title: Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes.
abstract: BACKGROUND
  Open tibial fractures are orthopedic emergencies that may present with severe soft tissue damage. Free tissue transfer is often required when local tissues are insufficient and patients may require hospital transfer to tertiary care centers for this purpose. Although the negative impact of inter-facility transfer has been well demonstrated in trauma patients, less is known regarding transfers for lower extremity injury patients. This study investigates differences in outcomes based on transfer status after open tibial fracture.
  
  
  METHODS
  Thirty-four consecutive open tibial fractures requiring free tissue transfer over a 13-year period (2001-2014) were retrospectively reviewed. Patients transferred from outside facilities were compared to non-transferred patients in regards to demographics, injury, surgical characteristics, and outcomes (mean follow-up of 2.5 years). Student t tests and chi square analysis were used to compare means and proportions, respectively.
  
  
  RESULTS
  One-half of patients were transferred from an outside hospital. Transferred and nontransferred patients were not significantly different in regard to age, sex, comorbidities, mechanism of injury, and Gustilo grade. There was no significant difference in the method of bony fixation or free flap used for soft tissue coverage. The time to wound vacuum-assisted closure placement was longer in transferred patients, though this difference was not found to be significant (2.4 vs 3.3 days, P = 0.55). Time to definitive bony fixation was delayed in the transfer group by 9 days (5.2 vs 14.1 days, P = 0.05) and to tissue coverage by 7 days (14.2 vs 20.9 days, P = 0.13). Rates of flap loss and amputation did not differ between the groups. However, transferred patients were more likely to develop osteomyelitis (risk ratio [RR], 3.0; P = 0.03), nonunion (RR, 5.0; P = 0.09), and require hardware removal (RR, 3.3; P = 0.01).
  
  
  CONCLUSIONS
  Transferred and nontransferred patients were not significantly different in their demographics or presentation. However, an analysis of clinical outcomes showed that transfer was associated with increased rates of osteomyelitis, nonunion, and hardware removal. Although likely multifactorial, this study suggests that a delay to definitive fixation and soft tissue coverage contributes to the increased rate of complications and poorer prognosis.
authors.affiliation: From the Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, CA.
authors.forename: Christopher S
authors.initials: CS
authors.lastname: Crowe
authors.forename: Anna
authors.initials: A
authors.lastname: Luan
authors.forename: Gordon K
authors.initials: GK
authors.lastname: Lee
mesh_terms: D005260:Female; D005597:Fractures, Open / Q000601:surgery*; D058752:Free Tissue Flaps; D006801:Humans; D008297:Male; D008866:Microsurgery / Q000379:methods*; D008875:Middle Aged; D010360:Patient Transfer / Q000706:statistics & numerical data*; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D012307:Risk Factors; D013978:Tibial Fractures / Q000601:surgery*; D016896:Treatment Outcome