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Late Amputation After Limb Salvage in Civilian and Military Trauma Patients
Jennifer Sabino, MD1; Raja Mohan, MD2; Devinder Singh, MD3; Eduardo D. Rodriguez4; Rachel Bluebond-Langner2; Ian L. Valerio, MD, MS, MBA1
1Walter Reed National Military Medical Center, Bethesda, MD; 2Johns Hopkins University / University of Maryland, Baltimore, MD; 3University of Maryland School of Medicine, Baltimore, MD; 4R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MA

Purpose: Given military conflicts in Iraq and Afghanistan, surgeons have gained significant experience concerning the management of soft tissue transfer for limb salvage in war wounded patients. However, we have yet to analyze the long term outcomes of limb salvage in the cohort of patients who undergo soft tissue transfer as part of their reconstruction. Furthermore, there are no comparisons between civilian patients and military patients, given the inherently different patient population and injury pattern. The purpose of this study is to compare limb salvage outcomes of civilian and military patients undergoing soft tissue transfer as part of their reconstruction.
Methods: This is a multi-institution retrospective review of patients treated with tissue transfer for extremity trauma at R Adams Cowley Shock Trauma Center and Walter Reed National Military Medical Center (WRNMMC) between January 2005 and July 2012.
Results: From 2005 to 2012, a total of 541 extremity cases requiring soft tissue coverage were reviewed, with 209 extremities reconstructed at Shock Trauma and 332 extremities reconstructed at WRNMMC, respectively. The upper extremity cohorts significantly differed between the institutions, comprising 8% of extremity procedures at Shock Trauma versus 41% of exteemity procedures at WRNMMC. Heterotopic ossification and pain were a more common complications within the military trauma group compared to the civilian trauma group, 3 versus 7% and 2 versus 17% (p=0.034 and p=0.000), respectively. Given noted differences in mechanisms of injury and complication rates, subgroup analysis of the lower extremity group revealed significant differences in lower extremity complications and amputation rates.

Infection and pain were the primary reason for amputation at WRNMMC (78%) and Shock Trauma (50%) (p=0.312 for amputation and 0.259 for pain). While the amputation rate after flap failure was higher at Shock Trauma, flap failure was not a common reason for failed limb salvage in either groups analyzed (9 versus 21%, p=0.257).
Conclusions: The military cohort of extremity injuries requiring soft tissue coverage had higher infection and pain rates than the civilian comparison cohort. Furthermore, lower extremity limb salvage outcomes were found to be significantly different in military patients than civilian patients undergoing soft tissue transfer based limb reconstruction. Psychosocial aspects of rehabilitation may play a role in late amputation because amputation secondary to medical necessity is similar between groups.

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