RECONSTRUCTIVE SURGERY

From Battleside to Stateside The Reconstructive Journey of Our Wounded Warriors Ian L. Valerio, MD, MS, MBA,*Þþ Jennifer Sabino, MD,* Gerhard S. Mundinger, MD,þ and Anand Kumar, MDþ Abstract: Recent military operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) have led to further refinements of the military medical system’s ability to provide advanced surgical care. The deployment of a global trauma care system has directly contributed to improved combat casualty survival rates. As a consequence of improved survivorship, a high-volume patient population of individuals having challenging multiple extremity injuries/amputations has presented to military treatment facilities. These patients present with unique mixed pattern blast injuries. Blast injuries incorporate multiple mechanisms of injury including penetrating fragmentary injury, blunt force trauma, f lash burn, and overpressure wave damage. These complex injuries have furthered refinements in traditional reconstruction and facilitated early application of regenerative medicine therapies. This article summarizes information presented at the inaugural Garry Brody, MD Family Invited Lectureship presented at the 63rd California Society of Plastic Surgeons Annual. Key Words: limb salvage, free tissue transfer, war trauma, extremity, blast injury (Ann Plast Surg 2014;72: S38YS45)

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ecent military operations during Iraq [Operation Iraqi Freedom (OIF)] and Afghanistan [Operation Enduring Freedom (OEF)] have presented our military treatment facilities (MTFs) with a significant number of wounded personnel with unique and complex warfarerelated injuries. Survivorship rates have significantly improved after these massive warfare-related injuries secondary to logistic advancements within the military trauma care delivery and transport systems. Systematic achievements, mainly centered on the rapid transit of injured personnel from the battlefield to advanced care facilities within the war theater and quickly to our highly specialized stateside MTFs, coupled with the notable improvements in combat headgear, eye protection, and body armor as well as the liberal use of extremity tourniquets for severe extremity injuries have all had great impact of survival rates.1Y3 These specific gains have improved upon those accomplishments achieved during previous major wars and various military conflicts.1Y3 Recent survivorship data from OEF have demonstrated Received October 29, 2013, and accepted for publication, after revision, January 6, 2014. From the *Walter Reed National Military Medical Center, Bethesda, MD; †Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; and ‡Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Conflicts of interest and sources of funding: none declared. 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, Army, Department of Defense, or the United States Government. Reprints: Ian L. Valerio, MD, MS, MBA, Department of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsplasticsurgery.com). Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-S038 DOI: 10.1097/SAP.0000000000000168

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current rates which approach an 11:1 survival ratio for warfare-related severe injury compared to those casualties killed in action. This ratio has improved upon the rates previously reported during the recent OIF conflict (a 9:1 survival to killed-in-action casualty ratio).3

CHANGING INJURY PATTERNS The trauma, orthopedic, and plastic surgery reconstructive teams at Continental United States MTFs have treated a large number of unique and complex blast injuries. Blast injuries secondary to improvised explosive devices are the primary causes of severe polytrauma to the war fighter throughout the modern Iraq and the Afghanistan Wars. However, this unique pattern of blast injury has changed over time spanning these 2 most recent military operations. The typical blast-injured patient from Iraq (OIF) was partially protected from direct blast exposures due to greater use of armored vehicles for more urban operations. This blast injury pattern has been referred to as a ‘‘mounted blast injury.’’ As the operations transitioned to the rural mountainous regions of Afghanistan, armored vehicle use is less predictable and reliable due to this transition in terrain and environment. Thus, ‘‘dismounted’’ patrols where our service members are more often on foot patrols within this environment have become more commonplace. These dismounted patrols expose the war fighter to more direct blast exposures. The resulting injury patterns from direct blast effect without vehicle shielding have been referred to as a ‘‘dismounted blast injury’’ and have resulted in higher rates of poly-limb injuries with or without concurrent amputations.

