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Background: Evolving management of combat-related extremity injuries has resulted in increased limb salvage opportunities. The nearly decade long Iraq and Afghanistan Wars have also presented military surgeons with soft tissue coverage challenges in patients who often have multiple injuries which can limit options for availability of known reconstructive workhorse flaps. The purpose of this study is to investigate our collective experience and compare outcomes for muscle and skin based flaps.
Methods: A multicenter retrospective review of injured Servicemembers treated with soft tissue transfer for limb reconstruction from 2003 through 2012 was completed. Data collected included patient demographics, flap location and type. Outcomes measured included complications such as hematoma and flap infection and total or partial flap loss, and extremity complications such as soft tissue infection and osteomyelitis, and failed limb salvage.
Results: Over the last decade, 350 flap procedures (215 pedicle, 135 free) were performed on 188 lower and 132 upper extremities (30 extremities underwent multiple procedures). Patients were mostly males, aged 17-63, with a mean injury severity score (ISS) of 18. A total of 98% of patients were followed with average follow-up of 26 months.

Flap Options
Muscle		Skin/Perforator		Other
	n (%)		n (%)		n (%)
Total	194 (55)	Total	147 (42)	Total	9 (3)
Free	64 (33)	Free	64 (44)	Free	7 (78)
Latissimus	45 (70)	Anterolateral thigh (ALT)	35 (54)	Pedicle	2 (22)
Rectus	12 (19)	Lateral arm	15 (23)
Serratus	3 (5)	Scapular	11 (17)
Pedicle	130 (67)	Pedicle	83 (56)
Gastrocnemius	62 (48)	Sural	21 (26)
Soleus	34 (26)	Groin	19 (23)
Latissimus	18 (14)	Radial forearm	8 (10)

Complications
	Muscle	Skin/Perforator
	n (%)	n (%)	P-value
Total	53 (27)	37 (25)	0.375
Flap infection	15 (8)	8 (5)	0.271
Hematoma/seroma	12 (6)	9 (6)	0.584
Flap Failure	26 (13)	11 (7)	0.035
Free Flaps	8 (13)	3 (5)	0.103
Pedicle Flaps	18 (14)	7 (8)	0.164
Soft tissue Infection	28 (14)	18 (12)	0.337
Osteomyelitis	29 (15)	13 (9)	0.061
Amputation	30 (15)	17 (11)	0.191

Conclusion: In nearly a decade of war trauma, our multicenter group has performed a high volume of complex extremity reconstructions. We present a broad range of flap options to provide adequate coverage in extremity salvage and will discuss our institutional algorithms for optimal flap selection in our patient population. Complication rates did not significantly differ between the muscle and skin/perforator-based flap groups. However, failure rates were significantly higher in the muscle group which may mean that while complication rates were not statistically different they were clinically different. Though there was no difference in failure rates when broken down into free and pedicle flap subgroups. Further investigation is warranted to determine the cause of the increased failure rate in muscle based flaps. Nonetheless, each of these flap categories has utility in our patients, but each must be carefully considered prior to transfer based on reconstructive and rehabilitation goals of our war wounded.