Complex War Extremity Wound Reconstruction: Improved Outcomes in the
Subacute Period.
Anand R. Kumar MD, Joanne F. Johnston MD, Thomas L. Chung, DO
Division of Plastic and Reconstructive Surgery, National Naval Medical Center,
Bethesda, Maryland.
Background: The National Naval Medical Center (NNMC) continues to treat injured
personnel supporting Operation Iraqi Freedom (OIF) and the Global War on Terrorism.
Optimal reconstruction of massive soft-tissue and bone defects secondary to high energy
wounding mechanisms such as improvised explosive devices (IEDs), mortars, rocket
propelled grenades (RPGs), and assault rifle projectiles remains poorly characterized.1, 2
Mutilating war extremity wounds associated with improvised explosive devices (IEDs)
have created a unique reconstructive challenge. Godina reported a 0.75% flap failure rate,
1.5 % infection rate and a union time of 6.8 months in limbs reconstructed within 72
hours of injury. He also reported a 12% flap failure rate, 17.5% infection rate and a 12.3
months time to union in patients reconstructed between 72 hours and 3 months of injury.3,
4
The challenge with high-energy military wound reconstruction is achieving early wound
closure. Evidence in the civilian literature indicates that early wound coverage provides
better outcomes.6-14 Due to multiple factors including transport times, war extremity
wounds have been reconstructed in the subacute time period.15 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 (Figures 1-4).
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.
Figure 1 IED related dorsal hand wound
Figure 2 Free ALT flap reconstruction
Figure 3 Open subtrochanteric femur fracture, ORAM flap
Figure 4 ORAM flap, 9 months post injury
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