STANDARDIZATION OF SUBACUTE RECONSTRUCTION Military treatment centers have evolved their treatment of complex warfare-related trauma. A better treatment plan incorporating the optimal timing and reconstruction method for craniofacial, torso, and extremity blast injuries has emerged. Due to various concomitant injuries and heavily contaminated wounds, our patients require frequent serial debridement and meticulous injury care to achieve a favorable wound before executing definitive reconstruction measures. Accordingly, subacute (injury days 7Y30) reconstruction has become the standard for achieving successful definitive wound closure for our recent warfare-related wounds and injuries. Early reconstruction (G7 days) treatments proved to be premature and contributed to higher complication rates secondary to higher infection rates, evolving tissue destruction as the wounds further declare over early treatment periods, and higher than expected flap and tissue necrosis within early treatment paradigms. Additionally, the logistical times required for evacuation from the battlefield to our stateside MTFs have also contributed to subacute reconstruction and extremity salvage becoming standard in these severely injured war wounded after initial stabilization in theater and through transition of care into our stateside MTFs.4,5 Given the rather unique logistical circumstances that the current conflicts have presented to our global military trauma system, our trauma, orthopedic, and reconstructive teams have worked together in establishing reproducible algorithmic protocols (termed clinical practice guidelines) to aid in medical decision making for treatment of complex war-related craniofacial, thoracoabdominal, and extremity injuries.6,7 These surgical and medical care protocols are readily available to our Annals of Plastic Surgery

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Wounded Warrior Reconstruction

FIGURE 1. The military Casualty Evacuation (CASEVAC) system. Addressing poly-limb contaminated war casualties begins at the time of the blast. Echelon I constitutes in-field medical care. Echelon II constitutes triage and limited life-supporting medical care in theater on base. Echelon III represents the Combat Support Hospital (CSH), Navy ships and Fleet Hospitals or Air Force Theater EVAC Hospitals. These facilities are all capable of further definitive care rendered within the combat zone, such as providing resuscitation, initial surgery, definitive and reconstructive surgery, postoperative care, and intensive care. Echelon IV is communications zone-level health service support, which includes the receipt of patients evacuated from the combat zone. This echelon involves treating the casualty in a general hospital. Here, patients receive further treatment to stabilize them for their evacuation to stateside MTFs. Echelon V is the most definitive care provided to all categories of patients at stateside military hospitals, where ultimate treatment capability for patients from the theater resides, including full rehabilitative care and tertiary-level care.

deploying and in-theater medical teams and have been shown to both decrease potential complications as well as improve patient survival rates, outcomes, and contribute to our reconstruction outcomes and success rates.

A GLANCE AT THE MILITARY INTERNATIONAL TRAUMA SYSTEM Within theater, our personnel are rapidly triaged at the initial site of their blast injury. Led by Army medics and/or Naval Hospital Corpsmen, this initial treatment phase has been termed ‘‘Echelon 1 or Role 1’’ care. These military medical assets provide rapid stabilization and resuscitation measures and secure extremity tourniquets and/or pressure dressings to control acute hemorrhage (Fig. 1). Injured personnel are then rapidly transferred to an Echelon 2Y3 or Role 2Y3 in-theater medical treatment facility where full trauma evaluations and interventions then take place. Early surgical interventions for life and limb preservation using a damage control surgery paradigm is the cornerstone of the rapid care assessment and treatment provided at this systematic level. Interventions common at this level include liberal use of craniotomy or craniectomy for addressing neurotrauma injuries, thoracoabdominal exposures for penetrating injuries and/or critical hemorrhage control, as well as debridement of contaminated wounds are addressed at this level of care. Vascular shunts and/or repairs are also performed to preserve the threatened limb, whereas orthopedic bone stabilization with application of external fixators to preserve limb length is also accomplished during this level of care. A * 2014 Lippincott Williams & Wilkins

FIGURE 2. Diagram of major transport routes for wounded allied forces through Landstuhl Regional Medical Center (gold star). BAMC/SAMMC, Brook Army Medical Center/San Antonio Military Medical Center; NMCP, Naval Medical Center Portsmouth; NMCSD, Naval Medical Center San Diego; WRNMMC, Walter Reed National Military Medical Center (all previously listed facilities are Echelon V). LRMC, Landstuhl Regional Medical Center (Echelon IV).\ www.annalsplasticsurgery.com

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The last decade of war trauma has presented our institution with a high volume of limb salvage cases. A number of trends have emerged over these recent conflicts which parallel the injury patterns described previouslyVthat is, ‘‘mounted’’ versus ‘‘dismounted’’ blast patterns of injury. Identified changing trends in extremity reconstruction include

