The Changing and Challenging Patterns of Extremity War Trauma: The Afghanistan Experience

Introduction:  Extremity injuries secondary to war trauma are often complex and offer many challenging dilemmas for the reconstructive plastic surgeon.  As aggressive forward resuscitative care and stabilization measures in the war theater have advanced, the survival rates of service members wounded in battle continue to improve.  Additionally, the rapid transport systems that have evolved enable the provision of complex medical care and reconstruction options to our wounded personnel in an abbreviated timeframe, with transfer from initial battlefield site of injury to a stateside definitive care setting within 3 to 4 days. 

Methods:  All extremity limb salvage cases treated over the last 16 months at the National Naval Medical Center were reviewed.  Outcomes assessed included: types of flaps utilized, flap success and failure rates, timing of wound coverage, pre-operative rates of certain co-morbidities, and complications.

Results:  A total of 40 limb salvage procedures were performed, consisting of 22 upper extremity and 18 lower extremity flaps.  Flaps utilized included 15 pedicled flaps and 24 free flaps, including 15 fasciocutaneous, 7 myocutaneous, 4 muscle, 1 osseous, and 1 omental flap.  Overall flap success rate was 95%, total flap failure rate was 5%, and partial flap failure was 5%, respectively.  One patient elected extremity amputation after flap failure (2.5%).  The average timing to free flap coverage was 21 days after initial injury. Pre-operative co-morbidities analyzed revealed DVT and/or PE rate of 30%, with all such patients being on full anticoagulation at time of definitive flap procedure.

Conclusion:  Limb salvage cases secondary to war related injuries are challenging and complex.  Trends such as 1) more dismounted blast exposures, 2) new and innovative protective body armor, 3) universal acceptance and use of tourniquets, as well as 4) aggressive forward care with rapid transport to continental Level V Military Medical Centers have all contributed to increased survival rates and opportunities for complex limb salvage cases.  Recent changing patterns of war-related limb salvage cases include: 1) a shift to more upper extremity compared to lower limb salvages, 2) an increase in the use of fasciocutaneous flaps, 3) higher “downrange” and pre-flap DVT and pulmonary emboli rates, and 4) acceptable flap success rate and outcomes in the subacute setting of injury.