Soft tissue coverage of combat wounds

Warfare-related open fractures with large soft tissue defects create a significant reconstructive challenge. The objective of this article is to review current and evolving treatment strategies for soft tissue coverage of warfare-induced extremity wounds. A review of previously published literature and current data evaluating combat-injured personnel requiring extremity flap reconstruction performed by a single surgeon within the National Capital Area from 2004 to 2009 was performed. Collected data reviewed included injury patterns, methods of reconstruction, and success rates. Seventy-five (59 pedicled flaps and 16 free) extremity reconstructions employing flaps (34 fasciocutaneous, 34 muscle, and 7 adipofascial) were performed in the subacute time period between 7 days and 3 months. One hundred percent of the wounds were associated with open fractures. Early postoperative infections (<6 {\it weeks from reconstruction) occurred in 10 patients (13%). Total flap loss occurred in two flaps (2.8%) and partial flap loss occurred in six flaps (8.3%). Two patients underwent early limb amputation after flap failure. Two additional patients underwent delayed amputation. Flap success was 97% and limb salvage rate was 94%. Based on the location of the extremity wounds, a reconstruction guide for flap type was created. Modern military limb reconstruction strategies in carefully selected patients with soft tissue defects have resulted in low flap loss rates and high limb salvage rates despite reconstruction in the subacute period between 7 days and 3 months. This limb salvage protocol is likely applicable in high-energy civilian motor vehicle accidents or industrial trauma when highly contaminated wounds are present.