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Wound Surface Area as a Risk Factor for Flap Complications among Patients with Open Fractures

Shea, Phelan, B.A.; O’Hara, Nathan N., M.H.A.; Sprague, Sheila A., Ph.D.; Bhandari, Mohit, M.D., Ph.D.; Petrisor, Brad A., M.D., M.Sc.; Jeray, Kyle J., M.D.; Zhan, Min, Ph.D.; Slobogean, Gerard P., M.D., M.P.H.; Pensy, Raymond A., M.D.; On behalf of the Fluid Lavage in Open Wounds Investigators

Plastic and Reconstructive Surgery: July 2018 - Volume 142 - Issue 1 - p 228-236
doi: 10.1097/PRS.0000000000004418
Reconstructive: Lower Extremity: Original Article

Background: Soft-tissue complications often dictate the success of limb salvage and the overall outcome of open fractures. Based on prior work at the R Adams Cowley Shock Trauma Center, the authors hypothesize that wounds larger than 200 cm2 are associated with a greater likelihood of both flap-related reoperation and wound complications among patients requiring soft-tissue reconstruction with a rotational flap or free tissue transfer.

Methods: This study was a secondary analysis of Fluid Lavage in Open Wounds trial data that included all patients who received a rotational or free tissue flap transfer for an open fracture. The primary outcome was flap-related reoperation within 12 months of injury. The secondary outcome was wound complication, which included events treated operatively or nonoperatively. Multivariable logistic regression was used to assess the association between wound size and outcomes, adjusting for confounders.

Results: Seventeen percent of the 112 patients required a flap-related reoperation. A wound size greater than 200 cm2 was not associated with reoperation in an unadjusted model (p = 0.64) or adjusting for Gustilo type (p = 0.70). The sample had an overall wound complication rate of 47.3 percent. Patients with a wound size of greater than 200 cm2 were three times more likely to experience wound complications (OR, 3.05; 95 percent CI, 1.08 to 8.62; p = 0.04) when adjusting for moderate to severe wound contamination and wound closure in the operating room.

Conclusion: The findings of this study demonstrate that wound surface area is an integral determinant for wound complication following soft-tissue flap treatment, but found no association between wound surface area and flap-related reoperation rates.


Baltimore, Md.; Greenville, S.C.; and Hamilton, Ontario, Canada

From the Departments of Orthopaedics and Epidemiology and Public Health, University of Maryland School of Medicine; the Department of Health Research Methods, Evidence and Impact, and the Division of Orthopaedic Surgery, Department of Surgery, McMaster University; and the Department of Orthopedic Surgery, Greenville Health System.

Received for publication April 5, 2017; accepted November 8, 2017.

This trial is registered under the name “Fluid Lavage of Open Wounds,” identification number (NCT00788398).

Trial authors from the Fluid Lavage in Open Wounds investigators are listed in the Appendix.

Disclosure:Dr. Bhandari reports receiving consulting fees from Stryker, Smith & Nephew, Amgen, Eli Lilly, DJO Global, Zimmer, and Ferring Pharmaceuticals, and grant support from Stryker, Amgen, DePuy Synthes, Eli Lilly, and DJO Global. Dr. Jeray receives consulting fees from Zimmer and Eli Lilly and lecture fees from Zimmer and AO North America. Dr. Petrisor reports consulting fees from Stryker and Pfizer, and research support from Stryker and Zimmer. Dr. Sprague is an employee of Global Research Solutions. Dr. Pensy reports consulting fees from Globus Medical. Dr. Slobogean reports being a paid presenter for Zimmer Biomet. No other potential conflict of interest relevant to this article was reported.

Raymond A. Pensy, M.D., R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, Md. 21201,

Copyright © 2018 by the American Society of Plastic Surgeons