Inferior clinical outcomes after femur fracture in the obese are potentially preventable.

INTRODUCTION: Obese patients with operative orthopedic trauma have increased risk of adverse outcomes, although the mechanisms accounting for the relationship remain unknown. This study examines the effect of body mass index (BMI) on outcomes after femur fracture fixation, and explores the mediating effects of pathophysiologic factors and clinical management. METHODS: A retrospective chart review was performed of adult patients with femur fractures undergoing surgical fixation at a Level 1 trauma center from 2010 to 2016. Demographics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and mechanism of injury (MOI) were collected along with operative data and complications. Primary outcomes were hospital length of stay (HLOS), ICU length of stay (ICU-LOS), mortality, complications, and time to mobility (time first out of bed, TFOB). Bivariate correlations and multiple regression models were used to examine the relationship between BMI and outcomes. Path analysis tested whether the relationship between BMI and clinical outcomes was mediated by differences in 1) clinical management, or 2) physiologic variables. RESULTS: Of 333 patients included, the majority were male (57.4%) with a mean age of 43.4 (22.7) years and ISS of 12.5 (6.8). Predominant MOIs were motor vehicle crashes (42.8%) and falls (34.5%). There was no association between BMI category and age, ISS, or GCS. In univariate analysis, higher BMI was linked to longer HLOS (r = .12), longer ICU-LOS (r = .15), longer TFOB, (r = .18), and higher number of complications (r = .12), p < 0.05. Controlling for age and ISS, obese patients had 6.66 times the odds of respiratory failure (p = 0.021, 95% CI 1.3,33.3) and a 3.88 odds of any complication (p = 0.020, 95% CI 1.24,12.1) compared to their normal weight counterparts. For every one point increase in BMI, time first out of bed was delayed 2.3 h (p < 0.001; 95% CI 1.08, 3.62). The effect BMI on poor outcomes was accounted for by delayed mobility (longer TFOB) in a mediation model. CONCLUSIONS: Higher BMI increases the risk of longer hospital stays and systemic complications. Mediation models indicate that the adverse clinical outcomes associated with obesity are explained by delays in mobility, an intervenable factor. Clinical strategies should be directed at early mobilization to minimize morbidity.

The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate.

Historical practices have advocated emergent operative debridement for all open fractures. To date only studies in guinea pigs have demonstrated decreased infection with surgical intervention within 6 hours of injury. Recent studies have questioned this practice in humans. The purpose of this study was to determine if there was an increased infection rate based on time delay from presentation to initial operative debridement. A retrospective chart review was done from 1998 to 2004 to identify patients who presented to our level 1 trauma center with open tibia shaft fractures and had at least 2 years of follow-up. Two hundred fifteen open tibia shaft fractures in 206 patients were included in this study. A time delay of 0 to 6 hours revealed a 10.8% (7/65) infection rate, of 6 to 12 hours a 9.5% (9/95) infection rate, of 12 to 24 hours a 5.6% (2/36) infection rate, and no infections in a delay >24 hours (N=19). Using the Mantel-Haenszel chi-square test, P=.12; Fisher exact test P value was .53. Combining time intervals to 0 to 12 hours and >12 hours returned 10% (16/160) and 3.6% (2/55) infection rates, respectively. Fisher exact test P value was .17. Statistical analysis failed to show significant differences among the various time interval groups. Based on current evidence, we recommend that in the absence of gross contamination, early informal irrigation should be done on an urgent basis along with initiation of intravenous antibiotics, while a formal debridement combined with fixation, if indicated, can be done later in a timely manner.