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Flap Coverage Outcomes Following Vascular Injury and Repair: Chronicling a Decade of Severe War-Related Extremity Trauma.
Abstract
Background:
Combat-related extremity injuries frequently require vascular repair within the combat theater before undergoing definitive reconstruction. This study examines the outcomes of early vascular repair with secondary soft-tissue extremity reconstruction over the past decade of war trauma.
Methods:
War-related extremity injuries necessitating a downrange vascular procedure followed by a definitive limb reconstruction were reviewed. Patient demographics, type and location of vascular injuries, vascular intervention, and soft-tissue reconstruction procedures were examined. Outcomes of vascular repair, tissue transfer, and limb salvage were analyzed.
Results:
From 2003 to 2012, 79 extremities in 78 patients had a vascular injury requiring in-theater intervention followed by 87 staged flap reconstructions performed distal to the vascular repair. Of the 74 arterial injuries requiring intervention, 27 were proximally located, with 73 percent requiring bypass. The early primary patency rate was 66 percent and the early primary-assisted patency rate was 93 percent for proximal artery repair procedures. The flap complication rate was 31 percent. Overall complications were examined by subtype and were not significantly different compared with flaps performed without a proximal vascular injury in the same limb. The flap success rate (93 percent) and the limb salvage rate (81 percent) were similar to the comparison cohort.
Conclusions:
This represents one of the largest series of traumatic extremity injuries requiring secondary limb reconstruction with tissue transfer following a vascular intervention. The authors identified no significant difference in outcomes related to flap coverage or limb salvage for patients with or without vascular injuries. Reconstructive options in combat extremity trauma are not limited by proximal vascular injury.
Clinical question/level of evidence:
Therapeutic, III.
... 4 A recent study investigating the outcomes of flap coverage after combat-related vascular injuries to the extremities found a flap complication rate of 31 per cent and amputation rate of 19 per cent. 5 However, the outcomes of soft tissue reconstruction for combined arterial and orthopedic fractures are not well understood. In this study, we retrospectively reviewed patients with lower extremity arterial injuries and concomitant fractures requiring soft tissue coverage. ...
... 2 The decreased rate of limb salvage in this patient group may be due to complications of compromised vasculature and resulting ischemia, leading to impaired healing, reduced bony union, and increased risk of infection. 5,8 Although patients with arterial injuries were not found to have a statistically greater risk of infection in this study, all three amputations in the arterial injury group were secondary to nonhealing infections. Wound infections have been shown to be a significant risk factor for amputation in patients with arterial injuries in other studies. ...
... A recent study by Casey et al. 5 reported that patients undergoing soft tissue coverage for combat-related lower extremity trauma with arterial injuries did not have an increased rate of flap failure or other complications compared with those with intact vasculature, which contrasts with our findings. 6 It is possible that these differences are due to differences in injury mechanism and severity between civilian and military trauma. ...
Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries. A retrospective review of 158 lower extremities with traumatic fractures, including 26 extremities with arterial injuries, was performed to determine the effects of vascular compromise on flap survival, successful limb salvage and complication rates. Patients with arterial injuries had a larger average flap surface area (255.1 vs 144.6 cm2, P = 0.02) and a greater number of operations (4.7 vs 3.8, P = 0.01) than patients without vascular compromise. Patients presenting with vascular injury were also more likely to require fasciotomy [odds ratio (OR): 6.5, confidence interval (CI): 2.3‐18.2] and to have a nerve deficit (OR: 16.6, CI: 3.9‐70.0), fracture of the distal third of the leg (OR: 2.9, CI: 1.15‐7.1) and intracranial hemorrhage (OR: 3.84, CI: 1.1‐12.9). After soft tissue reconstruction, patients with arterial injuries had a higher rate of amputation (OR: 8.5, CI: 1.3‐53.6) and flap failure requiring a return to the operating room (OR: 4.5, CI: 1.5‐13.2). Arterial injury did not correlate with infection or overall complication rate. In conclusion, arterial injuries resulted in significant complications for patients with lower extremity fractures requiring flap coverage, although limb salvage was still effective in most cases.
... The military surgeons of today are the most highly trained and experienced secondary to the decade-plus long conflict in the Middle East. [1][2][3][4] These surgeons are now regarded by their peers as experts in the care of the severely injured and have brought innumerable lessons home from the war that have radically changed civilian trauma practice. [5][6][7][8] However, as the U. S. military presence in Afghanistan in support of Operation Enduring Freedom draws down, the opportunity for military surgeons to treat the severely battle injured will evaporate. ...
... Second, the injuries seen in the wartime setting are far more complex compared to peacetime trauma. 2,4,5 Severe trauma cases occur regularly in high-intensity combat environments, such as those seen in Iraq and Afghanistan. 7 Yet these types of wounds and injuries are seldom seen in the Department of Defense beneficiary group during times of peace. ...
Introduction:
Surgical currency is a critical component of medical corps readiness. We report a review of surgeons embedded into a civilian institution and analyze whether this improves surgical currency and wartime readiness.
Methods:
Patient management and operative volume were acquired from four surgeons embedded at a civilian institution and compared to operative case loads of surgeons based at a military treatment facility (MTF).
Results:
The surgeons embedded in the civilian institution had a mean of 49.3 cases compared to a mean of 8.3 cases for surgeons at the MTF over this 6-month period. In addition, the embedded surgeons obtained 44.4 to 94.7% of these cases during their civilian experience as opposed to cases done at the MTF. The cases performed by the embedded orthopedic surgeon (n = 247) was over 20 times the mean number of cases (mean = 12) performed at the MTF. Over a 6-month period, the trauma surgeon and general surgeon each evaluated 150 and 170 new trauma patients, respectively. In addition, the trauma/critical care surgeon cared for 250 critical care patients over this same 6-month period.
