Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures

A Cohort Study of 140 North American Trauma Centers

Daniel Pincus, James P. Byrne, Avery B. Nathens, Anna N. Miller, Philip R Wolinsky, David Wasserstein, Bheeshma Ravi, Richard J. Jenkinson

Research output: Contribution to journalArticle

Abstract

OBJECTIVES: To measure time to flap coverage after open tibia fractures and assess whether delays are associated with inpatient complications. DESIGN: Retrospective cohort study. SETTING: One forty level I and II trauma centers in Canada and the United States. PATIENTS/PARTICIPANTS: Adult patients (≥16 years) undergoing surgery for (1) an open tibia (including ankle) fracture and (2) a soft-tissue flap during their index admission between January 1, 2012, and December 31, 2015, were eligible for inclusion. EXPOSURE: Time from hospital arrival to definitive flap coverage (in days). MAIN OUTCOME MEASUREMENTS: The primary outcome was a composite of the following complications occurring during the index admission: (1) deep infection, (2) osteomyelitis, and/or (3) amputation. The primary analysis compared complications between early and delayed coverage groups (≤7 and >7 days, respectively) after matching on propensity scores. We also used logistic regression with time to flap coverage as a continuous variable to examine the impact of the duration of delay on complications. RESULTS: There were 672 patients at 140 centers included. Of these, 412 (61.3%) had delayed coverage (>7 days). Delayed coverage was associated with a significant increase in complications during the index admission after matching (16.7% vs. 6.2%, P < 0.001, number needed to harm = 10). Each additional week of delay was associated with an approximate 40% increased adjusted risk of complications (adjusted odds ratio 1.44, 95% confidence interval 1.13-1.82, for each week coverage was delayed, P = 0.003). CONCLUSION: This is the first multicenter study of flap coverage for tibia fractures in North America. Complications rose significantly when flap coverage was delayed beyond 7 days, consistent with current guideline recommendations. Because the majority of patients did not have coverage within this timeframe, initiatives are required to improve care for patients with these injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Original languageEnglish (US)
Pages (from-to)161-168
Number of pages8
JournalJournal of orthopaedic trauma
Volume33
Issue number4
DOIs
StatePublished - Apr 1 2019

Fingerprint

Open Fractures
Trauma Centers
Tibia
Cohort Studies
Ankle Fractures
Propensity Score
Osteomyelitis
North America
Amputation
Multicenter Studies
Canada
Inpatients
Patient Care
Retrospective Studies
Logistic Models
Odds Ratio
Guidelines
Confidence Intervals
Wounds and Injuries
Infection

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures : A Cohort Study of 140 North American Trauma Centers. / Pincus, Daniel; Byrne, James P.; Nathens, Avery B.; Miller, Anna N.; Wolinsky, Philip R; Wasserstein, David; Ravi, Bheeshma; Jenkinson, Richard J.

In: Journal of orthopaedic trauma, Vol. 33, No. 4, 01.04.2019, p. 161-168.

Research output: Contribution to journalArticle

Pincus, Daniel ; Byrne, James P. ; Nathens, Avery B. ; Miller, Anna N. ; Wolinsky, Philip R ; Wasserstein, David ; Ravi, Bheeshma ; Jenkinson, Richard J. / Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures : A Cohort Study of 140 North American Trauma Centers. In: Journal of orthopaedic trauma. 2019 ; Vol. 33, No. 4. pp. 161-168.
@article{be2998fb3fc94a7a8d25d007026a5447,
title = "Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures: A Cohort Study of 140 North American Trauma Centers",
abstract = "OBJECTIVES: To measure time to flap coverage after open tibia fractures and assess whether delays are associated with inpatient complications. DESIGN: Retrospective cohort study. SETTING: One forty level I and II trauma centers in Canada and the United States. PATIENTS/PARTICIPANTS: Adult patients (≥16 years) undergoing surgery for (1) an open tibia (including ankle) fracture and (2) a soft-tissue flap during their index admission between January 1, 2012, and December 31, 2015, were eligible for inclusion. EXPOSURE: Time from hospital arrival to definitive flap coverage (in days). MAIN OUTCOME MEASUREMENTS: The primary outcome was a composite of the following complications occurring during the index admission: (1) deep infection, (2) osteomyelitis, and/or (3) amputation. The primary analysis compared complications between early and delayed coverage groups (≤7 and >7 days, respectively) after matching on propensity scores. We also used logistic regression with time to flap coverage as a continuous variable to examine the impact of the duration of delay on complications. RESULTS: There were 672 patients at 140 centers included. Of these, 412 (61.3{\%}) had delayed coverage (>7 days). Delayed coverage was associated with a significant increase in complications during the index admission after matching (16.7{\%} vs. 6.2{\%}, P < 0.001, number needed to harm = 10). Each additional week of delay was associated with an approximate 40{\%} increased adjusted risk of complications (adjusted odds ratio 1.44, 95{\%} confidence interval 1.13-1.82, for each week coverage was delayed, P = 0.003). CONCLUSION: This is the first multicenter study of flap coverage for tibia fractures in North America. Complications rose significantly when flap coverage was delayed beyond 7 days, consistent with current guideline recommendations. Because the majority of patients did not have coverage within this timeframe, initiatives are required to improve care for patients with these injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.",
author = "Daniel Pincus and Byrne, {James P.} and Nathens, {Avery B.} and Miller, {Anna N.} and Wolinsky, {Philip R} and David Wasserstein and Bheeshma Ravi and Jenkinson, {Richard J.}",
year = "2019",
month = "4",
day = "1",
doi = "10.1097/BOT.0000000000001434",
language = "English (US)",
volume = "33",
pages = "161--168",
journal = "Journal of Orthopaedic Trauma",
issn = "0890-5339",
publisher = "Lippincott Williams and Wilkins",
number = "4",

