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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0000000000000363
Reconstructive: Lower Extremity: Original Articles

Multiple Limbs Salvaged Using Tissue Transfers in the Same Casualty: A Cohort Comparison Study Chronicling a Decade of War-Injured Patients

Valerio, Ian M.D., M.S., M.B.A.; Sabino, Jennifer M.D.; Thomas, Shane D.O.; Tintle, Scott M.D.; Fleming, Mark D.O.; Shashikant, Mark M.D.; Kumar, Anand M.D.

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Bethesda and Baltimore, Md.; Pittsburgh, Pa.; and Fort Belvoir, Va.

From the Walter Reed National Military Medical Center; Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center; Department of Plastic and Reconstructive Surgery, The Johns Hopkins University School of Medicine; Uniformed Services University of Health Sciences; and Fort Belvoir Community Hospital.

Received for publication May 16, 2013; accepted September 10, 2013.

Presented at Plastic Surgery: The Meeting 2012, in New Orleans, Louisiana, October 28, 2012.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Army, Department of Defense, or the U.S. government.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Ian L. Valerio, M.D., M.S., M.B.A., Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Md. 20889,

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Background: Extremity battlefield injuries from Operation Iraq and Enduring Freedom (Afghanistan) requiring multiple limbs salvaged with tissue transfers in the same patient are an understudied population. This study aimed to report the limb salvage outcomes in patients requiring multiple flap procedures for two or more concurrent extremity injuries.

Methods: A retrospective cohort comparison of warfare-related extremity injuries treated for limb salvage from 2003 through 2012 at the National Capital Consortium was completed. Number of single and multiple flap limb salvages, Injury Severity Score, success rates, and complications were analyzed.

Results: A total of 359 limb salvage reconstructive procedures were performed, consisting of 311 cases of single extremity salvage and 48 cases of multiple flap or multiple extremity salvage. The Injury Severity Score was significantly higher in the multiple extremity group (23) than in the single extremity group (17; p < 0.001). Primary flap failure rate was 9 percent in single and 12 percent in multiple limb salvage cases (p = 0.390). The subgroup flap failure rate in the multiple limb salvage cohort was 8 percent, 7 percent, and 25 percent for pedicle flaps, pedicle/free flaps, and free flaps, respectively (p = 0.361). The total complication rate was 26 percent and 33 percent for single and multiple limb salvage cases, respectively (p = 0.211).

Conclusion: Limb salvage requiring multiple flap procedures in the polyextremity-injured patent is safe and equally effective when compared with a single-limb-injured cohort despite a significantly higher injury severity score. Overall complication rates were not significantly different, although subgroup analysis demonstrated a trend toward increased flap failure in the multiple free flap cohort.


Warfare-related extremity injury from blast injuries sustained during support of the Iraq and Afghanistan conflicts commonly involves multiple extremities of the same service member, often with massive soft-tissue losses.1–6 The typical blast exposure pattern not only causes significant wounds in multiple extremities but also can transmit effects to distant tissue donor sites outside of the potentially salvageable extremity. Because of the large corresponding zones of injury, these complex injuries may require treatment with more common free flaps (e.g., anterolateral thigh, latissimus, rectus, free fibula flaps) or less common flaps (e.g., scapular, omental, various perforator, free-style free flaps) for reconstruction of multiple extremity wounds. Multiple components of the reconstructive ladder may be used concurrently to reconstruct these complex extremity injuries. Delayed primary closure, dermal substitutes, massive skin grafts, regenerative medicine techniques, external tissue expanders, and the use of multiple rotational or free tissue transfers in various concurrent combination have proven effective in treatment of complex multiple extremity injury cases.4–8

Advances in forward surgical care have resulted in improved survivability of severely injured service members with greater survivability after blast-related injuries. As a result, the reconstructive surgeon has adapted and must now consider multiple extremity salvage rather than multiextremity amputation.9–11 In those cases in which amputation is required, successful preservation of the remaining threatened limbs is even more critical to facilitate early ambulation. Flap selection using the Bethesda protocol is based on coverage of vital structures exposed in the extremity wound, the wound geometry (size, shape), while maximizing potential function in the salvaged limb.12–14 Single flaps have been insufficient for coverage in certain cases when multiple extremities are threatened in the same casualty. In these unique instances, our team has performed two or more separate flap procedures for two or more separate threatened limbs in the same individual. The purpose of this review is to report our outcomes after limb salvage experience with particular interest in the subgroup of patients undergoing multiple flap procedures for two or more limb salvages compared with our single limb salvage population. Lessons learned from this unique battlefield cohort may be applied to the many civilian trauma centers treating complex polyextremity-injured patients.

