with weeks of skeletal traction did not preclude shock lung, fat embolism, and adult respiratory distress syndrome. He observed that patients did better when they had their femoral fractures treated with prompt reduction and intramedullary fixation performed atraumatically with percutaneous techniques. In this paper Dr. Bone documents the importance of this type of treatment in a prospective study. In 46 multiply injured patients with femoral fractures treated with prompt internal fixation, 16 pulmonary complications occurred. In 37 such patients treated with prolonged skeletal traction there were 50 complications. Other parameters such as length of stay, blood gas values, and total cost supported his conclusion: The overwhelming recommendation is that early stabilization of long bone fractures should be performed in multiply injured patients. Dr. Bone's paper contrasts starkly with that of Dr. A. H. Stephens published in 1837. Dr. Stephen's femur fracture patient upon whom A bank of earth had fallen burying him beneath had treatment with prompt venesection with removal of blood followed by medication with ammonia and camphor and arrow-root with brandy. The limb was smeared with balsam of Peru, covered with a yeast poultice and wrapped in cotton. Several days later the leg was amputated. Death, amputation, and deformity routinely followed femoral shaft fractures in the era that preceded the rise of modern medicine and Dr. Bone's seminal paper documents scientifically a major step in the evolution of trauma surgery.

Lawrence B. Bone (Fig 1), the author of this classic paper currently serves as Chairman and Program Director of the Department of Orthopaedic Surgery at the State University of New York Buffalo, School of Medicine and Biomedical Sciences. Born and raised in western New York in the family of a rural general surgeon he also earned his MD there. He took a general surgical residency at the same institution during which time general surgeons routinely took Trauma Call. As a result he gained wide experience in the treatment of fractures. This experience led to further training as an AO Fellow in Davos, Switzerland and eventually to an orthopaedic residency in Dallas, Texas at Southwestern and Parkland hospitals. During all of this Dr. Bone came to recognize that the then current wisdom of treating femur fractures with weeks of skeletal traction did not preclude “shock lung,” fat embolism, and adult respiratory distress syndrome. He observed that patients did better when they had their femoral fractures treated with prompt reduction and intramedullary fixation performed atraumatically with percutaneous techniques. In this paper Dr. Bone documents the importance of this type of treatment in a prospective study. In 46 multiply injured patients with femoral fractures treated with prompt internal fixation, 16 pulmonary complications occurred. In 37 such patients treated with prolonged skeletal traction there were 50 complications. Other parameters such as length of stay, blood gas values, and total cost supported his conclusion: “The overwhelming recommendation is that early stabilization of long bone fractures should be performed in multiply injured patients.”Fig 1.: Lawrence B. Bone, MD. (Used with permission from Walter J. Kabai.)Dr. Bone’s paper contrasts starkly with that of Dr. A. H. Stephens published in 1837. Dr. Stephen’s femur fracture patient upon whom “A bank of earth had fallen burying him beneath” had treatment with prompt venesection with removal of blood followed by medication with ammonia and camphor and arrow-root with brandy. The limb was smeared with balsam of Peru, covered with a yeast poultice and wrapped in cotton. Several days later the leg was amputated. Death, amputation, and deformity routinely followed femoral shaft fractures in the era that preceded the rise of modern medicine and Dr. Bone’s seminal paper documents scientifically a major step in the evolution of trauma surgery. Henry H. Sherk, MD A prospective randomized study comparing the results of early with delayed reduction and stabilization of acute femoral fractures in adults was performed over a two-year period in 178 patients. Only patients who were more than sixty-five years old and had a fracture of the hip were excluded. Arterial blood gases, injury-severity score at the time of admission, pulmonary function, days in the hospital, days in the intensive-care unit, and hospital costs were recorded for all patients. The patients were divided into two groups: those who had an isolated fracture of the femur and those who had multiple injuries. When stabilization of the fracture was delayed in the patients who had multiple injuries, the incidence of pulmonary complications (adult respiratory-distress syndrome, fat embolism, and pneumonia) was higher, the hospital stay was longer, and the number of days in the intensive-care unit was increased. The cost of hospital care showed a statistically significant increase for all patients who had delayed treatment of the fracture compared with those