Conclusion:
This study demonstrates that embedding surgeons into a civilian institution allows them to maintain skill sets critical for currency and wartime readiness.
... defects. 34,35 Isolated arterial injuries occur less than 10% of the time. 35 Patients with ballistic upper extremity injuries should undergo surgical exploration at the time of initial treatment to rule out vascular injury. ...
... Our group has found no increased tissue transfer or failed upper extremity limb salvage in patients who have undergone a successful proximal revascularization procedure after an injury secondary to ballistic trauma. 34 Further, definitive extremity reconstruction procedures will likely need to be performed in the setting of antiplatelet or anticoagulation to protect the repair. Vascular repairs should be monitored according to institutional protocol. ...
Management of upper extremity injuries secondary to ballistic and blast trauma can lead to challenging problems for the reconstructive surgeon. Given the recent conflicts in Iraq and Afghanistan, advancements in combat-casualty care, combined with a high-volume experience in the treatment of ballistic injuries, has led to continued advancements in the treatment of the severely injured upper extremity. There are several lessons learned that are translatable to civilian trauma centers and future conflicts. In this article, the authors provide an overview of the physics of ballistic injuries and principles in the management of such injuries through experience gained from military involvement in Iraq and Afghanistan.
... Casey et al. conducted a study with the aim of investigating the outcomes of flap healing following injury and revascularization. In line with the present study, the researchers did not report a significant difference in the outcomes of the flap with anastomosis and revascularization with the flap without revascularization (13).The health of the blood vessels of the gastrocnemius muscle is necessary to perform the gastrocnemius flap. For this reason, it is recommended to perform arteriography before using the flap. ...
The use of the gastrocnemius muscle flap has become an excellent choice for coverage of Knee Defects. However, the surgical management of gastrocnemius muscle flap in the injuries of the popliteal artery remains a challenging therapeutic problem. The purpose of this manuscript is to present a case of a successful knee gastrocnemius flap in a patient with popliteal artery injuries. In 2024, a 46-year-old woman with a tibia fracture and popliteal artery injury went to the emergency department of Namazi Hospital. In the first step, the external fixator of the tibia bone was performed to fix the fracture. Then, popliteal artery anastomosis was performed. After two weeks, all internal implants were removed due to abscess. Four weeks later, the patient's skin developed necrosis and was repaired using medial hemi gastrocnemius Muscle flaps. We present a case of the successful use of medial hemi gastrocnemius Muscle flaps for Coverage of knee defects in the injuries of the popliteal artery.
... The most common mechanism of injury was a blast mechanism (86.7%) followed by gunshot wound (7.4%). Multi-extremity trauma was present in 73.5% of patients and median injury severity score was 16.5 (IQR,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. ...
Abstract
Objectives:
To define the rate and primary drivers behind early and late amputation following flap-based limb salvage in the setting of combat extremity trauma.
Design:
Retrospective review.
Setting:
Level II trauma center.
Patients:
Three hundred seven (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003-2014.
Intervention:
We reviewed patient medical records, radiographs, and clinical photographs.
Main Outcome Measurements:
Early and late amputation rates, time to amputation, reason for amputation
Results:
Three hundred seven patients accounted for 323 limbs that underwent flap-based limb salvage treatment (187 lower extremities, 136 upper extremities). A total of 58 extremities (18%) initially treated with flap-based limb salvage ultimately underwent amputation at a median of 480 days (IQR, 285-715 days) from injury. Periarticular fractures and lower extremity injuries were risk factors for both early and late amputation. Other independent risk factors for early amputation were flap complications and vascular injuries, whereas risk factors for late amputation were fractures that went on to nonunion.
Conclusions:
This study highlights that a subset of patients ultimately require major limb amputation despite having achieved what is initially considered “successful” limb salvage. Flap-related complications, vascular injury, and lower extremity site of injury were associated with early amputation after successful expeditionary efforts at limb preservation. Conversion to late amputation was associated with lower extremity periarticular fractures and fracture nonunion. Chronic pain and persistent limb dysfunction were the most common reasons for late amputation.
... These outcomes are similar to the flap complication (28%) and failure (10%) rates in the cohort of patients who did not suffer a concurrent vascular injury ( p > 0.05). 41 Twentysix percent of flaps were performed in the setting of a pre-or perioperative venous thromboembolic event. However, we found no difference in flap or limb salvage outcomes in patients with or without a deep venous thrombosis or pulmonary embolism. ...
Scope and Significance: Reconstruction of traumatic injuries requiring tissue transfer begins with aggressive resuscitation and stabilization. Systematic advances in acute casualty care at the point of injury have improved survival and allowed for increasingly complex treatment before definitive reconstruction at tertiary medical facilities outside the combat zone. As a result, the complexity of the limb salvage algorithm has increased over 14 years of combat activities in Iraq and Afghanistan. Problem: Severe poly-extremity trauma in combat casualties has led to a large number of extremity salvage cases. Advanced reconstructive techniques coupled with regenerative medicine applications have played a critical role in the restoration, recovery, and rehabilitation of functional limb salvage. Translational Relevance: The past 14 years of war trauma have increased our understanding of tissue transfer for extremity reconstruction in the treatment of combat casualties. Injury patterns, flap choice, and reconstruction timing are critical variables to consider for optimal outcomes. Clinical Relevance: Subacute reconstruction with specifically chosen flap tissue and donor site location based on individual injuries result in successful tissue transfer, even in critically injured patients. These considerations can be combined with regenerative therapies to optimize massive wound coverage and limb salvage form and function in previously active patients. Summary: Traditional soft tissue reconstruction is integral in the treatment of war extremity trauma. Pedicle and free flaps are a critically important part of the reconstructive ladder for salvaging extreme extremity injuries that are seen as a result of the current practice of war.