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After obtaining institutional review board approval, a review of all consecutive patients treated with flap reconstruction for a limb-threatening injury was performed in the National Capital Area from 2003 to 2012. The National Capital Area previously consisted of the National Naval Medical Center (Bethesda, Md.) and Walter Reed Army Medical Center (Washington, D.C.) before their respective merger into a single institution in 2011 as the multiservice institution, the Walter Reed National Military Medical Center (Bethesda, Md.). The electronic medical record was used to identify two subgroups of interest: (1) patients who underwent flap reconstruction for single limb salvage and (2) patients who underwent flap reconstruction for two or more limb salvage attempts. Patients who underwent flap reconstruction to prevent amputation to a higher level were also included in the limb salvage cohort.

Additional demographic data collected included the Injury Severity Score, timing of coverage, duration of hospital stay, success rates, and complications such as infections, hematomas, seromas, partial and total flap necrosis rates, and amputation or failed limb salvage rates. Comparisons were made between the single and multiple flap cohorts to identify any significant differences.

Patient demographics and preoperative care are summarized using descriptive statistics and compared between groups using t test or Mann-Whitney test, as appropriate. Categorical demographics such as gender are summarized as a proportion and compared using a chi-square test. Outcomes were analyzed for statistically significant difference between groups using a chi-square test or Fisher’s exact test, as appropriate. Statistical significance was defined as p ≤ 0.05. All analysis was performed using SPSS 2.0 statistical software.

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From January of 2003 through July of 2012, 359 flap reconstructive procedures were performed for limb salvage secondary to extremity war injury. These procedures consisted of 311 cases of single extremity salvage and 48 cases of multiple extremity limb salvage. Upper extremities were reconstructed in 146 cases (41 percent) and lower extremities in 213 cases (59 percent), with a total of 216 pedicle and 143 free flaps used. The majority of patients were male (99 percent), and blasts from an improvised explosive device constituted the most common mechanism of injury (91 percent of all cases) (Figs. 1 and 2). The mean age of the patients was 25.6 years (range, 17 to 63 years). Most patients (95 percent) sustained Gustillo type IIB or C fractures; the remaining patients sustained soft-tissue wounds with no associated fractures or underwent reconstruction to preserve amputation length. Average time until wound coverage was 34 days in the single extremity group and 30 days in the multiple extremity group (range, 7 to 1227 days; p = 0.679). On average, six wound irrigation and débridement procedures were performed before definitive extremity reconstruction in the single extremity group, and seven were performed in the multiple extremity group (range, 0 to 29; p = 0.185). The average length of hospitalization was significantly shorter in the single extremity group (70 days) than in the multiple extremity group (93 days; range, 14 to 425 days; p = 0.007) (Table 1). There was a statistically significant difference when comparing injury severity scores. The single extremity group mean score was 17 compared with 24 for the multiple extremity group (p < 0.001) (Fig. 1).

Table 1
Table 1
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Fig. 1
Fig. 1
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Fig. 2
Fig. 2
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The total complication rate was not significantly different in the single extremity injury cohort (26 percent) compared with the multiple extremity injury cohort (33 percent; p = 0.211). The most commonly occurring complications in the total cohort were infection and flap or donor-site hematoma/seroma. There were significantly more hematomas in the multiple flap limb salvage cohort (17 percent; p < 0.001). Flap success rate was 90 percent for cases with single limb salvage and 87 percent for cases with multiple limb salvage (p = 0.390). The long-term amputation rate was also similar: 14 percent in both groups (p = 0.526) (Table 2). In patients who underwent amputation, average time to amputation was 10 months. Amputation was the result of non–flap-related complications such as pain or chronic osteomyelitis, with two patients preferring amputation after flap failure despite an additional flap procedure being offered. Both of these patients were in the single extremity cohort.

Table 2
Table 2
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In the 48 procedures involving multiple flap extremity salvage, 13 were pedicle-only flaps, 21 were a combination of pedicle and free flaps, and 14 were only free flaps. The complication rate in procedures with only pedicle flaps was 8 percent, consisting of one flap loss secondary to total necrosis. The complication rate in procedures with a combination of free and pedicle flaps was 33 percent, consisting of five hematomas, one incident of venous congestion, and infection; and one flap aborted intraoperatively. There was one flap failure in this group. In procedures using only free flaps, the complication rate was 36 percent, consisting of two incidents of hematoma, two incidents of soft-tissue infection, and one seroma. There were two cases of flap failure in this group, with one patient having two separate flaps fail. The difference in complication rates excluding flap failure was not statistically significant between groups (p = 0.143). The flap failure rate for pedicle flaps, pedicle/free flaps, and free flaps was 8 percent, 5 percent, and 25 percent, respectively (p = 0.361) (Table 3).

