The findings of this national study over a 7-year period indicate that delay of the first operative procedure is associated with a significantly increased probability of amputation in patients with open tibial fracture. Based on our findings, patients who do not have immediate amputation and who are medically stable for surgery should undergo debridement on the day of admission to reduce the probability of amputation. Plastic surgeons should be involved in care immediately, rather than days after admission, to ensure proper steps have been taken to maximize successful outcome.
Despite the preference for limb salvage by patients and physicians (23
), some patients clearly benefit from amputation over reconstruction, and we have learned from prior studies that the average patient has similar functional outcome after amputation compared to limb salvage (25
). It is clear from clinical experience that not all amputations are avoidable, even for cases in which early intervention is performed. However, despite the widely accepted practice of emergency treatment of open fractures (10
), it appears that at least 30% of patients in our national sample had initial procedures performed on hospital day 1 or later. These results are similar to findings in a recent population study by Namdari et al. (16
) that reported 24% of open tibial fracture patients in the National Trauma Data Bank experienced wait time to treatment greater than 24 hours. Patient injury severity may partially account for the delay in initial operative intervention. However, we controlled for overall injury severity score and limited our analysis to patients with primary diagnosis of open tibial fracture to minimize bias of associated traumatic injury on timing of procedures. We hypothesize that hospital or physician culture, practice patterns, and resource limitations likely play a role in determining initial operative timing in these patients. For example, some patients may have bedside irrigation of open fractures performed in the emergency department with delay of additional operative procedures the following day when treating surgeons are available. Such practices may be associated with higher probability of amputation. Contributing factors leading to delay at the provider and facility levels merit further examination, and are beyond the scope of this study. However, a growing body of literature has reported poor adherence to practice guidelines when the passive dissemination of information is employed, such as publishing clinical practice guidelines or studies (28
This study has limitations inherent in the analysis of administrative data, such as the retrospective nature and absence of accompanying detailed clinical data. Unique to this database, there is lack of longitudinal continuity beyond the admission on record. Thus, we were unable to capture late amputations or other late complications such as osteomyelitis. Late amputations occurred in approximately 3% of patients in the attempted reconstruction group of the Lower Extremity Assessment Project (LEAP) study, the largest prospective longitudinal multicenter study to date (25
). We would expect this proportion to be lower in our national sample because our sample included all open tibia fracture types, whereas the LEAP study included only severe open tibia fractures. In addition, the timing of the initial procedure was recorded in calendar days rather than hours. Despite this limitation, we are able to add to current knowledge surrounding delayed treatment in open fracture treatment, as the current literature does not address consequences of delay beyond 24 hours or the relationship between delay and limb amputation.
Another limitation is that we were constrained to using ICD-9-CM diagnosis and procedure codes to control for injury severity. As a consequence, we were unable to classify the open tibia fractures according to the commonly used Gustilo grading system (11
). However, we were able to control for arterial injury, nerve injury, and presence of a complex wound based on available ICD-9-CM codes, which account for the most severe types of open tibia fractures. Unfortunately, we are unable to distinguish the precise severity of soft tissue injury with presence of the complex wound diagnosis. Lastly, we could not consider patient social and psychological factors, such as family support and self-efficacy, which may impact the decision to pursue reconstruction versus amputation. In the literature these factors have been shown to impact functional outcomes after either treatment (25
). However, patient social and psychological factors have not been shown to impact the decision to perform amputation over limb salvage in the literature. Demonstration of the relationship between delay of treatment and increased probability of amputation can be strengthened in the future through separate analysis of another independent national data source or analysis of individual institution’s outcomes of open tibial fractures. However, review of data from institutions that do not treat large numbers of patients with open tibial fractures may not have sufficient power to fully evaluate the relationship.
Despite the limitations of this study, we were able to demonstrate a relationship between delay in initial operative intervention and an increased probability of amputation in patients with open tibia fracture. Hospitals and clinical departments treating these patients should examine practice patterns and limitations in being able to achieve early treatment. Medical stability is the only reason for delay that is in the best interest of the patient. All practitioners involved in managing these patients should seek a solution for any other barrier to achieving early operative intervention in order to prevent unnecessary amputation that may be attributed to delay in operative management. Changes in the process of care, such as immediate plastic surgery consultation and performing immediate operative intervention in medically stable patients, are unlikely to cause harm; rather these changes offer the potential to improve the likelihood of successful limb salvage.