Plastic Surgery Research Council

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Outcomes Associated with Free and Local Flap Reconstruction for Lower Extremity Open Fractures: 2010 - 2016 Nationwide Readmissions Database
Niv Milbar, BA1, Kelly Bridgham, BS1, Said C. Azoury, MD2, Joseph K. Canner, MHS1, Elliott R. Haut, MD, PhD, FACS1, Justin M. Sacks, MD, MBA, FACS1.
1The Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2The University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Open lower extremity fractures represent a complex set of challenges for reconstructive surgeons, requiring close collaboration with orthopedic colleagues and a multidisciplinary approach for achieving long-term success. Though previous studies have demonstrated that limb salvage results in higher quality-of-life metrics and less expensive lifetime costs for patients as compared to amputation, peri-operative management of these patients varies greatly. Largely due to inadequacies in national diagnosis and procedure coding systems, analysis of multi-center peri-operative outcomes has been limited. The Nationwide Readmissions Database, which is based on the International Classification of Disease (ICD) coding system, provides a basis for understanding the burden of these injuries to the patient and the healthcare system.
METHODS: Utilizing the Nationwide Readmissions Database between the years of 2010 - 2016, two cohorts were identified: ICD9-based admissions between 2010 - 2015Q3, and ICD10-based admissions between 2015Q4 - 2016. The ICD10 cohort allowed for precise identification of the various treatment groups due to the more granular coding scheme, but only captured admissions within a one-year period. The ICD9 cohort required several assumptions to identify appropriate treatment groups but was powered by an increased number of patients over a five year period. Chi-square and ANOVA were utilized to compare free flap vs. local flap vs. non-flap patients demographically and multivariable clustered models were used to identify predictors of increased readmissions, length of stay, and costs. Cause of injury, injury characteristics, and reasons for readmission were compared among treatment groups.
RESULTS: 18,815 open lower extremity fracture inpatients were identified in the ICD10 cohort, of which 370 underwent a local flap procedure, 76 underwent free flap, and 12 underwent both during initial admission. Patients undergoing flap reconstruction were more likely to have Gustilo type III fractures (p-value <0.001) and stayed in the hospital an adjusted average of 9.2 days longer (p-value <0.001) during index admission. 90-Day readmission rate was 19.5% for non-flaps, 26.7% for local flaps, and 37.5% for free flaps (p-value <0.001). Adjusted mean total cost at 90-days was $23,690 for non-flaps, $55,126 for local flaps and $69,495 for free flaps (p-value <0.001). These trends were corroborated by results from the ICD9 cohort which included 43,769 patients, of which 595 were free flaps, 592 were local flaps, and 103 were both.
CONCLUSION: This study compares national outcomes for open lower extremity fracture patients. Though the Nationwide Readmissions Database requires a number of assumptions for analysis, it provides a basis for which to understand the peri-operative experience for this patient population. Undergoing free or local flap reconstruction significantly increases hospital length of stay, cost, and likelihood of readmission at 90-days. Though longer-term follow up is required to understand the full scope of this disease state, this study allows patients and physicians to be better informed about the treatment process in the immediate aftermath of reconstruction. Anticipating the delivery of post-operative treatment and helping guide potential interventions will lead to improvements in the quality of care for this specific patient population.


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