who had early stabilization. Recent studies have led to the generally accepted principle that the immediate stabilization of femoral fractures in multiply injured patients drastically reduces the frequency of pulmonary failure and late septic complications, as well as the cost of hospital care.4,5,8,10 Unfortunately, all of the studies on this subject to date have been retrospective, to our knowledge. The prospective randomized study that is reported here was designed to yield more accurate quantitative data that could be used to compare the effects of early with delayed treatment of femoral fractures. MATERIALS AND METHODS The study was performed at Parkland Memorial Hospital in Dallas, Texas, from July 1985 to July 1987. All patients, sixteen through seventy-five years old, who had an acute femoral fracture and who were seen in the first twenty-four hours after injury were randomly assigned to either an early stabilization group (the first twenty-four hours after injury) or a late-stabilization group (more than forty-eight hours after injury). Patients who had sustained a fracture of the hip after a low-energy fall and were more than sixty-five years old were excluded from the study. One hundred and seventy-eight patients met the criteria for inclusion (Table 1). The mechanisms of injury were a motor-vehicle accident (sixty-five patients), a motorcycle accident (thirty-six patients), an automobile-pedestrian accident (thirty-five patients), a gunshot (twenty patients), a fall from a height (fifteen patients), a sports-related accident (four patients), and an aggravated assault (three patients).Table 1: Data on the One Hundred and Seventy-eight PatientsArterial blood gases were determined and radiographs of the chest were made in the emergency room. Each patient was evaluated, and resuscitation measures were performed by the general surgical trauma team as needed, according to a standard protocol. An injury-severity score was calculated for each patient, using the Hospital Trauma Index, recommended by the American College of Surgeons in 1980.1,2 All urgent surgical procedures were done according to the specific injury, with only the femoral fracture being randomized as to early or delayed treatment. Open femoral fractures were debrided in the operating room and were immediately stabilized in the patients who were randomized to the early treatment group. In the patients who were assigned to the delayed-treatment group, the fractured limb was placed in traction. Arterial blood-gas values were determined daily for each patient, with the patient breathing room air unless oxygen therapy was needed. When the clinical situation indicated, repeat radiographs of the chest were made. The arterial blood-gas determinations were discontinued postoperatively when the PO2 value was at least seventy-five millimeters of mercury with the patient breathing room air. Some patients who were intubated were admitted to the intensive-care unit because of the severity of the injury and the need for ventilatory support. Definitions A diagnosis of fat-embolism syndrome was made on the clinical basis of acute changes in mental status, deterioration in arterial oxygen levels, and radiographs of the chest showing interstitial infiltration. A declining Po2 value always accompanied these findings. Pulmonary failure was considered to be present when other specific causes of respiratory deterioration were absent, constant ventilation had been administered for more than ninety-six hours, and one or more of the following was present: a Pao2 of less than 250 mm of mercury when the patient was breathing 100% oxygen, a pulmonary arterial venous shunt of more than 25%, and a radiograph of the chest showing diffuse interstitial edema.10 Two grades of pulmonary failure were distinguished using the three criteria that were mentioned. The more severe derangement, adult respiratory-distress syndrome, requires that at least two of the criteria be met. The less severe syndrome, pulmonary dysfunction, requires that only one criterion be met. These two grades are different as to morbidity and mortality.11 Abnormal arterial blood-gas levels were defined as a Pao2 of sixty-five millimeters of mercury or less, with the patient breathing room air. Again using the three criteria, three levels of pulmonary failure were recorded, from least to most severe: fat-embolism syndrome, pulmonary dysfunction, and adult respiratory-distress syndrome. Other respiratory complications that did not meet the criteria for pulmonary failure were recorded as well, including pneumonia, pulmonary emboli, and abnormal blood-gas levels (Table 2).Table 2: Respiratory ComplicationsAll patients were prospectively followed for respiratory complications. The follow-up included recording the signs and laboratory determinations that were mentioned; the number of days in the intensive-care unit, on ventilatory support, and in the hospital; and the total cost of hospitalization. The latter calculation excluded physicians’ costs and other indirect costs from