Relationship between timing of emergency procedures and limb amputation in patients with open tibia fracture in the United States, 2003 to 2009

Abstract

Background: The authors aimed to characterize patterns in the timing of initial emergency procedures for patients with open tibia fracture and examine the relationship between initial procedure timing and in-hospital amputation.

Methods: Data were analyzed from the Nationwide Inpatient Sample, 2003 to 2009. Adult patients were included if they had a primary diagnosis code of open tibia fracture. Patients were excluded for the following reasons: they were transferred from or to another hospital, an immediate amputation was performed, more than one amputation was performed, no emergency procedure was documented, or they were treated at a facility that did not perform any amputations. The authors evaluated the association between timing of the first procedure and the outcome of amputation using multiple logistic regression, controlled for patient risk factors and hospital characteristics.

Results: Of 7560 patients included in the analysis, 1.3 percent (n=99 patients) underwent amputation on hospital day 2 or later. The majority (52.6 percent) underwent the first operative procedure on day 0 or 1. In adjusted analyses, timing of the first operative procedure beyond the day of admission was associated with more than three times greater odds of amputation (day 1, odds ratio, 3.81; 95 percent CI, 1.80 to 8.07).

Conclusions: Delay of the first operative procedure beyond the day of admission appears to be associated with a significantly increased probability of amputation in patients with open tibia fracture. All practitioners involved in the management of these patients should seek a solution for any barrier, other than medical stability of the patient, to achieving early operative intervention.

Clinical question/level of evidence: Risk, II.

Figure 1

Patient selection criteria.

Figure 2

Specifications of study variables. *CCS software accompanies NIS database to allow external cause of injury (E-Codes) to be grouped into limited categories.

Figure 3

Percentage of patients having amputation in each emergency procedure timing group.

Figure 4

Adjusted marginal probability of amputation in each emergency procedure timing group (vertical lines represent 95% confidence interval of estimates).