Does timing of flap coverage in open fractures affect the risk of fracture-related infections during the index hospital stay? A nationwide analysis of the United States.

Overview

abstract

INTRODUCTION: Open fractures are associated with soft tissue injury and may require reconstruction via delayed flap coverage. The timing of coverage is critical as prolonged time to coverage is associated with increased risk for wound complications. Few studies have included all lower extremity fractures when analyzing time from definitive fixation to coverage. We analyzed the effect of time to flap coverage from both admission and definitive fixation, on fracture-related infections (FRI) in patients admitted with open fractures of the lower extremity. METHODS: The National Inpatient Sample was queried from 2015-2019 for open fractures of the tibia, fibula, and femur that required flap coverage. Patients who underwent simple skin grafts only or fixation prior to admission were excluded. The number of days to coverage and days from fixation to coverage was determined using the inpatient stay day on which the flap coverage procedure was conducted. The primary endpoint was FRI acquired during the inpatient stay. Multivariable regression was used to quantify the odds of FRI for every day of delayed coverage. RESULTS: Between 2015-2019, 1970 patients underwent flap coverage for open fractures of the lower extremity. Isolated tibia fractures constituted the majority (33.7 %), followed by tibia and fibula (27.7 %), and isolated femur (26.1 %). The rate of FRI during the initial hospital stay was 9.9 %. The median times from admission to flap coverage (6 days, IQR 4-18, vs 3 days, IQR 1-8) and definitive fixation to flap coverage (2 days, IQR 1-10, vs 0 days, IQR 0-4) were significantly greater in the FRI group compared to the non-fracture related infection (nFRI) group (p < 0.001 and p < 0.001, respectively). After controlling for confounding variables, each day of delay from admission and from fixation was associated with 10.7 % and 9.1 % increased odds of acquiring inpatient FRI (OR: 1.107, 95 % C.I. 1.062-1.154, p < 0.001, and OR: 1.091, 95 % C.I. 1.047-1.138, p < 0.001, respectively). CONCLUSION: Our study analyzed all open fractures and did not employ arbitrary endpoints for coverage such as "late" and "early" coverage. Instead, we provide more general evidence in support of early flap coverage. We found that every additional day definitive flap coverage was delayed, the risk of FRI developed during the initial inpatient stay was increased by approximately 10 %. Despite our findings, it is critical to note that we only evaluated FRIs acquired during the inpatient stay, and many of these infections occur following discharge. However, the temporal relationship described in our study suggests that definitive wound closure should be achieved in the shortest time possible. Additionally, fixation should be performed as close to the definitive coverage procedure as possible. LEVEL OF EVIDENCE: Level III.