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Extremity Reconstruction Outcomes in War-related Trauma
Jennifer Sabino1, Owen Johnson2, Barry Martin1, Mark Shashikant3.
1Walter Reed National Military Medical Center, Bethesda, MD, USA, 2Womack Army Medical Center, Fort Bragg, NC, USA, 3Fort Belvoir Community Hospital, Fort Belvoir, VA, USA.

PURPOSE:
War-injured patients from Iraq and Afghanistan represent a substantial reconstructive challenge. In order to salvage severely damaged limbs, surgeons use local, distant, or free tissue transfers for soft tissue coverage. The purpose of this study is to compare the outcomes of pedicle and free tissue flaps and to look at the long term limb salvage rates after complex soft tissue reconstruction.
METHODS:
This was a single-institution retrospective review of injured American Servicemembers treated at Walter Reed Army Medical Center between January 2003 and May 2011.
RESULTS:
Over an eight year period, we performed 186 flaps (117 pedicle and 69 free) on 159 patients. Fifty-four upper and 112 lower extremities were reconstructed; 20 extremities underwent multiple reconstructions. Patients were mostly male aged 17 to 63 with a mean injury severity score of 16. The 30-day complication rate was similar, 24% for pedicle flaps and 29% for free flaps. Primary flaps were successful in 98 pedicle and 58 free flaps (84 and 87%). Flap failure occurred in 19 pedicle and 9 free flaps but additional procedures achieved soft tissue coverage in all but two. One failure in each group resulted in amputation. Pedicle flaps attained a limb salvage rate of 99.9% and free flaps 98.5% during the initial hospitalization. About one-quarter of patients eventually underwent amputation regardless of technique, mostly for pain and infection. Only one upper extremity was amputated. Ninety-eight percent of patients were followed with an average follow up of 26 months.
CONCLUSION:
Tissue transfer for complex extremity wounds sustained in trauma results in adequate soft tissue coverage. Flap failure rarely leads to amputation and additional procedures lead to a high initial salvage rate. Pedicle and free flaps have comparable short and long-term outcomes. Upper extremity salvage is almost always successful, however lower extremities have a high amputation rate as a result of morbidity not related to the flap.


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