Does the Zone of Injury in Combat-Related Type III Open Tibia Fractures Preclude the Use of Local Soft Tissue Coverage?

Objectives: Does the large zone of injury in high-energy, combat-related open tibia fractures limit the effectiveness of rotational flap coverage? Design: Retrospective consecutive series. Setting: This study was conducted at Brooke Army Medical Center, Walter Reed Army Medical Center, and National Naval Medical Center between March 2003 and September 2007. Patients/Participants: We identified 67 extremities requiring a coverage procedure out of 213 consecutive combat-related Type III open diaphyseal tibia fractures. Intervention: The 67 Type III B tibia fractures were treated with rotational or free flap coverage. Main Outcome Measures: Flap failure, reoperation, infection, amputation, time to union, and visual pain scale. Results: There were no differences between the free and rotational flap cohorts with respect to demographic information, injury characteristics, or treatment before coverage. The reoperation and amputation rates were significantly lower for the rotational coverage group (30% and 9%) compared with the free flap group (64% and 36%; P = 0.05 and P = 0.03, respectively). The coverage failure rate was also lower for the rotational flap cohort (7% versus 27%, P = 0.08). The average time to fracture union for the free flap group was 9.5 months (range, 5-15.8 months) and 10.5 months (range, 3-41 months) for the rotational flap group (P = 0.99). Conclusions: There was a significantly lower amputation and reoperation rate for patients treated with rotational coverage. Contrary to our hypothesis and previous reports, the zone of injury in combat-related open tibia fractures does not preclude the use of local rotational coverage when practicable.