... Concomitant vascular injuries are common in ballistic lower extremity wounds. In a recent report, 24 % of patients requiring flap coverage for ballistic lower extremity wounds had concomitant vascular injury that required emergent repair [20]. Flap coverage was performed at an average of 31 days following vascular repair with an overall flap failure and complication rate of 8 and 31 %, respectively, which was comparable to the complication rate of flaps not requiring vascular repair (10 and 28 %, respectively). ...
Ballistic high-energy trauma has substantially increased the severity of non-fatal extremity injuries incurred in modern warfare. Expedient medical care, refinement in surgical techniques, and soft tissue coverage have brought about a paradigm shift in the management of lower extremity wounds during the last decade with an increased emphasis on limb salvage.
A literature-based study was conducted to analyze reconstructive modalities based on the location, depth, and severity of wounds, as well as mechanism of injury, concomitant vascular injuries and open fractures, choice of flap, timing of definitive reconstruction, and complications.
Extremity injuries account for over 60 % of injuries in the recent conflicts in Iraq and Afghanistan, with the majority secondary to explosive devices. The severity of these injuries is profound compared with civilian registries, and conventional injury scoring systems have failed to accurately predict outcomes in combat trauma. The mainstay of treatment is serial debridement, negative pressure therapy, fracture stabilization, and treatment of concomitant injuries by the forward medical teams with subsequent definitive reconstruction after transport to an advanced military treatment facility. Autologous reconstruction with free tissue transfer and pedicled flaps remains the primary modality for soft tissue coverage in limb salvage. Adjunct innovative modalities, such as external tissue expansion, dermal substitutes, and regenerative matrices, have also been successfully utilized for limb salvage.
Lower extremity injuries account for the vast majority of injuries in modern warzones. Explosive devices represent the most common mechanism of injury, with blast impact leading to extensive soft tissue injuries necessitating complex reconstructive strategies. Serial debridement, negative pressure therapy, and autologous reconstruction with free tissue transfer and pedicled flaps remain the mainstay of treatment in recent conflicts.
Introduction
Military weapons primarily damage the upper and lower limbs of the body, causing significant structural disruption in these injuries. The goal of limb reconstruction is to keep the extremity’s sensorimotor functions, skeletal stability, and adorable aesthetic result.
Materials and methods
This is a descriptive prospective cross-sectional hospital-based study performed to assess presentation of extremities injuries due to war weapon in Khartoum, Sudan, during conflict period July–December 2023. All patients with lower and upper extremities wounds due to combat injury and who underwent reconstructive surgery were included. Patients with concomitant injuries to trunk and head and neck regions were excluded.
Results
Among 200 patients, 82% were male, while 18% were female. The majority of patients, accounting for 28.5%, were between 20 and 30 years old. The lower limb was the most commonly involved extremity (56%), while in 54.9% of cases, the upper limb is dominant. In most cases, all components were injured except for neural and vascular elements. The ratio of fasciocutaneous to muscle flap was 73–27%. Complications were not experienced by more than half of the patients, with infection being the most common complication encountered in 60% of complicated cases.
Conclusion
War-related trauma to the extremities leads to complex wounds with various structural complications, often contaminated, posing a significant challenge during the reconstruction phase. In resource-limited settings, a customized reconstructive ladder may be implemented if free flaps are not an option, utilizing pedicled flaps to achieve satisfactory outcomes.
Children may suffer injuries from military ordnance, improvised explosive devices, unexploded ordnances, or landmines during armed conflicts. In this patient population, penetrating and blunt trauma to the extremities accounts for 30–40% of all occurrences. Among these, soft tissue injuries, traumatic below-knee amputations, and closed femur fractures are the most common diagnoses. In order to reduce healing time, it is crucial to properly assess, preserve, and restore the soft tissue of the wounded upper or lower extremity. In this chapter, we focus on pre-operative evaluation, soft tissue classification, and complex reconstruction to guide the management of these injuries.KeywordsChildrenPediatric injuryLimb defectInjured limbSoft tissue injuryReconstructive surgeryConflictCombat
Unlabelled:
Identifying risk factors for traumatic lower extremity reconstruction outcomes has been limited by sample size. We evaluated patient and procedural characteristics associated with reconstruction outcomes using data from almost four million patients.
Methods:
The National Trauma Data Bank (2015-2018) was queried for lower extremity reconstructions. Univariable and multivariable analyses determined associations with inpatient outcomes.
Results:
There were 4675 patients with lower extremity reconstructions: local flaps (77%), free flaps (19.2%), or both (3.8%). Flaps were most commonly local fasciocutaneous (55.1%). Major injuries in reconstructed extremities were fractures (56.2%), vascular injuries (11.8%), and mangled limbs (2.9%). Ipsilateral procedures prereconstruction included vascular interventions (6%), amputations (5.6%), and fasciotomies (4.3%). Postoperative surgical site infection and amputation occurred in 2% and 2.6%, respectively. Among survivors (99%), mean total length of stay (LOS) was 23.2 ± 21.1 days and 46.8% were discharged to rehab. On multivariable analysis, vascular interventions prereconstruction were associated with increased infection [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.05-3.79, P = 0.04], amputation (OR 4.38, 95% CI 2.56-7.47, P < 0.001), prolonged LOS (OR 1.59, 95% CI 1.14-2.22, P = 0.01), and discharge to rehab (OR 1.49, 95% CI 1.07-2.07, P = 0.02). Free flaps were associated with prolonged LOS (OR 2.08, 95% CI 1.74-2.49, P < 0.001).