outside the hospital. All admissions to the intensive-care unit were principally for intubation and mechanical ventilation. These admissions were divided into three categories: parenchymal, mechanical, and convenience. The parenchymal category included patients who had pulmonary dysfunction due to a lesion involving the parenchyma of the lung. These patients always had abnormal blood-gas values, due to a major injury to the lung, such as fat embolism, adult respiratory-distress syndrome, or pulmonary dysfunction. The mechanical category included patients who had been placed in the forced supine position because of one or more other lesions. These patients also had abnormal blood-gas levels, but no parenchymal injury of the lung. The abnormal values were attributed to positional elevation of the diaphragm, which resulted in basilar atelectasis with perfused but non-ventilated lungs—for example, when a pneumothorax or multiple fractures of the ribs were present, when a laparotomy had been done, or when the patient was excessively obese. The category of convenience included patients who had normal arterial blood-gas levels, but who needed intubation because of other injuries. Some of these patients had a closed head injury and needed intubation for control of the airway. Others had severe facial fractures or a crush injury that necessitated frequent surgical procedures. The patients were subdivided into two groups on the basis of the injury-severity scores. The multiply injured patients had a score of 18 points or more, while the patients who had only a femoral fracture had a score of less than 18 points. Statistical analysis was performed by the Academic Computing Services at the University of Texas Southwestern Medical Center. The data were analyzed by assigning the 178 patients to one of four subgroups: early stabilization of an isolated femoral fracture, early stabilization in the presence of multiple injuries, late stabilization of an isolated femoral fracture, or late stabilization in the presence of multiple injuries. The proportion of positive responses for each selected set of variables of pulmonary function was computed, and the proportion for each of the four groups was compared with those of the others for statistical significance. Using an arcsine transformation of the proportions, each pair was tested against a significance level of 0.05. Descriptive statistics for the four groups were computed with regard to the numerical variables of age; number of days on the ventilator, in the intensive-care unit, and in the hospital; and hospital cost. A two-way analysis of variance was done for each variable. Pair-wise tests were done to compare each of the four groups with the other three. RESULTS Respiratory insufficiency did not develop in any of the patients who had an isolated femoral fracture that was treated with either early or late stabilization, but three patients in the late-stabilization group (two who had an isolated femoral fracture and one who had multiple injuries), as well as one patient who had early stabilization of an isolated femoral fracture, had late pulmonary emboli. Three emboli occurred after the patients had been discharged from Parkland Memorial Hospital, and they were subsequently admitted for treatment at another hospital. None of the patients who had an isolated fracture that was treated with either early or late stabilization needed intubation or placement in the intensive-care unit. Of the patients who had early stabilization and multiple injuries, eighteen patients were admitted to the intensive-care unit; only one of these patients was intubated for a parenchymal injury. In this patient, adult respiratory-distress syndrome developed after he was struck by a train. He had an injury-severity score of 66 points. Three patients were intubated for mechanical reasons and the remaining fourteen, for convenience. These fourteen patients included six who had a head injury, six who needed to be observed postoperatively, one who needed frequent débridement of a crush injury to the lower extremity, and one who had a pulmonary contusion and normal blood-gas values. Twenty-two patients were admitted to the intensive-care unit from the group that had late stabilization and multiple injuries. Ten of these patients needed intubation for a parenchymal injury of the lung: six for adult respiratory-distress syndrome, two for pulmonary dysfunction, and two for fat-embolism syndrome. Five patients were intubated for mechanical reasons and seven, for convenience, due to a closed head injury or the need for short-term observation. If the patients who had a closed head injury are subtracted from those who needed intubation and placement in the intensive-care unit, the average duration of intubation is reduced to 1.4 days in the group that had early stabilization and multiple injuries, and it is increased to 9.9 days in the group that had late stabilization and multiple injuries. Three patients in the series died, all of whom had multiple injuries (two who had early