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, 14 (7), e1002336

Timing of Femoral Shaft Fracture Fixation Following Major Trauma: A Retrospective Cohort Study of United States Trauma Centers


Timing of Femoral Shaft Fracture Fixation Following Major Trauma: A Retrospective Cohort Study of United States Trauma Centers

James P Byrne et al. PLoS Med.


Background: Femoral shaft fractures are common in major trauma. Early definitive fixation, within 24 hours, is feasible in most patients and is associated with improved outcomes. Nonetheless, variability might exist between trauma centers in timeliness of fixation. Such variability could impact outcomes and would therefore represent a target for quality improvement. We evaluated variability in delayed fixation (≥24 hours) between trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and measured the resultant association with important clinical outcomes at the hospital level.

Methods and findings: A retrospective cohort study was performed using data derived from the ACS TQIP database. Adults with severe injury who underwent definitive fixation of a femoral shaft fracture at a level I or II trauma center participating in ACS TQIP (2012-2015) were included. Patient baseline and injury characteristics that might affect timing of fixation were considered. A hierarchical logistic regression model was used to identify predictors of delayed fixation. Hospital variability in delayed fixation was measured using 2 approaches. First, the random effects output of the hierarchical model was used to identify outlier hospitals where the odds of delayed fixation were significantly higher or lower than average. Second, the median odds ratio (MOR) was calculated to quantify heterogeneity in delayed fixation between hospitals. Finally, complications (pulmonary embolism, deep vein thrombosis, acute respiratory distress syndrome, pneumonia, decubitus ulcer, and death) and hospital length of stay were compared across quartiles of risk-adjusted delayed fixation. We identified 17,993 patients who underwent definitive fixation at 216 trauma centers. The median injury severity score (ISS) was 13 (interquartile range [IQR] 9-22). Median time to fixation was 15 hours (IQR 7-24 hours) and delayed fixation was performed in 26% of patients. After adjusting for patient characteristics, 57 hospitals (26%) were identified as outliers, reflecting significant practice variation unexplained by patient case mix. The MOR was 1.84, reflecting heterogeneity in delayed fixation across centers. Compared to hospitals in the lowest quartile of delayed fixation, patients treated at hospitals in the highest quartile of delayed fixation suffered 2-fold higher rates of pulmonary embolism (2.6% versus 1.3%; rate ratio [RR] 2.0; 95% CI 1.2-3.2; P = 0.005) and required greater length of stay (7 versus 6 days; RR 1.15; 95% CI 1.1-1.19; P < 0.001). There was no significant difference with respect to mortality (1.3% versus 0.8%; RR 1.6; 95% CI 1.0-2.8; P = 0.066). The main limitations of this study include the inability to classify fractures by severity, challenges related to the heterogeneity of the study population, and the potential for residual confounding due to unmeasured factors.

Conclusions: In this large cohort study of 216 trauma centers, significant practice variability was observed in delayed fixation of femoral shaft fractures, which could not be explained by differences in patient case mix. Patients treated at centers where delayed fixation was most common were at significantly greater risk of pulmonary embolism and required longer hospital stay. Trauma centers should strive to minimize delays in fixation, and quality improvement initiatives should emphasize this recommendation in best practice guidelines.

Conflict of interest statement

ABN is the Director of the ACS Trauma Quality Improvement Program.


Fig 1
Fig 1. Derivation of the patient cohort.
Numbers of patients excluded reflect that patients may have met more than 1 criteria for exclusion.
Fig 2
Fig 2. Caterpillar plot showing trauma center odds ratios (ORs) and 95% confidence intervals (Cis) for delayed fixation, risk-adjusted for patient baseline and injury characteristics.
High outliers (greater than average odds of delayed fixation) and low outliers (lower than average odds of delayed fixation) are shown. In total, 57 (26%) centers showed significant differences in rates of delayed fixation unexplained by patient case mix. Data available in S3 Table.
Fig 3
Fig 3. Cumulative percentage of patients receiving definitive fixation as a function of time from emergency department (ED) arrival.
Hospitals in the highest quartile of delayed fixation (Quartile 4) achieved fixation in only 60% of patients at 24 hours, whereas 87% of patients underwent fixation within 24 hours at hospitals where delays were minimized (Quartile 1). Data available in S4 Table.

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Grant support

This work was supported by funds from the De Souza Chair in Trauma Research (ABN is the recipient). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.