Conclusions:
Prereconstruction vascular interventions were associated with higher incidences of adverse outcomes. Free flaps correlated with longer LOS, but otherwise similar outcomes. Investigating reasons for increased complication and healthcare utilization likelihood among these subgroups is warranted.
Evolution in extremity injury treatment often occurs during major conflicts, with lessons learned applied and translated among military and civilian settings. In recent periods of war, improvements in protective equipment, in-theater damage control resuscitation/surgery, delivery of antibiotics locally/systemically, and rapid evacuation to higher levels of medical care capabilities have greatly improved combat casualty survivability rates. Additionally, widespread application of lower extremity tourniquets also has prevented casualties from exsanguination, thus reducing hemorrhagic-related deaths. Secondary to these, a high number of combat casualties suffering lower extremity traumatic injuries have presented for functional limb reconstruction and restoration as well as residual limb care.
Introduction
The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations.
Materials and Methods
Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered.
Results
The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain.
Conclusions
Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.
Background
In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap.
Methods
Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage.
Results
There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing.
Conclusion
A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions.
Wartime vascular injury adds another dimension to the challenging management of vascular trauma. The ABCs of trauma guide the management with a special attention to controlling exsanguinating hemorrhage. Patients with wartime vascular trauma typically present with hard signs of vascular injury and are best managed with prompt exploration. Patients with soft signs are evaluated clinically and would benefit from CT angiography if available to further guide the management. Proximal and distal control are essential prior to exploring the injured area and exploring the missile trajectory. In unstable patients with multiple injuries a temporary shunt may be necessary to maintain the circulation while other life-threatening injuries are being addressed. Otherwise the injured area is debrided and reconstructed based on the degree of injury. An autogenous vein from the contralateral extremity is often used if the patient is stable. In unstable patients, prosthetic PTFE grafts have been used successfully even in the presence of contamination. Bypasses may be tunneled in a non-anatomic way to avoid a contaminated field. The extent and duration of ischemia greatly impact the outcome of the management. Furthermore, associated soft tissue injury is a major factor that affects the final outcome. Coverage of the vascular reconstruction with vascularized tissue is an essential principle to avoid infection and blowout of the suture lines. Throughout the management, the life before limb principle is strictly adhered to. Unstable patients with massive soft tissue and bony destruction may be best served with a primary amputation.
Background:
Warfare-related extremity injury associated with pelvic and long-bone fractures, massive soft-tissue injuries, and high Injury Severity Scores predispose patients to venous thromboembolic events, including deep vein thrombosis and/or pulmonary embolism. The success of flap reconstruction in this setting has not been well described.
Methods:
A retrospective review of war-related extremity injuries requiring flap coverage from 2003 to 2012 was completed, and the incidence of venous thromboembolic events determined. Outcomes compared included flap and limb salvage success rates and complications, such as partial/total flap failure, hematomas, and failed limb salvage.
Results:
A total of 173 combat extremity injury flap procedures were performed during the period reviewed, with 50 of these flaps (28.9 percent of all cases) identified as having a venous thromboembolic event during the course of care. Preoperative or perioperative events affected 45 flap procedures (26 percent). In the 41 patients with a preoperative event diagnosis, 21 had deep vein thrombosis (51 percent), 17 had a pulmonary embolism (42 percent), and three had both (7 percent). The complication rate in these cases was 29 percent (most commonly flap or donor-site hematoma). While the total complication rate was similar between the event and nonevent groups (29 versus 20 percent; p = 0.141), the hematoma rate was significantly different (20 versus 5 percent; p = 0.009).
Conclusions:
Venous thromboembolic events were detected in a high number of the authors' combat-injured patients requiring extremity flap coverage. Despite preoperative events and risks of therapeutic anticoagulation, flap transfers were performed with high success rates and comparable nonhemorrhage complication rates between flap cohorts.
Clinical question/level of evidence:
Therapeutic, III.
Explosions cause more complex and multiple forms of damage than any other wounding agent, are the leading cause of death on the battlefield, and are often used by terrorists. Because explosion-related injuries are infrequently seen in civilian practice, a broader base of knowledge is needed in the medical community to address acute needs of patients with explosion-related injuries and to broaden mitigation-focused research efforts. The objective of this review is to provide insight into the complexities of explosion-related injury to help more precisely target research efforts to the most pressing areas of need in primary prevention, mitigation, and consequence management.
An understanding of the physics and biological consequences of explosions together with data on the nature or severity of contemporary combat injuries provide an empiric basis for a comprehensive and balanced portfolio of explosion-related research. Cited works were identified using MeSH terms as directed by subtopic. Uncited information was drawn from the authors' surgical experience in Iraq, analysis of current combat trauma databases, and explosion-related research.
Data from Iraq and Afghanistan confirm that survivable injuries from explosions are dominated by penetrating fragment wounds, substantiating longstanding and well-known blast physics mechanisms. Keeping this factual basis in mind will allow for appropriate vectoring of funds to increase understanding of this military and public health problem; address specific research and training needs; and improve mitigation strategies, tactics, and techniques for vehicles and personal protective equipment.
A comprehensive approach to injury from explosions should include not only primary prevention, but also injury mitigation and consequence management. Recalibration of medical research focus will improve management of injuries from explosions, with profound implications in both civilian and military healthcare systems.
Extremity wounds and fractures traditionally comprise the majority of traumatic injuries in US armed conflicts. Little has been published regarding the extremity wounding patterns and fracture distribution in the current conflicts in Iraq and Afghanistan. The intent of this study was to describe the distribution of extremity fractures during this current conflict.
Descriptive epidemiologic study.