Table 3
Table 3
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Although the literature is replete with outcome analysis after single flap reconstruction of limb threatening injuries, few specifically report outcomes after multiple flap reconstruction of two or more limb-threatening injuries in the same patient.15,16 The conflicts in Iraq and Afghanistan have highlighted a unique group of patients surviving multiple extremity war injuries complicated by open fractures requiring complex reconstruction.1–3 Our limb reconstruction team has encountered a unique cohort of patients who are candidates for multiple flap procedures in order to salvage more than one threatened limb. In a series by Whitney and colleagues, the authors described their experience with simultaneous and sequential free tissue transfers in addressing various extremity injuries.17,18 Their group reported acceptable and successful multiextremity flap coverage for limb salvage without any significant increases in regards to flap failure or complications rates. Our reported overall complication rate for single flap (26 percent) and multiple flap (33 percent) also supports the cited literature. However, our series noted a significantly higher hematoma rate in the multiple flap limb salvage cohort than in the single flap limb salvage cohort (17 percent and 6 percent, respectively; p < 0.001).

The use of free tissue transfer to salvage amputation levels has been well established in the literature and has been successfully used to maintain postamputation extremity length and preserve joint function.19–21 In 2007, Baccarani and colleagues22 published their algorithm for free tissue transfer in upper extremity amputees. The authors stated that lack of available tissue for primary closure as well as preservation of major joint function and length to be indications for free tissue transfer in upper extremity amputees. Similarly, concerning lower extremity amputees, maintenance of the knee joint has been recognized as a major indication for free tissue transfer in transtibial amputations.20,21 Critical to each of the cases presented in our series was maintenance of residual limb length and a functioning joint (wrist joint and knee joint). Given the challenges that the polytraumatized combat amputee population faces during recovery, salvage of length and joint function is of utmost importance.23,24 Our experience supports limb salvage in the multiple extremity injured patient, with avoidance of a higher limb amputation levels despite a higher injury severity score.

Fasciocutaneous and perforator flaps were considered our first line flaps as each spares the need to potentially injury muscles that may benefit the polylimb or amputee patient in his or her rehabilitation and future quality of life needs. In larger wounds or those located on weight bearing surfaces, the latissimus muscle was our flap of choice as was the case in both transtibial amputations sites and one of the open tibia fractures. Large wounds can be covered using chimeric flaps from the same donor site to minimize donor-site morbidity and operative time. Meticulous preoperative planning to include including flap selection and timing is also necessary to minimize procedure related morbidity and operative trips. Flap selection is of critical importance in the war wounded patient with concurrent traumatic brain injury and multiple extremity amputations. Inappropriate flap selection can further worsen extremity function or complicate prosthetic wear. Despite increasing flap donor sites in the multiple extremity injured cohort, flap failure rates (12 percent) and total complication rates (33 percent) were not significantly elevated.

Despite successful outcomes, this study has limitations. It is a retrospective chart review with many confounding variables that are difficult to control for due to the unique nature of each extremity. The sample size in the multiple flap cohort was limited, and a larger patient cohort may introduce significant changes in clinical outcomes studies. Therefore, the study is not adequately powered to make definitive conclusions. Furthermore, the results of this study may not be generalizable to the civilian trauma population. The majority of our patients are young, previously healthy individuals who are highly motivated to pursue comprehensive rehabilitation. War-injured patients are unique in the mechanism of injury, severity, and environment in which they sustain trauma. Therefore, our findings must be applied cautiously to civilian cohorts where wounding patterns, psychosocial patient traits, and institutional support may be significantly different.

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The past decade of war trauma has presented our institution with a high volume of limb salvage cases, including a number of casualties who underwent multiple flaps for two or more limb salvages. Undertaking cases requiring multiple flap procedures in the polyextremity-injured patient is safe and equally effective when compared with a single limb injured cohort despite a significantly higher injury severity score. Overall complication rates were not significantly different between groups, but subgroup analysis demonstrated a trend toward increased flap failure using multiple free flaps and a significantly higher rate of hematoma in the multiple extremity injured cohort.

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8. Army Dismounted Complex Blast Injury Task Force. Dismounted Complex Blast Injury. 2011 Fort Sam Houston, TX Available at: Accessed September 6, 2012

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