Enhanced Recovery (ER) after surgery is the concept of taking a multidisciplinary approach toward standardised protocols to minimise peri-operative variation and achieve the highest quality of post-operative rehabilitation [1], [2], [3]. First pioneered in Denmark in the 1990’s [4], [5], [6], ER has rapidly developed into a world-wide concept used across a number of surgical specialties [7], [8], [9], [10]. Within the sphere of Ortho-Plastic trauma, there exists potential for ER to enhance the care and recovery of acute lower limb open fracture (ALLOF) patients. Particularly as 63-74 % of ALLOF cases are isolated injuries [11,12]. By applying the principles to ALLOF patients, it offers the opportunity to start the rehabilitative process earlier, shorten the length of stay and prevent disempowerment [13]. Objective endpoints used to demonstrate successful ER pathways have focussed on reducing complications whilst also shortening hospital length of stay (LOS) [1,[14], [15], [16]].

When the South Wales Major Trauma Network was launched in September 2020, the South Wales Ortho-Plastic Surgery (SWOPS) team was established to staff two Ortho-Plastics centres critical to managing ALLOFs optimally [17], [18], [19], [20], [21]. They were the Major Trauma Centre (MTC) at The University Hospital of Wales, Cardiff and the Microsurgical Reconstructive Centre at The Welsh Centre for Burns & Plastic Surgery, Swansea (site of free flap reconstruction). The ALLOF ER Protocol was introduced in April 2021 to standardise the post-operative management and recovery of these patients after definitive fixation and soft tissue coverage [22] (also known as ‘fix & flap’ [23]). The aims of this review were to evaluate the outcomes of ALLOFs for limb salvage, LoS following ‘fix & flap’, return to theatre, rate of successful flap salvage, flap failure and deep infection rates.