The Joint Theater Trauma Registry was queried for all US service members receiving treatment for wounds (ICD-9 codes 800-960) sustained in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) from October 2001 through January 2005. Returned-to-duty and nonbattle injuries were excluded. Wounds were classified according to region and type. Extremity wounds were analyzed in detail and compared to published results from previous conflicts.
A total of 1281 soldiers sustained 3575 extremity combat wounds. Fifty-three percent of these were penetrating soft-tissue wounds and 26% were fractures. Of the 915 fractures, 758 (82%) were open fractures. The 915 fractures were evenly distributed between the upper (461, 50%) and lower extremities (454, 50%). The most common fracture in the upper extremity was in the hand (36%) and in the lower extremity was the tibia and fibula (48%). Explosive munitions accounted for 75% of the mechanisms of injury.
The burden of wounds sustained in OIF/OEF is extremity injuries, specifically soft-tissue wounds and fractures. These results are similar to the reported casualties from previous wars.
Combat is associated with high-energy explosive injuries, often resulting in open tibial fractures complicated by nonunion and infection. We characterize the infections seen in conjunction with combat-associated type III tibial fractures.
We performed a retrospective medical records review to identify US military service members wounded in Iraq or Afghanistan with open diaphyseal tibial fractures who were admitted to our facility (Brooke Army Medical Center, Fort Sam Houston, Texas) between March 2003 and September 2006.
Of the 62 patients with open tibial fractures who were identified in our initial search, 40 had fractures that met our inclusion criteria as type III diaphyseal tibial fractures. Three patients were excluded because their fractures were managed with early limb amputation, and 2 were excluded because of incomplete follow-up records. Twenty-seven of these 35 patients had at least 1 organism present in initial deep-wound cultures that were performed at admission to the hospital. The pathogens that were identified most frequently were Acinetobacter, Enterobacter species, and Pseudomonas aeruginosa. Thirteen of the 35 patients had union times of >9 months that appeared to be associated with infection. None of the gram-negative bacteria identified in the initial wound cultures were recovered again at the time of a second operation; however, all patients had at least 1 staphylococcal organism. One patient had an organism present during initial culture and in the nonunion wound; this organism was a methicillin-resistant Staphylococcus aureus strain that was inadvertently not treated. Five of 35 patients ultimately required limb amputation, with infectious complications cited as the reason for amputation in 4 of these cases.
Combat-associated type III tibial fractures are predominantly associated with infections due to gram-negative organisms, and these infections are generally successfully treated. Recurrent infections are predominantly due to staphylococci.
A method for comparing death rates of groups of injured persons was developed, using hospital and medical examiner data for more than two thousand persons. The first step was determination of the extent to which injury severity as rated by the Abbreviated Injury Scale correlates with patient survival. Substantial correlation was demonstrated. Controlling for severity of the primary injury made it possible to measure the effect on mortality of additional injuries. Injuries that in themselves would not normally be life-threatening were shown to have a marked effect on mortality when they occurred in combination with other injuries. An Injury Severity Score was developed that correlates well with survival and provides a numerical description of the overall severity of injury for patients with multiple trauma. Results of this investigation indicate that the Injury Severity Score represents an important step in solving the problem of summarizing injury severity, especially in patients with multiple trauma.
To date, contemporary studies on wartime vascular trauma have focused on acute management strategies and early results, with no characterization of enduring functional limb salvage or its relation to quality of life. The objective of this study was to describe long-term, patient-based quality of life and function after extremity vascular injury (EVI).
The Joint Theater Trauma Registry was queried for U.S. troops with EVI. Injury and management data was obtained and the Medical Outcomes Study Short Form 36 (SF-36) Health Survey administered after patient contact and consent. Demographic, injury, and management variables were analyzed and examined for correlation with the primary end points of favorable or unfavorable outcome defined by SF-36 Mental (MCS) or Physical Component Summary (PCS) scores of >42 or <42 (effect size ≥0.8).
Surveys were completed by 214 patients, who were a median age of 25 years (range, 19-52 years). The Injury Severity Score was 15.3 ± 8.6 and the Mangled Extremity Severity Score was 5.65 ± 1.4. Amputation-free survival was 84% at mean follow-up of 61 ± 24 months. Overall SF-36 PCS and MCS scores were 43.0 ± 9.2 and 46.6 ± 12.4, respectively, with 92 respondents (43%) reporting favorable outcomes on both MCS and PCS. On multivariate analysis, older age, severe extremity injury (Mangled Extremity Severity Scores ≥7), and chronic pain were predictive of unfavorable physical outcomes (P < .05). Presence of pain, nerve injury, and junior rank (<E7) were predictive of unfavorable MCS scores (P < .05). Higher educational background (baccalaureate or above) was associated with favorable outcome (P < .05).
This study reports the first long-term patient-centered outcomes data after wartime EVI. At 5 years after injury, quality-of-life measures are reduced compared with national norms. Understanding high-risk characteristics, both demographic- and injury-specific, that are associated with unfavorable outcomes will help guide future acute management and long-term recovery strategies.
Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the pre-medical treatment facility (pre-MTF) environment.
The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.
For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.
Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention.Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force.
Background : Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system.
Methods : Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation.
Results : Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity.
Conclusion : Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.
The purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard.
The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis.
Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry. The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) <8 (28.6% vs 40.0%; P = 1.00) or shock (SBP <90; 10.5% vs 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006).
Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.
The extremities remain the most common sites of wounding in conflict, are associated with a significant incidence of vascular trauma, and have a high complication rate (infection, secondary amputation, and graft thrombosis).
The purpose of this study was to study the complication rate after extremity vascular injury. In particular, the aim was to analyze whether this was influenced by the presence or absence of a bony injury.
