From Duke University School of Medicine; the Division of Plastic and Reconstructive Surgery, the Department of Biostatistics and Bioinformatics, and the Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Duke University Medical Center; and the Department of Bioengineering, University of Pennsylvania.
Plast Reconstr Surg. 2018 Dec;142(6):1620-1628. doi: 10.1097/PRS.0000000000005007.
Controversy remains regarding the optimal timing of soft-tissue coverage following severe lower extremity trauma. This study identifies nationwide practice patterns and factors associated with discrepancies in time to first flap surgery following open tibia fractures.
A retrospective analysis was performed on the National Trauma Databank from 2008 to 2015 to identify patients who presented with an open tibia fracture and underwent subsequent flap reconstruction. A least absolute shrinkage and selection operator algorithm was performed, revealing those factors most significantly associated with differences in time to flap surgery from hospitalization.
A total of 3297 patients were included in the analysis. Mean ± SD and median times to first flap surgery were 230.1 ± 246.7 hours and 169.1 hours, respectively. Older age, nonwhite race, treatment in the South, and non-private insurance status were all independently associated with an increased time to flap surgery. In addition, more surgical débridements; a higher Injury Severity Score and/or Abbreviated Injury Scale score; and a nerve, vascular, and/or crush injury were independent predictors of an increased time to flap surgery.
Most patients who present with open tibia fractures requiring soft-tissue coverage undergo flap reconstruction after the historical 72-hour window. Specific sociodemographic and clinical factors were independently predictive of an increased time to flap surgery. These findings suggest that not all patients in the United States are receiving the same level of care in lower extremity trauma reconstruction, emphasizing the need to develop more explicit national standards.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
严重下肢创伤后软组织覆盖的最佳时机仍存在争议。本研究确定了全国范围内的实践模式以及与开放性胫骨骨折后首次皮瓣手术时间差异相关的因素。
对 2008 年至 2015 年国家创伤数据库进行回顾性分析，以确定有开放性胫骨骨折并随后行皮瓣重建的患者。采用最小绝对收缩和选择算子算法，揭示与皮瓣手术时间差异最显著相关的因素。
共纳入 3297 例患者。首次皮瓣手术的平均±标准差和中位数时间分别为 230.1±246.7 小时和 169.1 小时。年龄较大、非白种人、南部治疗和非私人保险状态均与皮瓣手术时间延长独立相关。此外，更多的手术清创术；更高的损伤严重程度评分和/或简明损伤评分；以及神经、血管和/或挤压伤是皮瓣手术时间延长的独立预测因素。
大多数有开放性胫骨骨折需要软组织覆盖的患者在历史上的 72 小时窗口后接受皮瓣重建。特定的社会人口和临床因素是皮瓣手术时间延长的独立预测因素。这些发现表明，美国并非所有患者在下肢创伤重建中都接受相同水平的治疗，强调需要制定更明确的国家标准。
临床问题/证据水平：风险，III 级。
