The Journal of Bone and Joint Surgery 82:1681 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Short-Term Wound Complications After Application of Flaps for Coverage of Traumatic Soft-Tissue Defects About the Tibia*
Andrew N. Pollak, M.D. ,
Melissa L. McCarthy, SC.D., O.T.R. ,
Andrew R. Burgess, M.D. and
the Lower Extremity Assessment Project (LEAP) Study Group, 
Investigation performed at the Division of Orthopaedic Traumatology,
The R Adams Cowley Shock Trauma Center, The University of Maryland
Medical System, and at the Center for Injury Research and Prevention,
The Johns Hopkins University School of Hygiene and Public Health,
Baltimore, Maryland
*The authors of this manuscript have chosen not to furnish information
to The Journal and its readers concerning any relationship
that might exist between a commercial party and material contained
in this manuscript that might represent a conflict of interest.
Funds were received in total or partial support of the research
or clinical study presented in this article. The funding source was
the National Institute of Arthritis, Musculoskeletal, and Skin Diseases.
Division of Orthopaedic Traumatology, The R Adams Cowley Shock
Trauma Center, The University of Maryland Medical System, 22 South Greene
Street, Baltimore, Maryland 21201-1595. Please address requests
for reprints to: A. N. Pollak, M.D., c/o Elaine P. Bulson, Editor,
Shock Trauma Orthopaedics, 22 South Greene Street, Room T3R64, Baltimore,
Maryland 21201-1595. E-mail address: ebulson{at}smail.umaryland.edu
Department of Emergency Medicine, Johns Hopkins University, 1830
East Monument Street, Suite 6-100, Baltimore, Maryland 21205.
§The Lower Extremity Assessment Project Study Group included
Ellen J. MacKenzie, Ph.D., Michael J. Bosse, M.D., James F. Kellam,
M.D., Andrew R. Burgess, M.D., Lawrence X. Webb, M.D., Marc F. Swiontkowski,
M.D., Roy Sanders, M.D., Alan L. Jones, M.D., Mark P. McAndrew, M.D.,
Brendan Patterson, M.D., and Melissa L. McCarthy, Sc.D.
Background: The purpose of the present study
was to compare the rate of short-term wound complications associated
with rotational flaps and that associated with free flaps for coverage
of traumatic soft-tissue defects about the tibia.
Methods: Of 601 patients prospectively enrolled
in a multicenter study of high-energy trauma of the lower extremity,
190 patients (195 limbs) required flap coverage and had six months
of follow-up. The injury data included the ASIF/OTA classification
of the tibial fracture and the soft-tissue injury and the functional
status of the neurovascular and muscular structures of the soft-tissue
compartments at the time of soft-tissue coverage. The treatment data
consisted of the type of flap, the timing of the flap coverage,
and the type of fixation. The patient characteristics that were
recorded included the age, gender, presence of comorbidities, and
smoking status at the time of the injury. Short-term complications
included wound infection, wound necrosis, and loss of the flap within
the first six months after the injury.
Results: Eighty-eight limbs were treated with
a rotational flap, and 107 limbs were treated with a free flap. Overall,
complications occurred after fifty-three (27 percent) of the 195
flap procedures; forty-six (87 percent) of the fifty-three required
operative treatment. The two treatment groups were similar with
respect to age, gender, comorbidities, preinjury smoking status,
ASIF/OTA classification of the fracture, and prevalence of vascular
injury requiring repair (p > 0.05). There were two important differences
between the two groups. First, three of the four leg compartments
- that is, the anterior, lateral, and deep posterior compartments -
were more likely to be functionally compromised in the free-flap
group than in the rotational flap group (p < 0.05), suggesting
that patients in the free-flap group had sustained more severe soft-tissue
injuries. Second, the Injury Severity Score was significantly higher
(p = 0.001) in the rotational flap group (mean, 14 points) than
in the free-flap group (mean, 11 points), suggesting that patients
in the former group had sustained more substantial total body trauma.
Overall, there were no significant differences between the two groups with
respect to the complication rates. However, among those with the
most severe grade of underlying osseous injury (an ASIF/OTA type-C
injury), 44 percent of the limbs that were treated with a rotational
flap had a wound complication compared with 23 percent of the limbs
that were treated with a free flap (p = 0.10). To control for any differences
between the two groups with respect to the severity of the injury,
the treatment methods, or the patient characteristics, multivariate
regression modeling was performed. An interaction effect between
the type of flap and the severity of the underlying osseous injury
demonstrated significance (p < 0.05) after controlling for other
factors. Of the limbs that sustained an ASIF/OTA type-C osseous
injury, those that were treated with a rotational flap were 4.3
times more likely to have a wound complication requiring operative
intervention than were those treated with a free flap. No significant
difference in the rate of complications was detected with respect
to the type of flap used for the limbs that had lower-grade osseous
injuries.
Conclusions: We found that use of a free flap
to treat limbs with a severe underlying osseous injury was significantly
less likely to lead to a wound complication requiring operative
intervention than was use of a rotational flap.
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