and one who had late stabilization) (Table 3). A twenty-three-year-old man in the early-stabilization group died of a severe closed head injury (a thalamic and occipital contusion in the mid-part of the brain, as determined by a computed tomography scan); he had an injury-severity score of 25 points. He was unconscious and unresponsive throughout the ten-day hospitalization, after débridement and stabilization of the fracture on the day of injury. The other patient in the early- stabilization group died of adult respiratory-distress syndrome, which developed after he was struck by a train. This forty-five-year-old man had an injury-severity score of 66 points that included hypotension; open fractures of the pelvis, hip, femur, tibia, and mid-part of the foot on the left; and bilateral pneumothorax. He had a cardiac arrest on induction of anesthesia, but he was resuscitated, and a laparotomy, a colostomy with irrigation, débridement, and stabilization of the open fractures were performed. Disseminated intravascular coagulation subsequently developed, and a disarticulation at the left hip was done for myonecrosis. Seven days after the injury, he died from acute renal failure, sepsis, and adult respiratory-distress syndrome.Table 3: DeathsThe third patient who died was in the late-stabilization group. This thirty-nine-year-old man had been injured in an automobile-pedestrian accident and had an injury-severity score of only 24 points. He was hypotensive when emergency personnel reached him, with a blood pressure of seventy millimeters of mercury. After seventy minutes in the emergency room, he became hypotensive again, with a blood pressure of eighty millimeters of mercury. He was resuscitated with crystalloid both times. After 200 minutes in the emergency room, he became hypotensive a third time, with a blood pressure of eighty millimeters of mercury, and he received colloid. He was taken to the operating room, where the Grade-I open femoral fracture was debrided, and he was placed in skeletal traction. In the recovery room, he was stable hemodynamically, and extubation was performed. When the arterial blood-gas levels were deemed acceptable while he breathed supplemental oxygen, he was sent to the orthopaedic floor, even though he had been somewhat combative. The next morning, he was lethargic and disoriented, with a Po2 of thirty-four millimeters of mercury while breathing room air. He was immediately intubated and sent to the intensive-care unit, where he eventually died of adult respiratory-distress syndrome and multiple-system organ failure. In the group that had early stabilization and multiple injuries, there were seventy-one additional fractures, of which twenty-one were tibial fractures, nine of them open. Six of the patients had a femoral fracture bilaterally, and seven had a fracture of the hip that was associated with the femoral fracture. A total of twenty-three open fractures was recorded for this group. In the group that had late stabilization and multiple injuries, there were forty-nine additional fractures, of which ten were tibial fractures, six of them open. Two of the patients had a femoral fracture bilaterally, and three had a fracture of the hip that was associated with the femoral fracture. There was a total of twelve open fractures in this group. There were six open femoral fractures in each group. In the patients who had early stabilization and multiple injuries compared with those who had late stabilization and multiple injuries, there were six and seven laparotomies, three and zero craniotomies, six repairs of a peripheral vascular injury in each group, two and zero repairs of a ruptured bladder, four and three thoracostomies for a hemothorax, and eleven and eight closed head injuries (Table 4).Table 4: Associated InjuriesDISCUSSION The association between a fracture of a long bone and respiratory insufficiency in the form of fat-embolism syndrome, fat globules in the lung with arterial hypoxemia, mental changes, and skin or retinal petechiae was classically described by Peltier in 1957. This syndrome has since been described as a contributing source of adult respiratory-distress syndrome,11 in which progressive respiratory failure often leads to death. Not until 1975, however, did the relationship between the management of a fracture of a long bone and the incidence of fat-embolism syndrome became apparent. Riska and Myllynen, of Finland, reported a major decrease in the incidence of fat-embolism syndrome with early stabilization of a fracture of a long bone in multiply injured patients. Patients who were treated non-operatively or with late stabilization of the fracture had a 22% incidence of fat-embolism syndrome, as compared with a 4.5% incidence in those who had early stabilization. A further decrease in the incidence of fat-embolism syndrome to 1.4% occurred in the next consecutive 211 patients who were treated with early stabilization.8 Similarly, Goris et al reported a decrease in the incidence of adult respiratory-distress syndrome in patients