Study Finds Delay in Flap Coverage as a Predictor of Complications

Open tibial fractures remain a challenging problem for orthopedic
surgeons. The ways in which surgeons approach and treat these fractures are
often controversial, according to orthopedic surgeon Jean-Claude
D’Alleyrand, MD, of R. Adams Cowley Shock Trauma in the department of
orthopaedics at the University of Maryland School of Medicine.

  Jean-Claude D’Alleyrand
  Jean-Claude D’Alleyrand

Previous studies on flap coverage have reported increased complications
and infections when the coverage is delayed. However, only one study has
controlled for risk factors for complications associated with flap coverage in
open tibia fractures. In that study, timing of flap coverage was not found to
have a significant influence on outcome. D’Alleyrand’s study
hypothesis was that the timing of flap coverage of open tibia fractures
requiring flap coverage is not predictive of complications when controlling for
risk factors.

“Patients were examined for a number of risk factors,”
D’Alleyrand told the audience at the 2010 Orthopaedic Trauma Association
Meeting in Baltimore.

D’Alleyrand’s team reviewed acute fractures of the tibia that
required flap coverage. From 2004 to 2009, 74 patients required flap coverage
for fractures of the tibia. Of the 74 patients, 45 had tibial shaft fractures,
17 had plateau and 12 had pilon fractures.

Electronic records were reviewed as were data in the prospective trauma
database. All fractures were classified by a trauma fellowship–trained
orthopedic surgeon. According to D’Alleyrand, the primary outcome of the
study was determining flap complications, which his group defined as infection
or other flap failure requiring surgical treatment. Analysis was performed
using logistic regression analysis adjusting for multiple risk factors such as
age, injury severity, fracture classification and initial treatment

Despite controlling for fracture severity and other parameters thought
to increase risk for complication, time to flap coverage was a significant
predictor of complication after a certain period of time.

“What we found is that time is a significant factor for this
patient population,” D’Alleyrand explained. “While we found no
increase in complication or infection rate on a day-to-day basis for the first
7 days, the risk ratio increases 1% per day after the first 7 days.”

The study found that the breakpoint for increased infection appeared to
be around 7 days. In fact, a second logistic regression model that separated
the first days after surgery from subsequent days found the odds of
complication increased by 18% for each day beyond day 7, according to
D’Alleyrand’s study.

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, according to D’Alleyrand.

In contrast to previous studies D’Alleyrand and his group attempted
to control for risk factors for complication but still found a significant
increase in infection despite controlling for severe injuries as well. —
by Anthony Calabro


Generally, the patients who are late in their flaps at level one trauma
centers are delayed for medical reasons, not for convenience issues. The goal
is to have flap coverage performed at the fastest possible opportunity once the
wound is stable. The key questions are: when is the wound stable and when is
the patient stable enough to have the operation?

A coverage procedure can last anywhere from an hour, if it is just a
rotational flap to 6 or 7 hours if the procedure is a free flap. The patient
would likely take a physiological hit following a free flap.

A number of factors go into that timing. Availability of the surgeons is
one of them. Clearly, the people at shock trauma do not suffer from those
issues because they were able to get early coverage on many of these patients.
But another issue is the complexity of the wound. When is the wound no longer
demonstrating evolution of injury?

Typically, the patient would be brought back into the operating room
every 2 or 3 days for repeat debridement. The flap would be performed only when
there is no further debridement necessary and the tissues are essentially
healthy. Initial debridements are the more aggressive approach and a faster way
to get to a flap. At the same time, the more aggressive the debridement, the
more likely one may end up with a free flap. There is a balance that needs to
be struck.

— Paul Tornetta III, MD
Vice chairman and
residency program director, department of orthopaedic surgery, Boston
University School of Medicine

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