Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries

War wounds associated with Operation Iraqi Freedom have created a unique reconstructive challenge. The objective of this study was to report and analyze the timing and success rates of lower extremity reconstruction associated with devastating war wounds.

A retrospective review was conducted of injured personnel requiring extremity flap reconstruction at the National Naval Medical Center over a 30-month period. Collected data included mechanism of injury, time from initial injury to closure, number of prereconstruction wound washouts, types of flap, flap failures, associated injuries, and wound culture characteristics.

From September of 2004 to February of 2007, 46 (36 pedicled and 10 free flaps) lower extremity flap reconstructions (10 fasciocutaneous, 34 musculocutaneous, and two adipofascial) were performed on 43 patients. Patient age ranged from 19 to 37 years. Time to reconstruction ranged from 7 to 82 days (average, 21 days). Seventy-six percent of all injuries were associated with an improvised explosive device blast. Mean number of prereconstructive washouts was five (range, two to 13). Fifty percent of all wounds cultured at admission revealed positive results, of which 57 percent were associated with Acinetobacter species. Total flap loss occurred in one flap and partial flap loss occurred in two flaps.

Despite reconstruction in the subacute period, the high rate of antimicrobial colonization before wound closure, and the devastating nature of improvised explosive device blast injuries, early analysis of the National Naval Medical Center war extremity reconstruction cohort demonstrates low total and partial flap loss rates and acceptable infection rates.