A prospectively maintained trauma registry was retrospectively reviewed for all UK military casualties with extremity injuries (Abbreviated Injury Score >1) December 8, 2003 to May 12, 2008. Demographics and the details of their vascular injuries, management, and outcome were documented using the trauma audit and medical notes.
Thirty-four patients (34%)--37 limbs (30%)--had sustained a total of 38 vascular injuries. Twenty-eight limbs (22.6%) had an associated fracture, 9 (7.3%) did not. Twenty-nine limbs (23.4%) required immediate revascularization to preserve their limb: 16 limbs (13%) underwent an initial Damage Control procedure, and 13 limbs (10.5%) underwent Definitive Surgery. Overall, there were 25 limbs (20.2%) with complications. Twenty-two were in the 28 limbs with open fractures, 3 were in the 9 limbs without a fracture (p < 0.05). There was no significant difference in the complication rate with respect to upper versus lower limb and damage control versus definitive surgery.
We have demonstrated that prognosis is worse after military vascular trauma if there is an associated fracture, probably due to higher energy transfer and greater tissue damage.
The microbiology of war wounds has changed as medicine and warfare have evolved. This study was designed to determine the microbial flora and bacterial quantification of present-day war wounds in US troops from Iraq and Afghanistan upon arrival at the National Naval Medical Center (NNMC).
Patients with extremity combat wounds treated with a vacuum-assisted wound closure device were enrolled in study. Wounds were biopsied every 48 to 72 hours with quantitative microbiology performed on all biopsies.
Two hundred forty-two wound biopsies from 34 patients; 167 (69%) showed no growth, and 75 (31%) showed positive growth. The incidence of any bacterial isolation from biopsies weekly from the time of injury was 28% (first), 31% (second), and 37% (≥third). Acinetobacter baumannii was the most prevalent isolate.
Most soft-tissue wounds from Iraq and Afghanistan do not have significant bacterial burden upon arrival to and during initial treatment at NNMC. Improved evaluation of combat wound microbiology at all levels of care is warranted to determine shifts in microbiology and to impact care practices.
Selective tibial revascularization refers to the practice of vessel repair vs ligation or observation based on factors observed at the time of injury. Although commonly employed, the effectiveness of this strategy and its impact on sustained limb salvage is unknown. The objective of this study is to define the factors most relevant in selective tibial artery revascularization and to characterize limb salvage following tibial-level vascular injury.
The cohort of active-duty military patients undergoing infrapopliteal artery repair comprises the tibial Bypass group. A similarly injured cohort of patients that did not undergo operative vascular intervention (No Bypass group) was identified. All tibial vessel injuries were documented by angiography. Data were compiled via medical records and patient interview. The primary outcome measure was failure of limb salvage. Multivariate regression was performed to identify factors associated with revascularization and to describe factors associated with amputation.
Between March 2003 and September 2008, 135 of 1332 patients with battle-related vascular injuries had documented tibial vessel disruption or occlusion. Of these, 104 were included for analysis. Twenty-one underwent autologous vein bypass at the time of injury (Bypass group), and the remaining 83 patients were managed without revascularization (No Bypass group). Mean follow-up (39 vs 41 months; P = .27), age (25 vs 27 years; P = .66), and mechanism of injury (88% vs 92% penetrating blast; P = .56) were similar, but the No Bypass group had higher Injury Severity Scores (ISS; 16.3 vs 11.7; P < .01). Injury characteristics, including Gustilo III classification (49% vs 43%; P = .81) and nerve injury (55% vs 53%; P = 1.0), were similar. Subjects were more likely to receive tibial bypass with an increasing number of tibial vessel occlusions and documented ischemia on initial exam. However, of the 23 in the No Bypass group with initially unobtainable Doppler signals, 17 (74%) regained pedal flow following resuscitation and limb stabilization. Amputation rates were similar (23% vs 19%; P = .79), but the prevalence of chronic limb pain was lower in the Bypass group (10% vs 30%, respectively; P = .08). Cox regression analysis of amputation-free survival demonstrated an association between mangled extremity severity score >5 (hazard ratio [HR], 2.7; P = .01) and amputation.
This report provides outcomes data for wartime tibial vascular injury, which supports a selective approach to tibial artery revascularization. Clinical factors such as ISS and degree of ischemia guide which patients are best suited for tibial vascular repair, while injury-specific characteristics are associated with amputation regardless of revascularization status.
War-trauma, especially due to blast injury, can be associated with long bone fracture. Immediate external fixation of fractures, followed by internal fixation when the patient is medically stabilized (damage control orthopedics [DCO]), is the U.S. Army policy for war-related fractures. Data on infectious outcomes when DCO is used for war-trauma fractures are scant.
A retrospective review of U.S. war-trauma patients from 2003 to 2007 with femoral or tibial fractures treated by DCO was conducted. Fisher's Exact and Mann-Whitney tests were used for comparisons.
Fifty-eight soldiers were identified. Fifty-five were males with a median age of 26 years (19-54 years) and a median time to internal fixation by intramedually nailing of 9 days (4-414 days). Eighty-eight percent of fractures were open, and 57% were femoral fractures. The median duration of follow-up was 447 days (20-1,340 days). Fracture site infection occurred in 40% (23 of 58), with suspected osteomyelitis in 17% (10 of 58). Of infected nails, fracture union occurred in 70% and nail retention in 57%. Median time to infection after nail placement was 15 days (0-717 days) with 75% of infections occurring by day 113. Multiple bacterial pathogens including Acinetobacter baumannii and Staphylococcus spp. were causative organisms. Blast injuries occurred in 91% of infected versus 47% of uninfected (p = 0.005). There was no difference between infections occurring in femoral (61%) versus tibial (39%) (p = 0.620) location.
