Differences in Practice Patterns in the Use of Temporary External Fixation for the Management of Open Lower-Extremity Fractures

Background: External fixation is often used in the management of open lower-extremity fractures. The objectives of this study were to identify hospital characteristics that are associated with greater use of temporary external fixation and to determine if external fixation reduces the odds of surgical site infection (SSI) and unplanned reoperation among patients with open lower-extremity fractures. Methods: This is a secondary analysis of the Aqueous-PREP and PREPARE-Open trials involving open lower-extremity fractures. Wilcoxon rank-sum and Fisher exact tests were used to assess if temporary external fixation use varied between hospital clusters. Mixed-effects logistic regression models controlling for hospital cluster and participant characteristics estimated the associations between temporary external fixation and SSI or unplanned reoperation. Results: There were 2,438 patients with an open lower-extremity fracture identified, with 568 (23.3%) undergoing temporary external fixation. There were 34 participating hospitals with a median external fixation rate of 21.5%. Hospitals with higher temporary external fixation use had a higher number of surgeons treating patients with fracture (p = 0.02). There was no difference in SSI at 90 days (odds ratio [OR], 1.16 [95% confidence interval (CI), 0.82 to 1.66]; p = 0.40) or 1 year (OR, 1.30 [95% CI, 0.97 to 1.75]; p = 0.08) between patients who did and did not undergo temporary external fixation. Patients who underwent temporary external fixation were more likely to have unplanned reoperations within 1 year (OR, 1.40 [95% CI, 0.96 to 1.79]; p = 0.05). Conclusions: More temporary external fixation for open lower-extremity fractures was performed at hospitals with more surgeons treating fractures. There was no difference in SSI at 90 days or 1 year between patients who did and did not undergo temporary external fixation. Temporary external fixation tended to be used in more critically ill patients and patients with more severe fractures but was not associated with increased unplanned reoperations at 90 days or at 1 year.