who had early management of a fracture of a long bone. Of fifty patients who had an injury-severity score of more than 50 points, there was an 11% incidence of the syndrome in the thirty-eight patients who were treated with early endotracheal intubation, ventilatory support, and early management of the fracture, compared with an incidence of 75% (nine of twelve) in the patients in whom the fracture was managed with traction.4 There was also a major decrease in the rate of late death from sepsis in the patients who had a fracture that was managed with early stabilization. Recent retrospective reviews have corroborated these results. Johnson et al analyzed a group of 132 consecutive patients who had multiple fractures of the long bones and an injury-severity score of 18 points or more. A delay of more than twenty-four hours in stabilization of a major fracture was associated with a fivefold increase in the incidence of adult respiratory-distress syndrome. Of the patients who had an injury-severity score of more than 40 points, the incidence of the syndrome was 17% in those who had early stabilization and 75% in those who had late stabilization. Seibel et al compared the results for twenty multiply injured patients who were treated by early stabilization with those for twenty patients who were managed with preliminary traction for at least ten days. The former group needed 3.4 days of ventilatory support, 7.5 days of intensive care, and twenty-three days of acute care in the hospital. Only four complications that were associated with the fracture developed in these patients. The group that had traction needed 9.4 days of ventilatory support, fifteen days of intensive care, and forty-five days of hospitalization. These patients sustained twelve complications that were related to the fracture and were thought to be secondary to the treatment in traction. A specific modality of treatment of fat-embolism syndrome and other forms of pulmonary complications after fracture of a long bone has been sought, but remains elusive. Intravenous administration of alcohol and steroids has been used without success.3,4 The standard management remains appropriate pulmonary support for the patient, often with positive-pressure ventilation and strict management of fluids and electrolytes.3,4,11 In some patients who have fat-embolism syndrome, adult respiratory-distress syndrome develops, with a mortality rate as high as 50%, as described by Weigelt. It is apparent that the best solution is prevention. This prospective randomized study was designed to determine if early stabilization of a fracture of a long bone in the initial twenty-four hours after injury appreciably influenced the incidence of either syndrome. The two groups of patients who had multiple injuries were similar with regard to injury-severity score (more than 18 points), age, and type of injury. Management of the injuries was similar in the two groups, except for the time of operative stabilization of the femoral fracture. The results confirmed that early stabilization, within the initial twenty-four hours after injury, decreases pulmonary morbidity.4,5,8,10 It also markedly decreases the incidence of adult respiratory-distress syndrome, pulmonary dysfunction, fat-embolism syndrome, pulmonary emboli, and pneumonia in multiply injured patients. Forty-eight hours is a relatively short delay compared with those that have been reported in previous studies, but even this short time-period resulted in an increased incidence of major pulmonary complications. It also led to an additional five days in the intensive-care unit and an additional ten days in the hospital for each patient. These average increases led to a significant increase in the average hospital cost ($32,915 compared with $19,854) for the patients who had multiple injuries and delayed stabilization. The exact mechanism by which early stabilization of a fracture of a long bone reduces the incidence of respiratory complications is not known, but it is probably multifactorial. Surgical stabilization of the fracture should reduce continued embolism of fat marrow and motion at the fracture site, and immobilization should reduce pain and the need for narcotic analgesics, which are respiratory depressants. Furthermore, early stabilization eliminates the need for the supine position that the patient must assume for skeletal traction. Mobilizing the torso improves pulmonary function by increasing functional residual capacity, avoiding atelectasis, and decreasing pulmonary venous shunting.6 Based on this study, as well as on previous, retrospective studies by Riska and Myllynen, Goris et al, Johnson et al, and Seibel et al, the overwhelming recommendation is that early stabilization of a fracture of a long bone should be performed in multiply injured patients.4,5,8,10 If this is done in conjunction with early intubation, ventilatory support, and proper management of fluids, the rate of pulmonary failure in these patients will be drastically reduced, at a major savings to all concerned.

