Objectives: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. Design: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage.Setting: Fourteen level-1 trauma centers across the United States.Patients: Two hundred ninety-six (n = 296) consecutive patientswith Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage.Intervention: Delay definitive fixation and flap coverage in tibial type III fractures. Main Outcome Measurements:(1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding.Results: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P , 0.001). Conclusion:Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures.

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Category: Other Introduction/Purpose: Under-representation of women in surgery is commonly attributed to lacking mentorship and exposure in medical school, societal perceptions regarding career priorities, and concerns of “fitting in” in a work culture predominantly comprised of men. Furthermore, this disparity is also reflected in research productivity across academic medicine with male faculty being more likely to publish research compared to female colleagues. In this study we aim to describe the representation and longevity of female investigators among the authors of three foot and ankle research journals from 1993 to 2017. Methods: In this retrospective bibliometric analysis, authors of original research from three prominent foot and ankle research journals (Foot and Ankle International, The Journal of Foot and Ankle Surgery, Foot and Ankle Clinics) were extracted from PubMed. For authors with a complete first name listed, gender was determined by matching first name using an online database containing 216,286 distinct names across 79 countries and 89 languages. Proportion of female first, middle, and senior authors were determined over time, as well as total publication count per author. A sub-analysis of authors first publishing between 2007-2012 was followed for 5 years to identify how often authors continued to publish after first publication. Student t-test, chi-square analysis, and Cochran-Armitage trend tests were used to determine significance between groups. Results: From 1993 to 2017, 8,132 original articles were published in three foot and ankle research journals. A total of 6,597 (81.1%) had first names listed, identifying 25,329 total authors, of which 22,961 (90.7%) were successfully matched to a gender. 9,273 unique authors were identified (female: 19.2%). Female representation increased for first and senior authors from 6.5% and 5.9% (1993-1997) to 16.9% and 13.1% (2013-2017, p<0.001). Compared with male authors, female authors published fewer articles (mean: 1.7 vs 2.4, p<0.001). Of 2,691 authors who first published during 2006 to 2011, 369 authors (13.0%; female: 8.1% vs male 15.0%, p<0.001) continued to publish 5 years after their first publication. Female authors were more likely to only publish one article (75.6% vs 69.4%, p=0.016). Conclusion: Female representation in academic foot and ankle research has increased over two-fold over the past 2 decades. Despite these advances, compared to male authors, female authors are less likely to continue publishing 5 years after initial publication, and on average publish fewer articles. Although women are increasingly supported in the surgical workforce, our findings suggest that disparities in academic productivity exist in foot and ankle surgery. Further analysis of barriers to research amongst women may result in more equitable academic advancement and promotion for female foot and ankle surgeons.