Infection was associated with 40% of DCO-associated intramedullary nails. Blast injury was a predictor of infection. Despite infection, fracture union and nail retention rates were high, suggesting a good outcome.
MESS (Mangled Extremity Severity Score) is a simple rating scale for lower extremity trauma, based on skeletal/soft-tissue damage, limb ischemia, shock, and age. Retrospective analysis of severe lower extremity injuries in 25 trauma victims demonstrated a significant difference between MESS values for 17 limbs ultimately salvaged (mean, 4.88 +/- 0.27) and nine requiring amputation (mean, 9.11 +/- 0.51) (p less than 0.01). A prospective trial of MESS in lower extremity injuries managed at two trauma centers again demonstrated a significant difference between MESS values of 14 salvaged (mean, 4.00 +/- 0.28) and 12 doomed (mean, 8.83 +/- 0.53) limbs (p less than 0.01). In both the retrospective survey and the prospective trial, a MESS value greater than or equal to 7 predicted amputation with 100% accuracy. MESS may be useful in selecting trauma victims whose irretrievably injured lower extremities warrant primary amputation.
A method for comparing death rates of groups of injured persons was developed, using hospital and medical examiner data for more than 2,000 persons. The first step was determination of the extent to which injury severity as rated by the Abbreviated Injury Scale correlates with patient survival. Substantial correlation was demonstrated. Controlling for severity of the primary injury made it possible to measure the effect on mortality of additional injuries. Injuries that in themselves would not normally be life threatening were shown to have a marked effect on mortality when they occurred in combination with other injuries. An Injury Severity Score was developed that correlates well with survival and provides a numerical description of the overall severity of injury for patients with multiple trauma. Results of this investigation indicate that the Injury Severity Score represents an important step in solving the problem of summarizing injury severity, especially in patients with multiple trauma. The score is easily derived, and is based on a widely used injury classification system, the Abbreviated Injury Scale. Use of the Injury Severity Score facilitates comparison of the mortality experience of varied groups of trauma patients, thereby improving ability to evaluate care of the injured.
Salvage of lower-extremity Gustilo type IIIC fractures is difficult, time-consuming for the patients and physicians, and not universally successful because of poor functional outcomes. Even if successful with limb salvage, the functional result may be unsatisfactory because of mutilating injuries to muscle and nerve, bone loss, and the presence of chronic infection. From July 1991 until July 1994, revascularizations of open IIIC fractures were attempted for wounds with Mangled Extremity Severity Score (MESS) < or = 10. The functional results were evaluated at 2 years after injury. Thirty-six lower-extremity revascularizations were performed on 34 patients, including 1 patient with bilateral distal tibial IIIC fractures and a child with IIIC femoral fracture accompanied by ipsilateral distal tibial amputation. Excluded were patients with below-ankle IIIC fractures as well as patients who underwent immediate amputation at admission. After the revascularization, seven patients with IIIC fractures (7 of 36, 19.4%) underwent secondary amputation within 1 week. At the 2-year follow-up, the overall secondary amputation rate was 25% (9 of 36) and the salvage rate was 75% (27 of 36). Those were no deaths. Of the 29 salvaged limbs among these 27 patients, 23 limbs (23 of 29, 79.3%) required secondary coverage procedures that included 12 free flap transfers (12 of 29, 41.4%). Every patient needed subsequent reconstructive surgery to achieve an acceptable functional result. In this series, MESS was able to predict the secondary amputation rate and the functional result. Sixteen of the 17 limb-salvaged patients with MESS < or = 7 were able to achieve minimal functional requirements, whereas 3 of the 10 patients with MESS = 8 to 10 failed to achieve minimal functional requirements at the 2-year follow-up. Using statistical analysis, we found that the salvaged limbs with MESS < or = 9 exhibited a significant difference in achieving adequate function compared with limbs with MESS > 9. Using our protocol for treatment for IIIC fractures, the threshold for immediate amputation can be raised from MESS = 7 to MESS = 9. Our conclusions are (1) more severely injured limbs have poor functional results, (2) every patient needs subsequent reconstructive surgery, and (3) the MESS may be helpful in decision-making.
The purpose of this study was to document outcome and adverse prognostic factors in patients requiring combined free tissue transfer and distal bypass grafting for otherwise nonreconstructible infrainguinal arterial occlusive disease and advanced tissue necrosis.
Between July 1990 and November 1999, 65 patients, all of whom would have required at least below-knee amputation, underwent free tissue transfer in conjunction with infrainguinal bypass grafting at the University of Rochester. Preoperative variables were assessed for their influence on outcome with chi(2) and outcome with life-table analysis with Cox proportionate hazard testing.
Free tissue transfer was performed synchronously with arterial reconstruction with autologous vein in 49 patients and after a previous functioning venous bypass graft in 16 patients. The 30-day mortality rate was 5%, and major complications occurred in another 16% of patients. Flap location, weight-bearing status, preexisting osteomyelitis, and the timing of bypass grafting relative to flap construction had no effect on outcome. All five free flap failures occurred within the first 30 days. All other flaps subsequently survived, even in seven patients whose bypass grafts thrombosed. Five-year limb salvage and patient survival rates were 57% and 60%, respectively, and 65% of patients regained meaningful ambulation. The combination of diabetes and dialysis-dependent renal failure was the strongest predictor of overall limb loss (P <.005; relative risk = 4.0), and diabetes alone was the strongest predictor of death (P <.02; relative risk = 5.2).
Free tissue transfer combined with infrainguinal bypass grafting in selected patients is safe and effective. The combination of diabetes and chronic renal insufficiency, particularly the need for dialysis, is a powerful predictor of failure and should be considered a strong contraindication for this procedure.
Factors thought to influence the decision for limb salvage include injury severity, physiologic reserve of the patient, and characteristics of the patient and their support system.