}

TY - JOUR

T1 - Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures

T2 - A Cohort Study of 140 North American Trauma Centers

AU - Pincus, Daniel

AU - Byrne, James P.

AU - Nathens, Avery B.

AU - Miller, Anna N.

AU - Wolinsky, Philip R

AU - Wasserstein, David

AU - Ravi, Bheeshma

AU - Jenkinson, Richard J.

PY - 2019/4/1

Y1 - 2019/4/1

N2 - OBJECTIVES: To measure time to flap coverage after open tibia fractures and assess whether delays are associated with inpatient complications. DESIGN: Retrospective cohort study. SETTING: One forty level I and II trauma centers in Canada and the United States. PATIENTS/PARTICIPANTS: Adult patients (≥16 years) undergoing surgery for (1) an open tibia (including ankle) fracture and (2) a soft-tissue flap during their index admission between January 1, 2012, and December 31, 2015, were eligible for inclusion. EXPOSURE: Time from hospital arrival to definitive flap coverage (in days). MAIN OUTCOME MEASUREMENTS: The primary outcome was a composite of the following complications occurring during the index admission: (1) deep infection, (2) osteomyelitis, and/or (3) amputation. The primary analysis compared complications between early and delayed coverage groups (≤7 and >7 days, respectively) after matching on propensity scores. We also used logistic regression with time to flap coverage as a continuous variable to examine the impact of the duration of delay on complications. RESULTS: There were 672 patients at 140 centers included. Of these, 412 (61.3%) had delayed coverage (>7 days). Delayed coverage was associated with a significant increase in complications during the index admission after matching (16.7% vs. 6.2%, P < 0.001, number needed to harm = 10). Each additional week of delay was associated with an approximate 40% increased adjusted risk of complications (adjusted odds ratio 1.44, 95% confidence interval 1.13-1.82, for each week coverage was delayed, P = 0.003). CONCLUSION: This is the first multicenter study of flap coverage for tibia fractures in North America. Complications rose significantly when flap coverage was delayed beyond 7 days, consistent with current guideline recommendations. Because the majority of patients did not have coverage within this timeframe, initiatives are required to improve care for patients with these injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

AB - OBJECTIVES: To measure time to flap coverage after open tibia fractures and assess whether delays are associated with inpatient complications. DESIGN: Retrospective cohort study. SETTING: One forty level I and II trauma centers in Canada and the United States. PATIENTS/PARTICIPANTS: Adult patients (≥16 years) undergoing surgery for (1) an open tibia (including ankle) fracture and (2) a soft-tissue flap during their index admission between January 1, 2012, and December 31, 2015, were eligible for inclusion. EXPOSURE: Time from hospital arrival to definitive flap coverage (in days). MAIN OUTCOME MEASUREMENTS: The primary outcome was a composite of the following complications occurring during the index admission: (1) deep infection, (2) osteomyelitis, and/or (3) amputation. The primary analysis compared complications between early and delayed coverage groups (≤7 and >7 days, respectively) after matching on propensity scores. We also used logistic regression with time to flap coverage as a continuous variable to examine the impact of the duration of delay on complications. RESULTS: There were 672 patients at 140 centers included. Of these, 412 (61.3%) had delayed coverage (>7 days). Delayed coverage was associated with a significant increase in complications during the index admission after matching (16.7% vs. 6.2%, P < 0.001, number needed to harm = 10). Each additional week of delay was associated with an approximate 40% increased adjusted risk of complications (adjusted odds ratio 1.44, 95% confidence interval 1.13-1.82, for each week coverage was delayed, P = 0.003). CONCLUSION: This is the first multicenter study of flap coverage for tibia fractures in North America. Complications rose significantly when flap coverage was delayed beyond 7 days, consistent with current guideline recommendations. Because the majority of patients did not have coverage within this timeframe, initiatives are required to improve care for patients with these injuries. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

UR - http://www.scopus.com/inward/record.url?scp=85063631709&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85063631709&partnerID=8YFLogxK

U2 - 10.1097/BOT.0000000000001434

DO - 10.1097/BOT.0000000000001434

M3 - Article

VL - 33

SP - 161

EP - 168

JO - Journal of Orthopaedic Trauma

JF - Journal of Orthopaedic Trauma

SN - 0890-5339

IS - 4

ER -