an increase in upper extremity injury and salvage for the recent OEF conflict compared to primarily isolated lower extremity injury pattern and salvage during the early years of the recent OIF conflict. These changes have necessitated an increase in the use of free transfer with high limb salvage success rates during the subacute (7Y30 days) period of injury. Numerous studies published in the civilian literature have recommended early wound coverage with low corresponding rates of f lap-related complications and improved outcomes.8Y15 In contrast, our experience has demonstrated that early wound coverage (G7 days) was associated with high complications and poor outcomes in patients with warfare-related extremity injuries.16,17 A review of our experience with all consecutive limb salvage cases requiring flap reconstruction for warfare-related extremity injury was performed at Walter Reed National Military Medical Center. Data assessed included patient demographics, injury patterns, and preoperative care including coverage timing and number of procedures performed before flap. Outcomes measured included success rates, flap complications such as infection, hematoma/seroma, partial and total f lap necrosis, and related extremity complications such as concomitant soft tissue infection, osteomyelitis, and nonunion. Long-term outcome such as bony union, time to ambulation, and delayed amputation rates were also reviewed. Time to union was calculated by examination of radiographs and clinical assessments by an independent orthopedic surgeon. The data collected were divided into 2 groups, flaps procedures performed between 2003 and 2008 and those performed from 2009 to present. These 2 periods correspond to the changing shifts in injury patterns identified within our war wounded. Specifically, extremity injuries associated with the first period were more representative of OIF, and those of the second period were more representative of OEF. Patient demographics, preoperative care, and outcomes were analyzed for statistical significance between the groups. Descriptive variables were compared using Student t test for means and Mann-Whitney for medians. Categorical variables were compared using W2 or Fisher exact test, as appropriate. Significance was defined as 2-tailed P value less than or equal to 0.05. All analysis was performed using SPSS statistical software. All patients studied were men aged 19 to 45 years (mean, 24 years). The mechanism of injury in most cases was high velocity explosives (Table 1). Injury severity score increased from 13.1 in 2004 to 30.8 in 2012 (Fig. 3). Of the 173 cases, 89 involved upper extremity reconstruction, whereas 84 cases were lower extremity cases. The operation tempo during the first period consisted of 75 procedures versus an increase in procedures to 98 completed during the second period reviewed. The average time to definitive limb salvage procedure was 27 days (range, 7Y170 days) for the first period and decreased to 24 days (range, 7Y255 days) during the latter. The median days to flap were not significantly different, 18 versus 19 days for the first period and second

FIGURE 3. Injury Severity Score (ISS) by year for reconstructed patients. Trend line: ISS = 1.5711x = 31133.3; R2, 0.4409.

FIGURE 4. Days to f lap and number of procedures before f lap coverage during the study period.

TABLE 1. Patient Demographics Age, y Injury severity score (ISS)

Mean (SD)

Range

24 (4.9) 22 (10) n

19Y45 8Y50 %

87 84

51 49

155 9 5 2

91 5 3 1

Extremity Upper Lower Mechanism of injury Blast GSW MVC Other

full surgical and medical complement team that parallels that of our nation’s level 1 trauma centers is thus situated at this in-theater battlefield tertiary hospital facility. From the Role 3 hospital centers, the trauma patients are then rapidly transferred from in-theater MTFs to the Role 4 hospital located within Landsthul, Germany. This hospital center is the main receiving center for many NATO coalition patients injured in the Afghanistan conflict, and these trauma patients are then transferred to their host countries for ongoing and definitive medical care at their home countries (Fig. 2). Those US service members being treated for warfare-related injuries undergo continued medical care including serial debridement of their wounds until transfer to our stateside multiservice denominated military Role 5 MTFs such as Walter Reed National Military Medical Center and San Antonio Military Medical Center. After reaching the Role 5 hospital systems, definitive orthopedic stabilization measures, soft tissue coverage, and eventual definitive reconstruction measures can be safely realized for our wounded warriors. The military combat casualty medical care system outlined previously involves a rather rapid transfer of the casualty from the battlefield injury site to receipt of these casualties at definitive stateside MTFs typically in an average of less than 5 days from their initial injury.

COMPLEX EXTREMITY TRAUMA RECONSTRUCTION

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Wounded Warrior Reconstruction

FIGURE 5. Patient 1. Upper left, Early acute period after right below-knee amputation (BKA) and left lower extremity soft tissue injury in process of serial debridement in preparation for definitive reconstruction. Upper right, First-stage left lower extremity reconstruction with preparation of lateral genicular artery f lap recipient vessels and hybrid reconstruction. Lower left, Definitive reconstruction showing hybrid technique with free latissimus transfer for knee and upper tibial coverage, and extracellular and dermal regenerative template for soft tissue augmentation. Lower left, Early follow-up of left lower extremity salvage at early follow-up after split-thickness skin grafting.

