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The Effect of Flap Coverage on Length of Stay and Costs for Patients with Fractures of the Tibia

Thakore, Rachel V. B.S.; McClure, D. Jake M.D.; Sathiyakumar, Vasanth B.A.; Higdon, Kent K. M.D.; Sethi, Manish K. M.D.

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Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 444e-445e
doi: 10.1097/
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The rising costs of health care, a third of which are inpatient expenses,1 have left hospitals struggling to find ways to reduce expenses. Controlling length of stay is an effective strategy for minimizing costs while decreasing hospital resource utilization.2,3 A few studies have shown that open tibia fractures are associated with long lengths of stay,4,5 but none has quantified the length of stay and cost increases that occur when a reconstructive procedure for flap coverage is required for closure. We compared length of stay and costs for open tibia fractures requiring flap coverage with those in fractures that were closed primarily, and provide recommendations on how to improve coordination between plastic and orthopedic surgical care.

After receiving institutional review board approval from Vanderbilt University, we searched the medical records database at a level I trauma center for patients with tibia fractures treated from January of 2000 to December of 2011. Current Procedural Terminology code 27759 was used to identify patients treated by intramedullary nail. Eight additional codes were queried to find patients with muscle, pedicle, or free flap coverage. Patients with closed fractures, multiple injuries, or incomplete charts were excluded. Age, sex, race, and American Society of Anesthesiologists physical status classification were collected. Hospital length of stay was calculated by subtracting the admission date from the discharge date at a cost of $4503 per night. A Mann-Whitney U test and linear stepwise regression adjusting for age, sex, race, and physical status classification were performed. Data were stored in an Excel database (Microsoft, Redmond, Wash.), and statistical analysis was performed using SPSS software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, N.Y.)

We found 520 patients with tibia fractures who were treated with intramedullary nail, 91 of whom had open isolated tibia or tibia fibular fractures with complete charts. Fifty-five patients received primary closure of their wounds, and 36 required subsequent flap coverage, including six free flaps.

The mean length of stay for patients with tibia fractures who received primary closure was 4.5 days, with a hospitalization cost of $20,341.14. Patients who required flap coverage had a mean length of stay of 11.0 days and $49,428.28 in costs. There was a significant difference in mean length of stay and costs between patients who required flap coverage and those who received primary closure of their wounds (p < 0.001). The mean number of days between intramedullary nail and flap coverage was 2.9 days. Patients remained in the hospital for an average period of 6.5 days following reconstructive surgery (Table 1).

Table 1
Table 1:
Mean Length of Stay and Costs Based on Type of Procedure

Our results demonstrate that improved communication between plastic and orthopedic teams can reduce length of stay and costs for patients with open tibia fractures who require flap coverage. Although we utilized a standard hospitalization cost, patients who require free flaps are monitored for a minimum of 3 days in the intensive care unit or in similar levels of care management, which leads to higher costs than reported. In these cases, early involvement by plastic surgeons with microsurgical skills can decrease the length of time from admission to surgery. Weekly conferences between orthopedic and plastic surgeons can serve to improve awareness of indications of a potential need for flap coverage, increase interdepartmental coordination of care, and accelerate patient recovery.


The authors have no financial interest to declare in relation to the content of this article. There was no actual or potential source of funding in relation to this article.

Rachel V. Thakore, B.S.

D. Jake McClure, M.D.

Vasanth Sathiyakumar, B.A.

Kent K. Higdon, M.D.

Manish K. Sethi, M.D.

Vanderbilt Orthopaedic Institute Center for Health Policy

Vanderbilt University

Nashville, Tenn.


1. Agency for Healthcare Research and Quality. . Statistical Brief #396: National Health Care Expenses in the U.S. Civilian Noninstitutionalized Population, 2010. 2010 Rockville, Md Agency for Healthcare Research and Quality Available at: Accessed July 27, 2013
2. Stephen AE, Berger DL. Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection. Surgery. 2003;133:277–282
3. Wentworth DA, Atkinson RP. Implementation of an acute stroke program decreases hospitalization costs and length of stay. Stroke. 1996;27:1040–1043
4. Briel M, Sprague S, Heels-Ansdell D, et al. Economic evaluation of reamed versus unreamed intramedullary nailing in patients with closed and open tibial fractures: Results from the Study to Prospectively Evaluate Reamed Intramedullary Nails in Patients with Tibial Fracture (SPRINT). Value Health. 2011;14:450–457
5. Schmidt AH. The impact of compartment syndrome on hospital length of stay and charges among adult patients admitted with a fracture of the tibia. J Orthop Trauma. 2011;25:355–357


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