Postoperative outcomes based on timing of definitive fixation and flap coverage in Gustilo-Anderson 3B open tibia fractures

Objective Management of Gustilo 3B tibias remains problematic with high complication rate. Controversy persists about coverage timing, and whether the clock starts at time of injury or definitive fixation. Postoperative outcomes of 3B open tibia fractures and the effect of fixation and flap timing were reviewed retrospectively. Methods Design: Retrospective observational study. Setting: Data derived from Bellwether PearlDiver, a multicenter insurance claims database. Patient Selection Criteria: 1066 Gustilo 3B tibia fractures were identified with flap coverage within 45 days of fixation (2009 ... 2021). Fixation within 3days of injury was classified as prompt. The remaining fixations were designated as delayed. Flap coverage within 3 days of fixation was considered prompt. Coverage after this was considered delayed. Outcome Measures and Comparisons: Complications and return to OR were analyzed. Separately, patients were divided by days to definitive fixation or days to flap coverage, irrespective to the other. One-year complication incidence was compared using linear regression analysis. Results 252 (23.6 %) patients received prompt fixation and prompt flap. 519 (48.7 %) received prompt fixation and delayed flap. 271 (25.4 %) underwent both delayed fixation and flap while only 24 (2.3 %) received prompt flap following a delay in fixation. By linear regression analysis, surgical site infection (SSI), wound disruption (WD), and reoperation incidence increased by 0.53 % (p < 0.001), 0.84 % (p < 0.001), and 0.63 % (p < 0.001), respectively, with each day between fixation and flap coverage. Days from injury to fixation was significant for increased WD incidence (0.38 %, p = 0.03). Conclusions Early flaps demonstrated fewer complications. Very few patients with delayed fixation received prompt flap coverage. Prior research suggested that delayed fixation had few consequences when followed by prompt flap coverage. This appears to be rare in practice. Prompt multidisciplinary orthopaedic and plastics management of Gustilo 3B tibia fractures is important for optimal outcomes in these injuries.