period, respectively. On average, 8 wound irrigation and debridement operations were performed before definitive flap coverage, which did not significantly change during the period examined (Fig. 4). Most f lap reconstructions performed were within a subacute period. From 2003 to 2008, 50 lower extremity limb salvages were performed (Figs. 5Y8; see Video 1, Supplemental Digital Content 1, http://links.lww.com/SAP/A110) versus 25 upper extremity cases (Figs. 9Y11). From 2009 to 2012, upper extremity salvages became more common, with 64 upper extremity procedures performed versus 34 lower extremity reconstructions (Fig. 12). During the former period, 61 pedicle flaps and 14 free flaps were performed. Pedicle flaps accounted for 78% of lower and 76% of upper extremity cases. More recently there was a transition away from pedicle flaps for limb salvages as free tissue transfer procedures were performed almost twice as commonly, 39 versus 59 procedures, respectively (Fig. 13). The number of cutaneous flaps significantly increased during the time, 35% versus 54% of flaps (P = 0.023) (Fig. 14). Complication rates and flap failure rates were not statistically different during the 2 periods (7% vs 2%, P = 0.157) (Table 2). Flap success rate did not significantly differ (93% vs 98%, P 9 0.05). There was no difference in total complications or f lap failure between free flaps and pedicle f laps, 21% versus 22% (P = 0.925) and 5% versus 3% (P = 0.463), respectively. Amputation rates decreased which correlates to increased upper extremity salvages. Failed limb salvage rates were similar between free and pedicle f laps, 4% versus 8% (P = 0.356). Radiographic union was achieved in 87% of patients with median time to union of 162 days (range, 27Y1020 days; SD, 138 days) in patients * 2014 Lippincott Williams & Wilkins

FIGURE 6. Patient 1 demonstrating swing stability in extreme sports activities after left lower extremity limb salvage and right upper extremity prosthesis. www.annalsplasticsurgery.com

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polymicrobrial organisms and display ongoing necrosis secondary to blast-damaged tissue. Blast trauma causes devastating orthopedic and soft tissue injuries that pose formidable reconstructive challenges to surgeons. These wounds are often complicated by injury beyond what is immediately apparent and gross contamination with polymicrobrial multidrugYresistant organisms. Furthermore, delayed extrication times (1Y3 hours) and the transit time required to transfer the patient from battlefield to stateside treatment facilities also compound these issues. Recently, we have reported a change in injury patterns and severity secondary to dismounted high-energy blast injuries. This dismounted injury pattern presents with bilateral lower extremity traumatic amputations with significant upper extremity complex injury patterns. Large zones of injury and contamination with bacteria, fungus, and foreign material routinely complicate these dramatic wounds. The shift toward upper extremity salvage cases is the result of fewer lower extremities presenting for salvage due to an increase in lower extremityYrelated dismounted blast injuries. This pattern differs to the mounted injury pattern seen during OIF where military operations were conducted within a vehicle. The efficacy of early radical debridement and definitive coverage with vascularized tissue is well established in the civilian literature for trauma flap coverage.8Y15 However, definitive closure of these wounds within 3 to 7 days is usually not possible in our patients given the multiple reasons discussed previously. Surgeons outside the deployed environment take into account the necessity to adequately and reliably cover vital structures, maximize function, and preserve aesthetics and need facilitate prompt rehabilitation. Patients undergo multiple washouts and stabilization procedures from the point of injury, during transport, and after arrival at our tertiary hospital to prepare for definitive surgical treatment and wound closure or coverage. Although many civilian studies report worse outcomes for flap coverage in the subacute period, citing higher flap failure, infection, and nonunion rates when compared to early coverage, our experience demonstrates successful subacute reconstruction with acceptable comparative complication rates to early coverage.4,5,16,17 Subacute f lap reconstruction at our facility has resulted in low f lap failure rates compared to the literature.4,5 These results are not completely FIGURE 7. Patient 2. Upper left, Appearance of right lower extremity after second rotational gastrocnemius flap for limb salvage after prior partial left rotational gastrocnemius flap from downrange. Upper right, Subacute image after control of soft tissue envelope before definitive reconstruction with open knee joint. Lower left, Free latissimus transfer using genicular artery as recipient vessels for coverage of open knee joint. Lower right, Appearance after reconstruction with split-thickness skin grafting of latissimus free flap.

with flap coverage over a fracture. The average time to union was similar between free and pedicle flaps, 176 versus 192 days (P = 0.552). Eight patients underwent amputation that involved the fracture, 4 patients have documented nonunion, whereas additional 6 patients did not achieve union at the time of last radiographic follow-up in the military health care system. Median time to ambulation in lower extremity salvage cases was 51 days (range, 15-480 days; SD, 110 days). Average follow-up was 728 days or approximately 24 months (range, 49Y2676 days).