Three porous ceramic bone graft materials were compared with regard to their ability to heal a 2.5 cm defect created surgically in a bilateral canine radius model. The ceramic materials were analyzed at 12 and 24 weeks after surgery and included tricalcium phosphate, hydroxyapatite, and collagen hydroxyapatite, which contained a mixture of 35% tricalcium phosphate and 65% hydroxyapatite with added collagen. Each material was evaluated alone and with added bone marrow aspirate. All the implants were compared with a graft of autogenous cancellous bone in the contralateral radius. Biomechanical testing and radiographic evaluation revealed that the addition of bone marrow aspirate was essential for tricalcium phosphate and hydroxyapatite to achieve results comparable with those of cancellous bone. Collagen hydroxyapatite performed well without the addition of bone marrow, although the addition of marrow did have a positive effect. Further qualitative radiographic and histological analysis demonstrated that tricalcium phosphate was the only ceramic that showed any sign of degradation at 24 weeks. This observed degradation proved to be an important factor in evaluating radiographs because the radiodensity of collagen hydroxyapatite and hydroxyapatite interfered with the determination of radiographic union. At 24 weeks, tricalcium phosphate with bone marrow was the material that performed most like cancellous bone. In this study, the biomechanical and radiographic parameters of tricalcium phosphate with bone marrow were roughly comparable with those of cancellous bone at 12 and 24 weeks. Tricalcium phosphate was the only implant that showed significant evidence of degradation at 24 weeks by both histological and radiographic evaluations, and this degradation took place only after a degree of mechanical competence necessary for weight-bearing was achieved.

The osteoconductive capacity of fibrillar collagen‐biphasic calcium phosphate composition was compared to autogenous bone in a canine spinal fusion model. All animals underwent a standard intervertebral body fusion (L2–L4) with rigid internal fixation and received either autogenous bone alone or a mixture of the ceramic and autogenous bone (3:1) as the graft material. Animals were followed for 12 months and the quality of fusion in each animal assessed by biomechanical testing and histological analysis. The fused L2–L4 segment of each dog was embedded in bone cement and mounted in a specially designed mechanical tester for testing in flexion, extension, and side bending. Overall, the mean rigidity of the fusion mass was not significantly different between the two groups [10.5 ± 4.1 (SD) for autogenous bone vs. 11.3 ± 1.7 for the ceramic plus autogenous bone, p > 0.05]. Similar findings were obtained for mean bending moment, compressive load, angular deformation, and energy absorbed for the two groups. Histological analysis was performed on transverse nondecalcified specimens. Quantitation of bone ingrowth using back‐scattered electron imaging disclosed no significant differences in the amount of new bone formed at the graft site between autogenous bone and the ceramic plus autogenous bone recipients (23.4 ± 10% vs. 25.8 ± 8.8%) when correction for the autogenous bone volumes was performed. Light microscopic analysis of toluidine blue‐stained transverse sections demonstrated new bone growth around and through the ceramic bone graft material. These results suggest that use of a collagen‐biphasic calcium phosphate ceramic and autogenous bone mixture (3:1) provides a suitable osteoconductive alternative to the use of autogenous bone and results in the formation of a mechanically competent fusion mass not significantly different from that obtained with autogenous bone alone.

A prospective randomized study of severe open tibial fractures (Type II and III) was performed. Individual fractures were randomized to treatment groups according to initial antibiotic therapy: One consisted of a first-generation cephalosporin, and the other consisted of a third-generation cephalosporin. Initial antibiotic therapy was given in all patients for 48 h and then specific antibiotic treatment was used as indicated by culture. The purpose of this study was to determine whether or not additional gram-negative coverage had an effect on the overall infection rate or the type of infection in severe open tibial fractures. Additional factors, such as the timing of bone grafts and soft tissue coverage, were evaluated in this study as well. Although there was no statistical difference in the rate of infection with the use of a first- versus a third-generation cephalosporin, there was a trend toward a decreased infection rate as well as toward less morbid infections with the use of a third-generation cephalosporin. The study also confirms that early bone graft should not be performed prior to 6 weeks post injury or after successful soft tissue coverage has been achieved. On the other hand, soft tissue coverage procedures should be performed at the earliest possible date to decrease the overall infection rate.