Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures

BACKGROUND

 Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed.

METHODS

 An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor.

RESULTS

 A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression.

CONCLUSION

 Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

Open fractures: evidence-based best practices

Open fracture management is a common challenge to orthopaedic trauma surgeons and a burdensome condition to the patient, health care, and entire society. Fracture-related infection (FRI) is the leading morbid complication to avoid during open fracture management because it leads to sepsis, nonunion, limb loss, and overall very poor region-specific and general functional outcomes. This review, based on a symposium presented at the 2022 OTA International Trauma Care Forum, provides a practical and evidence-based summary on key strategies to prevent FRI in open fractures, which can be grouped as optimizing host factors, antimicrobial prophylaxis, surgical site management (skin preparation, debridement, and wound irrigation), provision of skeletal stability, and soft-tissue coverage. When it is applicable, strategies are differentiated between optimal resource and resource-limited settings.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis

INTRODUCTION

Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center.

METHODS

A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score.

RESULTS

The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes.

CONCLUSION

Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures.

LEVEL OF EVIDENCE

Therapeutic level IIa.

Enhanced recovery for acute open lower limb fracture 'fix and flap'

INTRODUCTION

Enhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following 'fix & flap', return to theatre, rate of successful flap salvage, flap failure and deep infection rates.

METHODS

An observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases.

RESULTS

161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %.

CONCLUSION

In isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

Interfacility Transfer Patients With Pelvic, Acetabular, and Lower Extremity Fractures Are at Higher Risk for Major Complications and Readmissions

OBJECTIVE

To compare the adverse event profile and patient comorbidity profile of lower extremity orthopaedic trauma patients admitted via interfacility transfer (IT) to direct admission (DA) patients from home.

METHODS

A total of 39,497 patients from 2012 to 2019 were identified in the American College of Surgeon National Surgical Quality Improvement Program database. DA patients were compared with IT patients for differences in preoperative comorbidities, adverse events, length of stay, and readmissions in the 30-day postoperative period. Student t tests were used to assess continuous variables. Pearson χ 2 test and odds ratios (ORs) were used for categorical variables.

RESULTS

The IT group comprised 7167 patients, and the DA group comprised 32,330 patients. IT patients were on average older (65.5 vs. 58.8 years, P < 0.01), more likely to be American Society of Anesthesiologists Status >2 ( P < 0.01), and had a worse comorbidity profile for numerous preoperative risk factors. IT patients had significantly higher rates of mortality [3.3% vs. 1.4%; odds ratio (OR) 2.29; 95% confidence interval (CI), 1.96-2.77], major complications (10.2% vs. 6.1%; OR 1.74; 95% CI, 1.60-1.91), significantly higher readmission rates (5.8% vs. 4.8%, P < 0.01, OR 1.22 95% CI, 1.09-1.36), and more infectious complications (7% vs. 4.7%; OR 1.54; 95% CI, 1.38-1.71) than DA patients. Transfer remained a significant factor predicting major adverse events in regression analysis controlling for patient characteristics and fracture type ( P < 0.01; B 1.197; 95% CI, 1.09-1.32).

CONCLUSIONS

This study revealed that IT patients undergoing operative management of pelvic, acetabular, and lower extremity fractures are at a significantly increased risk of major complications, readmission, and have a higher morbidity burden than DA patients. As healthcare transitions to value-based care and bundled payments, hospitals that accept a high volume of ITs will face exposure to added risk and financial penalties without adequate policy protections.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures

OBJECTIVES

We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection.

DESIGN

A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage.

SETTING

Fourteen level-1 trauma centers across the United States.

PATIENTS

Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage.

INTERVENTION

Delay definitive fixation and flap coverage in tibial type III fractures.

MAIN OUTCOME MEASUREMENTS

(1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding.

RESULTS

Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001).

CONCLUSION

Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Direct admission versus transfer to a tertiary hospital for definitive management of lower extremity injuries: Systematic review and meta-analysis

BACKGROUND

Delays in definitive management for traumatic lower extremity injuries may result in morbidity. We compared patients with lower extremity injuries directly admitted to a tertiary hospital for definitive care with patients transferred to that hospital following initial treatment elsewhere.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were searched. Participants sustained lower extremity injuries, definitively treated at a tertiary hospital. Interventions were direct admission to a tertiary hospital for definitive care and patients transferred to that hospital for definitive care after initial management at another location. PRISMA, Cochrane, and grading of recommendations assessment, development and evaluation certainty-evidence guidelines were implemented.

RESULTS

Nineteen studies published from 1991 to 2020 compared 3,367 patients directly admitted with 1,046 patients transferred to a hospital for definitive management of lower extremity injuries. Direct admission to a tertiary center, compared with transfer, decreased time to first definitive surgical procedure (standard mean difference, -0.36; 95% confidence interval [CI], -0.57 to -0.16; p = 0.0006; participants, 788; studies, 6; I2 = 34%; high-certainty evidence) and wound infections (risk ratio [RR], 0.38; 95% CI, 0.19-0.77; p = 0.007; participants, 475; studies, 7; I2 = 27%; high-certainty evidence). Risks for diabetic patients (RR, 0.87; 95%CI, 0.77-0.98; p = 0.03; participants, 2,973; studies, 4; I2 = 0%; moderate-certainty evidence), total number of surgeries (standard mean difference, -0.69; 95% CI, -1.02 to -0.36; p < 0.0001; participants, 259; studies, 4; I2 = 35%; moderate-certainty evidence), osteomyelitis (RR, 0.47; 95% CI, 0.28-0.80; p = 0.006; participants, 212; studies, 2; I2 = 0%; moderate-certainty evidence), and total complications (RR, 0.47; 95% CI, 0.32-0.67; p < 0.0001; participants, 729; studies, 5; I2 = 32%; moderate-certainty evidence) are likely lower for direct admits compared with transfers. Direct admission may reduce risks for systemic infections (RR, 0.08; 95% CI, 0.01-0.51; p = 0.007; participants, 198; studies, 2; I2 = 0%; low-certainty evidence), venous thromboembolism (RR, 0.09; 95% CI, 0.01-0.73; p = 0.02; participants, 94; studies, 1; low-certainty evidence), and postoperative bleeding (RR, 0.74; 95% CI, 0.59-0.93; p = 0.01; participants, 2,725; studies, 3; I2 = 0%; low-certainty evidence), compared with transfer.

CONCLUSION

Earlier admission to a definitive tertiary center avoids morbidity associated with transfer delays.

LEVEL OF EVIDENCE

Systematic Review/meta-analysis, level III.

Open fractures with soft-tissue loss: Coverage options and timing of surgery

Open fractures with soft-tissue loss remain challenging injuries to treat. These often high-energy fractures are at a higher risk of delayed healing and at much higher risk of infection than open fractures with less significant soft-tissue injury. The initial management of the open wound, flap coverage options, and the timing of definitive coverage all remain areas of controversy, which will be discussed in this article.