DISCUSSION Military operations in Iraq and Afghanistan during the past decade have presented our military and civilian reconstructive teams with many unique and complex traumatic injuries. Blast-related injuries in most of these patients are complicated with heavy colonization with S42

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FIGURE 8. Patient 2 continued recovery after successful limb salvage with assistive brace device. * 2014 Lippincott Williams & Wilkins

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without precedent; previous literature has also reported acceptable failure and infection rates for subacute wound coverage.18,19 Higgins et al20 reported timing of coverage greater or less than 3 days had no effect on infection rates. We have advocated definitive flap coverage after achievement of a favorable wound before successful tissue transfer in the shortest amount of time that is possible and safe in war trauma and blast-injured patients.

Wounded Warrior Reconstruction

Varying studies have been published comparing pedicle versus free tissue flaps in limb reconstruction.4,21Y24 Tintle et al21 recommend that when adequate local tissue is available, the traditional ladder of reconstruction should be followed in war-injured patients. Burns et al23 found a lower amputation and reoperation rate in patients treated with rotational coverage compared to free tissue transfer. We have demonstrated a shift toward free tissue transfer due to the

FIGURE 9. Patient 3. Upper left, Humeral blast injury after initial debridement with external fixator to maintain humeral length and orientation. Upper right, Facilitation of wound closure with external tissue expander. Middle right, Fibula harvest for humeral shaft reconstruction. Middle right, Right upper extremity salvage after free fibular f lap. Lower left, Preoperative radiograph. Lower right, Postoperative radiograph demonstrating vascularized fibula with donor-recipient bony union. * 2014 Lippincott Williams & Wilkins

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FIGURE 12. Percentage of reconstructive procedures for upper extremity versus lower extremity for each 2-year period.

FIGURE 10. Patient 3 demonstrating right upper extremity functionality during activity duty deployment in Afghanistan 18 months postreconstruction.

increasing frequency of upper extremity injures noted during the later part of the study period. The paucity of large suitable local f laps in the upper extremity has led to greater reliance on free tissue transfer. Free tissue harvested from outside the zone of injury has avoided possible ongoing and delayed muscle necrosis and local wound infection. Dismounted blast injuries as previously noted have resulted in severely mutilated upper limbs with concurrent lower extremity amputations; thus, reducing potential donor sites for local and regional transfers. In selected injuries and careful patient selection, asymmetric elevation up the reconstructive ladder has not increased complication rates.25

FIGURE 11. Patient 4. Far left: vascularly threatened hand with exposed radial artery, open ulnar fracture with 15-cm segmental ulnar artery loss and ulnar nerve injury. Left, Laparoscopic harvest of omental flap. Right, Appearance after inset of flow through omental flap bridging proximal ulnar artery stump to base of superficial palmar arch and split-thickness skin grafting. Far right, Appearance at 1-year follow-up. S44

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FIGURE 13. Percentage of f laps that were pedicle versus free for each 2-year period.

FIGURE 14. Flap types by study period. * 2014 Lippincott Williams & Wilkins

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TABLE 2. Complications

Total Infection Hematoma/seroma Partial necrosis Flap failure Amputation/failed limb salvage

2003Y2008, n (%)

2009YPresent, n (%)

19 (20) 4 (5) 3 (4) 3 (4) 5 (7) 12 (9)

23 (24) 3 (3) 8 (8) 5 (5) 2 (2) 2 (2)

