Background: The National Naval Medical Center (NNMC) continues to treat injured personnel supporting Operation Iraqi Freedom and the Global War on Terrorism. Mutilating war extremity wounds associated with improvised explosive devices (IEDs) have created a unique reconstructive challenge. The objective of this study is to report and analyze the timing and success rates of war extremity reconstruction performed in the subacute period (72 hours to 3 months).

Methods: A retrospective review was conducted of injured personnel requiring extremity flap reconstruction at NNMC over a 30-month period. All flap reconstructions were performed on this cohort by a single surgeon. Collected data included type and number of flaps, partial and total flap failure rates, number of pre-reconstruction wound washouts, time from initial injury to closure, post-operative early infection rates (within 6 weeks), associated injuries (fractures, neurovascular), use of negative pressure wound therapy and early flap failure necessitating limb amputation.

Results: From September 2004 to February 2007, seventy-two (56 pedicled flaps and 16 free) extremity flap reconstructions (27 fasciocutaneous, 39 muscle, and 6 adipofascial) were performed on sixty-six patients. Patient age ranged from 19 to 42 years (median age 23). Time to reconstruction ranged from 7 to 161 days (average 25 days). Seventy-one percent of all injuries were associated with an IED blast. Twenty-five upper (35 percent) and forty-seven lower (65 percent) extremity flaps were performed. Eight (11.1 percent) flaps were used to close proximal extremity wounds. Twenty-three (31.9 percent) flaps were used to close mid-extremity wounds and forty-one (57 percent) flaps were used to close distal extremity wounds. Median number of pre-reconstructive washouts was four (range 2 to 22). One hundred percent of injuries were associated with regional open fractures managed with negative pressure wound therapy prior to reconstruction. Thirty-two percent and twenty-one percent of injuries were associated with nerve and vascular injuries respectively. Forty percent of all wounds were cultured positive at admission, of which sixty-nine percent were associated with Acinetobacter species. Post-operative early infections occurred in ten flaps (13.9 percent). Total flap loss occurred in two flaps (2.8 percent) and partial flap loss occurred in six flaps (8.3 percent). Two patients underwent early limb amputation after flap failure.

Conclusions: Despite reconstruction in the subacute period, the high rate of antimicrobial colonization prior to wound closure, and the devastating nature of IED blast injuries, early analysis of the NNMC war extremity reconstruction cohort demonstrates low total and partial flap loss rates as well as acceptable infection rates. Longer-term data such as osteomyelitis rates, fracture union rate, time to ambulation, and patient satisfaction with limb salvage are currently under investigation.
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