Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures.

OBJECTIVES: We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection. DESIGN: A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage. SETTING: Fourteen level-1 trauma centers across the United States. PATIENTS: Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage. INTERVENTION: Delay definitive fixation and flap coverage in tibial type III fractures. MAIN OUTCOME MEASUREMENTS: (1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding. RESULTS: Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001). CONCLUSION: Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gender Trends in Authorship of Foot and Ankle Academic Literature Over 24 Years.

Underrepresentation of females in surgery is reflected in research productivity across academic medicine, with male faculty being more likely to publish research than their female counterparts. In this study, we aimed to describe the representation and longevity of female investigators among the authors of articles in 3 foot and ankle research journals from 1993 to 2017. In this retrospective bibliometric analysis, authors from 3 prominent foot and ankle research journals (Foot and Ankle International, The Journal of Foot and Ankle Surgery, and Foot and Ankle Clinics) were identified. The proportion of female authors who were first, middle, and senior authors and the total publication count per author were determined. From 1993 to 2017, 8132 original articles were published and a total of 6597 (81.1%) had an accessible author list. This allowed us to identify 25,329 total authors, of whom 22,961 (90.7%) were successfully matched to a gender. A total of 9273 unique authors were identified (females, 19.2%). Female representation increased for first and senior authors over the years from 6.5% and 5.9% (1993 to 1997) to 16.9% and 13.1% (2013 to 2017, p < .001), respectively. However, compared with male authors, female authors published fewer articles (mean: 1.7 versus 2.4, p < .001). Of the 2691 authors who first published during 2006 to 2011, 369 authors (13%), consisting of 8.1% females and 15% males (p < .001), continued to publish 5 years after their initial publication. Female representation in academic foot and ankle research has increased >2-fold over the past 2 decades. But despite these advances, compared to male authors, female authors are less likely to continue publishing 5 years after initial publication, and on average publish fewer articles.