P 0.356 0.406 0.244 0.260 0.157 0.014

Selection of f lap harvest location and type of tissue is essential in these patients with limited soft tissue. Areas of the body protected by body armor have become the workhorse of our reconstructive effort. Furthermore, cutaneous f laps including custom free style perforator f laps have proven useful and limit harvest of core muscle f laps that are necessary for rehabilitation in poly extremity injury and amputee patients. The utility of cutaneous and fasciocutaneous f laps in extremity trauma are well described in the civilian literature with high reported success rates. They are currently preferred over muscle f laps as previously noted.15,26 The National Intrepid Center of Excellence for patients with traumatic brain injury and other multidisciplinary rehabilitation centers allow many wounded warriors to return to high levels of activity and function. Although most of our patients do not return to active duty service, they can lead highly productive personal lives and remain important members of the military community. Work with this patient community underscores a number of areas where further efforts are need to optimize outcomes for this highly complex trauma patient population. On the basis of our experience, future efforts to regenerate muscle and skin through fabricated templates, vascularized composite tissue allotransplantaton, segmental bone regeneration, and prefabricated composite tissue flaps augmented with regenerative medicine applications are areas where research and clinical efforts may translate directly to improved patient reconstruction. ACKNOWLEDGMENTS The authors thank Patrick Basile, Thomas Chung, Robert Howard, Kerry Latham, Barry Martin, and the Departments of Plastic Surgery, Orthopaedic Surgery, and Trauma Surgery at Walter Reed Bethesda for the continued and ongoing support in wounded warrior care projects. Informed consent was received for publication of the figures in this article. REFERENCES 1. Ramasamy A, Hill AM, Clasper JC. Improvised explosive devices: pathophysiology, injury profiles and current medical management. J R Army Med Corps. 2009;155:265Y272. 2. Shen-Gunther J, Ellison R, Kuhens C, et al. Operation Enduring Freedom: trends in combat casualty care by forward surgical teams deployed to Afghanistan. Mil Med. 2011;176:67Y78. 3. http://www.defense.gov/news/casualty.pdf.

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Wounded Warrior Reconstruction

4. Kumar AR. Standard wound coverage techniques for extremity war injury. J Am Acad Orthop Surg. 2006;14(10 Spec No.):S62YS65. 5. Kumar AR, Grewal NS, Chung TL, et al. Lessons from Operation Iraqi Freedom: successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg. 2009;123:218Y229. 6. http://www.usaisr.amedd.army.mil/assets/cpgs/02_CENTCOM_JTTS_CPG_ Process_2_Apr_12.pdf. 7. http://usaisr.amedd.army.mil/clinical_practice_guidelines.html. 8. Byrd HS, Cierny G III, Tebbetts JB. The management of open tibial fractures with associated soft tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg. 1981;68:73Y82. 9. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285Y292. 10. Francel TJ, Vander Kolk CA, Hoopes JE, et al. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg. 1992;89:478Y487. 11. Hertel R, Lambert SM, Muller S, et al. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg. 1999;119:7Y12. 12. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma. 1989;29:1086Y1094. 13. Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma. 2000;48:913Y917. 14. Yazar S, Lin CH, Lin YT, et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg. 2006;117:2468Y2475. 15. Yildirim S, Gideroglu K, Akoz T. Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction. J Reconstr Microsurg. 2003;19:225Y233. 16. Murray C, Obremskey W, Hsu JR, et al. Prevention of infections associated with combat-related extremity injuries. J Trauma. 2011;71:S235YS257 17. Bermudez LE. Abstract: Microsurgery in war wounds. Presented at the 69th Scientific Meeting of the American Society of Plastic Surgeons (ASPS), Los Angeles, CA, October 14Y18, 2000. 18. Yaremchuk MJ, Brumback RJ, Manson PN, et al. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg. 1987;80:1Y14. 19. Steiert AE, Gohritz A, Schreiber TC, et al. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapyVworse or worth? J Plast Reconstr Aesthet Surg. 2009;62:675Y683. 20. Higgins TF, Klatt JP, Beals TC. Lower extremity assessment project (LEAP)Vthe best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am. 2010;41:233Y239. 21. Tintle SM, Gwinn DE, Andersen RC, et al. Soft tissue coverage of combat wounds. J Surg Orthop Adv. 2010;19:29Y34. 22. Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am. 2000;82:1681Y1691. 23. Burns TC, Stinner DJ, Possley DR, et al. Does the zone of injury in combat related type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma. 2010;24:697Y703. 24. Saint-Cyr M, Gupta A. Indications and selection of free flaps for soft tissue coverage of the upper extremity. Hand Clin. 2007;23:37Y48. 25. Sabino J, Johnson ON, Martin BD, et al Abstract: Extremity reconstruction outcomes in war related trauma. Presented at the 91st Annual Meeting of the American Association of Plastic Surgery (AAPS), San Francisco, CA, April 14Y17, 2012. 26. El-Sabbagh AH. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg. 2011;27:511Y523.

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From battleside to stateside: the reconstructive journey of our wounded warriors.

Recent military operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) have led to further refinements of the milit...
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