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Pediatric Open Tibial Fractures in the United States: Analysis of Incidence, Management Strategies and Resource-Utilization Over 15 Years
Alexandra Bucknor, MBBS, MRCS, MSc1, Klaas Ultee, PhD2, Anne Huang, BSc1, Anmol Chattha, BA1, Austin D. Chen1, Salim Afshar, MD, DMD3, Samuel J. Lin, MD, MBA, FACS1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Erasmus University Rotterdam, The Netherlands, Rotterdam, Netherlands, 3Boston Children's Hospital, Boston, MA, USA.

Background
Open tibial fractures are complex injuries to manage, often requiring combined plastic and orthopedic care. Centralization of services may improve patient outcomes and cost-efficiency.1 This study aims to characterize the epidemiology, management and resource-utilization of pediatric open tibial fractures in the United States.
Methods
Retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database for all available years (1997, 2000, 2003, 2006, 2009 and 2012) was undertaken. Data were retrieved for children ≤18 admitted with open tibial fractures. The Cochran-Armitage test was used to evaluate trends in patient and hospital characteristics, post-operative complications and operative modality over time.
Results
Over the years sampled, 9,339 children were admitted with open tibial fractures. Mean age was 12.35 years. Most were white (45.2%) males (75.2%) with Medicaid insurance (58.6%). Median household income was first or second quartile (29.6% and 26.0%).
The incidence of open tibial fractures has decreased, from 1,924 (27.7 per million) in 1997 to 1,005 (13.9 per million) in 2012. From 1997 to 2012 there were significant changes in management over time. The proportion of cases admitted to large hospitals increased over time (51.9% to 69.8%, p<0.001); with a concomitant decrease in cases admitted to medium (33.76% to 22.07%, p<0.001) and small hospitals (14.34% to 8.11%, p<0.001). There was a significant increase in cases managed at urban, teaching hospitals (49.8% to 75.8%, p<0.001). Complication rates were stable (3.1% to 3.3%, p=0.475), while hospital charges increased over time ($20,067 to $65,736, p<0.001)(table 1).
Operative trends are summarized in table 1. Primary choice of skeletal stabilization changed over time. Primary and secondary internal fixation and increased (p<0.001) and there was a concomitant decrease in cases managed by reduction-only (p<0.001). Flap reconstruction decreased (38.6% to 26.7%, p<0.001), while rates of debridement remained stable (p=0.240).
Conclusions
Our results support previous work highlighting the decreasing incidence of pediatric open tibial fractures.2 There is a clear trend toward centralization of care; however, there has been no improvement in complications, with a decrease in flap reconstruction. The role of plastic surgeons in the management of these injuries should be further investigated.
References
1.
Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Kelly KN, Hensley BJ, et al. High volume improves outcomes: The argument for centralization of rectal cancer surgery. Surgery. 2016;159:73648.
2.
Rao P, Schaverien M V, Stewart KJ. Soft tissue management of children's open tibial fractures--a review of seventy children over twenty years. Ann R Coll Surg Engl [Internet]. Royal College of Surgeons of England; 2010 [cited 2017 Feb 21];92:3205. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20501017
Table 1. Outcomes and operative trends by year of admission.

Outcome199720002003200620092012P
Charges in $ (95% CI)20,067
(19,003-21,130)
25,189
(23,728-26,651)
36,320
(33,860-38,780)
41,218
(38,826-43,611)
55,279
(51,275-59,282)
65,736
(60,826-70,646)
<0.001
Complications (n, %)60
(3.05)
56
(3.19)
67
(4.16)
48
(3.26)
33
(2.79)
34
(3.32)
0.475
Skeletal stabilization
Reduction only336
(22.5)
253
(18.7)
205
(15.7)
172
(14.1)
129
(13.0)
97
(11.5)
<0.001
Primary internal fixation691
(35.1)
682
(38.9)
716
(44.5)
773
(52.4)
668
(56.4)
606
(59.2)
<0.001
Secondary internal fixation85
(4.3)
101
(5.8)
130
(8.1)
98
(6.7)
92
(7.8)
79
(7.7)
<0.001
Soft tissue management
Debridement1,556
(79.1)
1,381
(78.7)
1,282
(79.6)
1,191
(80.7)
969
(81.8)
831
(81.2)
0.265
Skin graft116
(5.9)
125
(7.1)
104
(6.5)
82
(5.6)
56
(4.7)
42
(4.1)
0.859
Flap reconstruction760
(38.6)
574
(32.7)
511
(31.7)
466
(31.6)
352
(29.7)
273
(26.7)
<0.001


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