title: Lessons from the modern battlefield: successful upper extremity injury reconstruction in the subacute period.
abstract: BACKGROUND
  Reconstructive techniques and protocols for limb salvage of upper extremity battlefield injuries remains poorly defined. Our study describes the types of flaps, the timing of reconstruction, and success rates of war upper extremity reconstruction during a 30-month period using the Bethesda limb salvage protocol.
  
  
  METHODS
  Soldiers with significant upper extremity injuries with complex open fractures from Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan who underwent tissue transfer flaps were reviewed (n = 26, free flaps n = 6). Data analysis included mechanism of injury, associated injuries, types of flap, postoperative complications, wound infection rates, and outcome data.
  
  
  RESULTS
  The cause of injury consisted of improvised explosive device (61%), rocket-propelled grenades (15%), motor vehicle crash (8%), land mine (8%), and gunshot wound (4%). Mean age was 25 years. Mean number of prereconstructive washouts was six (range, 3-22). Forty-six percent of wounds were culture positive at admission (75% were Acinetobacter species). All patients had other coexisting extremity, trunk or facial injuries. Average time to flap reconstruction was 31 days (range, 9-161). In 66% of the cases, a fasciocutaneous flap was used, and in the remaining cases, muscle (19%) and adipofascial (15%) flaps were performed. Flap success rate was 96%, with one flap loss because of venous congestion (managed with limb shortening). Infection rate was 8%. Complete coverage was achieved in all upper extremity wounds and early occupational therapy resulted in improved return to function.
  
  
  CONCLUSIONS
  Despite massive bone and soft tissue defects, high preoperative wound colonization, and delays in definitive reconstruction, devastating war wounds can be successfully reconstructed in the subacute period with low flap failure, infection, and amputation rates.
authors.affiliation: Department of Surgery, Division of Plastic and Reconstructive, Surgery, University of California, Los Angeles, California 90095-6960, USA.
authors.forename: Anand R
authors.initials: AR
authors.lastname: Kumar
authors.forename: Navanjun S
authors.initials: NS
authors.lastname: Grewal
authors.forename: Thomas L
authors.initials: TL
authors.lastname: Chung
authors.forename: James P
authors.initials: JP
authors.lastname: Bradley
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000671:Amputation, Surgical / Q000706:statistics & numerical data; D050723:Fractures, Bone / Q000601:surgery*; D006801:Humans; D054542:Iraq War, 2003-2011; D023821:Limb Salvage / Q000379:methods; D008297:Male; D050279:Metacarpal Bones / Q000293:injuries; D008889:Military Personnel; D009104:Multiple Trauma / Q000601:surgery; D011885:Radius Fractures / Q000601:surgery; D019651:Plastic Surgery Procedures; D017695:Soft Tissue Injuries / Q000601:surgery; D013524:Surgical Flaps; D013530:Surgical Wound Infection / Q000453:epidemiology; D014458:Ulna Fractures / Q000601:surgery; D014481:United States; D034941:Upper Extremity / Q000293:injuries*; D055815:Young Adult