Initial management of open tibial fractures in peripheral hospitals does not necessarily correlate with an increase in flap failure rates

Abstract

The landmark paper of Naique et al. has formed the basis for the new guidelines on combined management of open tibial fractures, yet there are no other studies that have confirmed their findings, specifically with respect to an increase in flap failure rate in cases managed initially in peripheral hospitals. 1 Naique S.B. Pearse M. Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br. 2006 Mar; 88: 351-357 Google Scholar , 2 Standards for the management of open fractures of the lower limb. BOAST Guidelines from the British Orthopaedic Association and the British Association of Plastic & Aesthetic Surgeons, 2009http://www.bapras.org.uk/downloaddoc.asp?id=141 Google Scholar Our unit previously reviewed the management of open tibial fractures with respect to the 1997 guidelines which emphasized timing of debridement and flap cover, rather than combined care in Specialist Centres. 3 Singh S. Lo S.J. Soldin M. Adherence to national guidelines on the management of open tibial fractures: a decade on. J Eval Clin Pract. 2009 Dec; 15: 1097-1100 Google Scholar This demonstrated, as have others, that fracture fixation revision and need for further debridement was unacceptably high in cases managed in non-specialist units. 35% cases required further operative intervention prior to flap cover, including a fracture fixation revision rate of 22% and re-debridement of 13%. However, re-analysis of our original data with respect to flap failures gives us differing conclusions from Naique et al. All failures in their series occurred in the group managed in District General Hospitals (6 out of 63 cases, 9.5% flap failure rate). Although this failed to reach statistical significance (p = 0.076), this was attributed to the low power of the study. In our series of 36 cases of IIIB open tibial fractures that required flap coverage, 23 cases were treated initially in a District General Hospital and 13 cases treated primarily at the Specialist Centre. Patients that were managed primarily in a District General Hospital rather than the Specialist Centre, were not statistically more likely to suffer primary flap failure. Of the free flap reconstructions, 3/11 free flaps failed in patients from peripheral units, 1/5 free flaps failed in patients managed primarily in the Specialist Centre (Fishers exact test, 2 tailed p value = 1.00). Likewise, for local flaps the failure rates were 1/12 and 1/8 respectively (p = 1.00).