Acute Treatment Patterns for Lower Extremity Trauma in the United States: Flaps versus Amputation

Abstract

Background Treatment algorithms for large soft tissue defects in lower extremity trauma are not clearly defined. The aim of this study is to determine if there are geographic or demographic differences in the management of open tibia fractures with soft tissue defects requiring either soft tissue reconstruction or amputation in the United States (US). Methods A retrospective analysis was performed on the Nationwide Inpatient Sample (NIS), 2000 to 2011. We evaluated flap and amputation rates in the open tibia fractures with soft tissue defects based on geographic and socioeconomic factors. Results From 2000 to 2011, there were 175,283 open tibia fractures in the US; 7.2% (n = 12,620) had a concomitant soft tissue defect requiring either flap or amputation. The overall flap rate was 73.2% (n = 9,235). When compared with the South at 68%, flap rates were highest in the West at 79% (adjusted odds ratio [AOR] = 2.06; 95% confidence interval [CI] = 1.49, 2.86; p < 0.0001), followed by the Northeast at 77% (AOR = 1.63; 95% CI = 1.22, 2.19; p = 0.001), and the Midwest at 74% (AOR = 1.76; 95% CI = 1.25, 2.47; p = 0.001). Flap rates were lower in the rural hospitals in the West (AOR = 0.24; 95% CI = 0.07, 0.84; p = 0.03) and Northeast (AOR = 0.55; 95% CI = 0.37, 0.82; p = 0.003) when compared with the urban hospitals. Flap rates were highest in the highest income quartile at 77% (AOR = 1.53; 95% CI = 1.05, 2.25; p = 0.03) compared with 72% in the lowest income quartile. Conclusions Reconstruction rates were significantly higher in three major US regions when compared with the South, urban hospitals in the West and Northeast, and the highest income quartile.

Assessment of Function after Free Tissue Transfer to the Lower Extremity for Chronic Wounds Using the Lower Extremity Functional Scale

“…The treatment algorithm for traumatic lower extremity wounds is also poorly defined, with some studies suggesting that the question of free tissue transfer versus amputation in this population, is largely incumbent upon regional variability in practice, in urban versus rural hospital settings, with the former presumably more likely to have large academic facilities capable of free tissue transfer. 19 Studies originating out of our modern war experience have shown that healthy patients with an otherwise traumatized or painful extremity can in fact do better with an amputation. 20 This bears a critical distinction from the chronic wound patient: the former possesses physiologic reserve enough to entrain his or herself to an amputation.…”

“Primary free-flap tibial open fracture reconstruction with the Masquelet technique” and internal fixation

“…Treatment of critical-size bone defects and extensive soft tissue loss of the tibia in open fractures is a challenge because of the limited amount of soft tissue in the tibia, the subcutaneous location of the bone, its poor vascularity, and the high risk of infection [2] . The amputation rate for Gustilo grade IIIB/C open fractures can be as high as 26.8% [3] . The main purpose of open fracture treatment is to repair bone defects and perform soft tissue reconstruction.…”

Microsurgery and external fixation in orthoplastic reconstruction of tibial injuries

“…Historically, primary treatment with amputation was strongly suggested, to avoid early complication such as infectionsandtissuenecrosispropagation,withasignificantlowering of life quality for patients. On the other hand, when salvage is the primary option, late bone infections, delayed bone union or non-union,venousinsufficiency,representadditionalpost-operativecriticismsthatseverelyaffecttherestorationoflimbstructure andfunction [3,4].…”