title: Sequential free tissue transfers for simultaneous upper and lower limb salvage.
abstract: BACKGROUND
  The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients.
  
  
  METHODS
  All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free-flap limb salvage cohorts.
  
  
  RESULTS
  Seventy-four free flap limb salvage cases were performed over the 10-year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626).
  
  
  CONCLUSIONS
  The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients.
authors.affiliation: Department of Plastic & Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA. ian.valerio@med.navy.mil
authors.forename: Ian L
authors.initials: IL
authors.lastname: Valerio
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sabino
authors.forename: Adam
authors.initials: A
authors.lastname: Bevevino
authors.forename: Scott M
authors.initials: SM
authors.lastname: Tintle
authors.forename: Mark
authors.initials: M
authors.lastname: Fleming
authors.forename: Anand
authors.initials: A
authors.lastname: Kumar
mesh_terms: D000328:Adult; D055826:Afghan Campaign 2001-; D000673:Amputation, Traumatic / Q000601:surgery; D001134:Arm Injuries / Q000601:surgery*; D001753:Blast Injuries / Q000601:surgery*; D058752:Free Tissue Flaps; D006801:Humans; D054542:Iraq War, 2003-2011; D007869:Leg Injuries / Q000601:surgery*; D023821:Limb Salvage / Q000379:methods*; D008297:Male; D008889:Military Personnel; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000601:surgery; D055815:Young Adult