Sat., 10/16/10 Polytrauma & Femur, Paper #71, 10:52 am OTA-2010
Is Time to Flap Coverage an Independent Predictor of Flap Complication
Jean-Claude G. D’Alleyrand, MD1; Lindsay Dancy, BS1; Renan Castillo, PhD2;
J.B. Bertumen, BS1; Theodore T. Manson, MD1; Robert V. O’Toole, MD1; Tom Meskey, BS2;
1R Adams Cowley Shock Trauma, Dept of Orthopaedics, University of Maryland School
of Medicine, Baltimore, Maryland, USA;
2Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland, USA
Purpose: Many studies have reported increased complications and infections associated with delay in flap coverage of open tibia fractures. Only one previous study has attempted to control for risk factors for complication and this study found no influence of timing of flap coverage on outcome. Our hypothesis is that timing of flap coverage of open tibia fractures requiring flap coverage is not predictive of complication after controlling for previously described risk factors for complication.
Methods: A retrospective review of all acute fractures of the tibia requiring flap coverage at a single Level 1 trauma center yielded 74 patients from 2004 to 2009. Patients were excluded if they required a flap later for wound breakdown or infection. Most patients had tibial shaft fractures (n = 45), but 17 of the patients had plateau, and 12 had pilon fractures. Electronic records were reviewed as were data in the prospective trauma database. All fractures were classified using the AO system by a trauma fellowship–trained orthopaedic surgeon. Our primary outcome was flap complication, which we defined as infection or other flap failure requiring surgical treatment. Analysis was performed using logistic regression adjusting for either multiple confounders (including factors such as age, injury severity, fracture classification, and initial treatment characteristics) or for a single summary score due to sample size limitations. Results were substantially similar with both approaches.
Results: Even after controlling for fracture severity and other parameters thought to increase risk for complication, time to flap coverage was a significant predictor of complication. The odds of complication increased 14% for every day of delay (95% confidence interval [C.I]: 1.5%, 28.5%; P = 0.028). Including only the patients with infection increased the magnitude of the effect (17.1% increased odds for every day delay, P = 0.023). A breakpoint for increased infection appeared to exist around 7 days from injury: a second logistic regression model that separated the first 7 days to surgery from subsequent days found no increased risk for days 1 to 7 (P = 0.95). However, the odds of complication increased by 18% for each day beyond day 7 (95% CI: 1.3%, 37.2%; P = 0.033).
Conclusions: One explanation for the observation that infection rates increase with delay in flap coverage of open tibia fractures is that worse injuries and sicker patients undergo flap coverage later. In contrast to previous studies in the literature, we attempted to control for risk factors for complication and still observed a significant increase in infection despite controlling for injury severity.
Alphabetical Disclosure Listing (292K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.