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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.

Plastic and Reconstructive Surgery: August 2014 - Volume 134 - Issue 2 - p 333–338
doi: 10.1097/PRS.0000000000000363
Reconstructive: Lower Extremity: Original Articles
Press Release

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.


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,

©2014American Society of Plastic Surgeons