Eligible patients were between the ages of 16 and 69 with Gustilo type IIIB and IIIC tibial fractures, dysvascular limbs resulting from trauma, type IIIB ankle fractures, or severe open midfoot or hindfoot injuries. Data collected at enrollment relevant to the decision-making process included injury characteristics and its treatment, and the nature and severity of other injuries. Logistic regression and stepwise modeling were used to determine the effect of each covariate on the variable salvage/ amputation.
Of 527 patients included in the analysis, 408 left the hospital with a salvaged limb. Of the 119 amputations performed, 55 were immediate and 64 were delayed. The multivariate analysis confirmed the bivariate analysis: all injury characteristics remained significant predictors of limb status with the exception of bone loss; and soft tissue injury and absence of plantar sensation were the most important factors in accounting for model validity.
Soft tissue injury severity has the greatest impact on decision making regarding limb salvage versus amputation.
The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries.
From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed.
Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 [88%]) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts. Sixty-seven (63%) patients underwent diagnostic angiography. The most common indication was mechanism of injury (42%), followed by abnormal examination (33%), operative planning (18%), or evaluation of a repair (7%).
This interim report represents the largest analysis of US military vascular injuries in more than 30 years. Wounding patterns reflect past experience with a high percentage of extremity injuries. Management of arterial repair with autologous vein graft remains the treatment of choice. Repairs in contaminated wound beds should be avoided. An increase in injuries from improvised explosive devices in modern conflict warrants the more liberal application of contrast arteriography. Endovascular techniques have advanced the contemporary management and proved valuable in the treatment of select wartime vascular injuries.
Recent events have refocused attention on certain principles regarding the surgical management of casualties on the battlefield. Extremity vascular injuries predominate, representing 50 to 70% of all injuries treated during Operation Iraqi Freedom, and exsanguination from extremity wounds is the leading cause of preventable death on the modern battlefield. Recent advances in military medicine have translated into a greater percentage of wounded soldiers surviving during Operations Enduring and Iraqi Freedom than in any other previous American conflict. The combat-experienced military surgeon, a fraction of those in uniform until recently, rarely has had the opportunity to convey lessons learned to the newly indoctrinated war surgeon. The purpose of this review is to do exactly that.
We collectively reviewed the experience and opinions of five U.S. Army surgeons with regard to management of extremity vascular injuries in a combat zone
The modern battlefield has a staunch reputation of being unclean, noisy, and lacking of valuable resources. High-kinetic energy injuries such as those resulting from high explosives, munitions, and high-velocity missiles often cause soft-tissue destruction that is not routinely seen in civilian settings. Military-specific considerations in the management of these injuries are reviewed.
The management of extremity vascular injuries on the modern battlefield presents many unique and demanding challenges to even the most seasoned of surgeons. Preparation goes a long way in overcoming some of the obstacles to seamless patient care.
Although the etiology of chronic pain following trauma is not well understood, numerous retrospective studies have shown that a significant proportion of chronic pain patients have a history of traumatic injury. The present analysis examines the prevalence and early predictors of chronic pain in a cohort of prospectively followed severe lower extremity trauma patients. Chronic pain was measured using the Graded Chronic Pain Scale, which measures both pain severity and pain interference with activities. Severe lower extremity trauma patients report significantly higher levels of chronic pain than the general population (p<0.001). Their levels are comparable to primary care migraine headache and back pain populations. A number of early predictors of chronic pain were identified, including: having less than a high school education (p<0.01), having less than a college education (p<0.001), low self-efficacy for return to usual major activities (p<0.01), and high levels of average alcohol consumption at baseline (p<0.05). In addition, high reported pain intensity, high levels of sleep and rest dysfunction, and elevated levels of depression and anxiety at 3 months post-discharge were also strong predictors of chronic pain at seven years (p<0.001 for all three predictors). After adjusting for early pain intensity, patients treated with narcotic medication during the first 3 months post-discharge had lower levels of chronic pain at 84 months. It is possible that for patients within these high risk categories, early referral to pain management and/or psychologic intervention may reduce the likelihood or severity of chronic pain.
To assess long-term outcome and prognostic factors for extreme surgery by vascular and plastic surgical teamwork for leg salvage in patients with critically ischemic large tissue defects.
Combined vascular reconstruction and microvascular free-flap transfer has been used to improve distal perfusion and cover large tissue defects caused by the critical limb ischemia (CLI) in few dedicated centers during the past 15 years. Comorbidities compromise the results of these demanding operations, and it is unclear how far this mode of treatment should be extended.
During 1989 to 2003, altogether 2157 vascular or endovascular revascularizations for CLI manifested as tissue lesions were performed. These included 81 revascularizations combined with microvascular free flap transfers in 79 patients (37-85 years). All the patients were candidates for major amputation. The patients were followed up at least 2 years or to death (mean follow-up, 62 months; SD, +/-34 months).
One- and 5-year leg salvage rates were 73% and 66%, survival rates 91% and 63%, and amputation-free survival rates of 70% and 41%, respectively. Male gender and American Society of Anesthesiologists score 4 were associated with an increased risk of death, whereas the involvement of the heel mostly with calcaneal osteomyelitis and a large size of defect predicted major amputation.
A combined vascular reconstruction and free-flap transfer offers an option for advanced limb salvage in a selected group of patients with CLI and a major tissue defect. Poor general condition, the involvement of the heel, and a large defect would indicate an amputation over extreme attempts for limb salvage.
Contemporary management of wartime trauma
- Fox Cj Gillespie Dl
- O Donnell
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Fox CJ, Gillespie DL, O'Donnell SD, et al. Contemporary management of wartime trauma. J Vasc Surg. 2005;41;638–644.