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Purpose: Given military conflicts in Iraq and Afghanistan, a substantial amount of data concerning the management and outcomes of soft tissue transfer for limb salvage in war wounded patients has been published. There is debate, however, whether these results can be applied to civilian trauma given the inherent differences in the military patients and injury patterns. The purpose of this study is to compare military and civilian patients undergoing limb salvage after trauma and to compare outcomes of soft tissue transfer between the two groups.
Methods: This is a multi-institution retrospective review of patients treated with tissue transfer for extremity trauma at R Adams Cowley Shock Trauma Center (STC) and Walter Reed National Military Medical Center (WRNMMC) between 2005 and 2012. 
Results: From 2005 to 2012, 359 soft tissue transfers were performed at WRNMMC and 251 were performed at STC. Upper extremity comprised 8% of procedures at STC and 41% at WRNMMC. Free tissue transfers were performed for 53% of limb salvages at STC versus 45% at WRNMMC. Patients treated at WRNMMC were significantly younger, had higher injury severity scores, were performed later, and had more procedures prior to definitive flap coverage compared to the civilian patients.

	STC		WRNMMC
	Mean	SD	Mean	SD	p-value
Age	36.6	14.2	25.7	6.4	0.000
Injury severity score (ISS)	15.8	10.2	19.5	9.6	0.000
Procedures prior	3.2	2.6	6.4	4.1	0.000
Days to flap	14.0	30.7	34.2	82.1	0.000
Procedures after	3.3	3.9	4.3	2.9	0.004
Hospital days	26.0	16.5	67.2	43.1	0.000

Despite the aforementioned differences, there was no significant difference in flap outcomes and complications between the military and civilian cohorts. However, the lower extremity amputation rate was significantly higher in military patients (12 vs 24%, p=0.004).

	STC	WRNMMC
	n (%)	n (%)	p-value
Total complications	64 (25)	84 (27)	0.701
Flap failure	25 (10)	30 (10)	0.779
Pedicle flaps	11 (9)	21 (12)	0.581
Free flaps	14 (11)	9 (6)	0.200
Failed limb salvage	25 (12)	46 (14)	0.601
Upper extremity	1 (8)	1 (1)	0.151
Lower extremity	24 (12)	45 (24)	0.004

Given differences in amputation rates, subgroup analysis of the lower extremity group revealed significant differences.

	STC	WRNMMC
	n (%)	n (%)	p-value
Osteomyelitis	46 (22)	58 (30)	0.038
Soft tissue infection	22 (11)	36 (19)	0.046
Heterotopic ossification	6 (3)	13 (7)	0.102
Pain	4 (2)	42 (22)	0.000

Infection and pain were the primary reason for amputation at WRNMMC (78%) and STC (50%) (p=0.312 for amputation and 0.259 for pain). While the amputation rate after flap failure was higher at STC, flap failure was not a common reason for failed limb salvage in either groups analyzed (9 vs 21%, p=0.257).
Conclusions: Patients treated within the military system for combat related injuries were significantly younger and typically have more severe injuries than those treated at a comparative Level I trauma center. Despite differences in mechanism of injury, demographics, and course of care, flap outcomes and complication rates were similar between groups. However, lower extremity amputation rates were significantly higher in military patients. Psychosocial aspects of rehabilitation may play a role in late amputation because amputation secondary to medical necessity is similar between groups.