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Background: Extremity war trauma injuries offer complex and challenging issues for the reconstructive plastic surgeon. While aggressive forward resuscitative care measures within the war theater have improved survival rates, the injured war wounded often are faced with significant extremity reconstructive challenges. The experience of treating war related extremity injuries during the Afghanistan War will be outlined and presented.

Methods: All extremity limb salvage cases treated over the last 18 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 49 limb salvage procedures were performed, consisting of 30 upper extremity and 19 lower extremity flaps. Flaps utilized included 16 pedicled flaps and 33 free flaps, including 19 fasciocutaneous, 6 myocutaneous, 6 muscle, 1 osseous, and 1 omental flap. Overall flap success rate was 92%, total flap failure rate was 8%, and partial flap failure was 4%, respectively. One patient elected extremity amputation after flap failure (2%). 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.

Conclusions: Limb salvage cases secondary to war related injuries are challenging and complex. While innovative protective body armor, aggressive use of extremity tourniquets, and advanced forward care teams have contributed to increased survival rates, these advances along with increased dismounted blast exposures have also contributed to increased extremity injuries and opportunities for complex limb salvage cases. Furthermore, changing patterns in extremity wounds and limb salvage has begun to emerge which includes the following: a) more upper extremity compared to lower limb salvages, b) increased use of fasciocutaneous flaps in efforts to spare muscles necessary for rehabilitation, c) higher existing pre-flap DVT and pulmonary emboli rates acquired "downrange" or early after war wounded's battlefield injuries, and d) acceptable flap success rates and outcomes in a subacute setting of injury.