Wound Surface Area as a Risk Factor for Flap Complications Among Patients with Open Fractures

Background: Soft tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at our institution, we hypothesize that wounds greater than 200cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft tissue reconstruction with a rotational flap or free tissue transfer. Methods: We performed a secondary analysis of FLOW trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. Our primary outcome was flap-related reoperation within 12 months of injury. Our secondary outcome was wound complication, which included events treated operatively or non-operatively. Multivariable logistic regression was used to assess the association between wound size and the outcomes, adjusting for confounders. Results: 17.0% of the 112 patients required a flap-related reoperation. A wound size of greater than 200cm2 was not associated with reoperation in an unadjusted model (p=0.64) or adjusting for Gustilo type (p=0.70). The sample had an overall wound complication rate of 47.3%. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (Odds Ratio: 3.05, 95% CI 1.08- 8.62, p=0.04) when adjusting for moderate-severe wound contamination and wound closure in the operating room. Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates. * list of trial authors is listed in the Appendix Financial disclosure statement: The study was funded by the Canadian Institutes of Health Research (MCT-93173), the U.S. Army Institute of Surgical Research Orthopedic Trauma Research Program (W81XWH-08-1-0473), U.S. Army Institute of Surgical Research Peer Reviewed Orthopedic Research Program (W81XWH-12-1-0530), and Association Internationale pour l'Ostéosynthèse Dynamique. Dr. Bhandari reports receiving consulting fees from Stryker, Smith & Nephew, Amgen, Eli Lilly, DJO Global, Zimmer, and Ferring Pharmaceuticals, and grant support from Stryker, Amgen, DePuy Synthes, Eli Lilly, and DJO Global; Dr. Jeray, receiving consulting fees from Zimmer and Eli Lilly and lecture fees from Zimmer and AO North America; Dr. Petrisor reports consulting fees from Stryker and Pfizer, and research support from Stryker and Zimmer; Dr. Sprague, being an employee of Global Research Solutions; Dr. Pensy reports consulting fees from Globus Medical; and Dr. Slobogean reports being a paid presenter for Zimmer Biomet. No other potential conflict of interest relevant to this article was reported. Statement of institutional review board approval: The study was approved by the ethics committees at McMaster University, Greenville Health System, and each participating center. All the patients provided written informed consent. Clinical trial registration:ClinicalTrial.gov Identifier: NCT1069315 Corresponding Author: Raymond A. Pensy, MD, R. Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 Greene St., Baltimore, MD 21201, Email: rpensy@umoa.umm.edu ©2018American Society of Plastic Surgeons

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