Management of Soft-Tissue and Bone Defects in a Local Population: Plastic and Reconstructive Surgery in a Deployed Military Setting.

Abstract

Gunshot injuries, blast injuries, and major contusions can cause extensive extremity defects. In countries with damaged or destroyed infrastructure, local national patients with these injuries pose a challenge. Deployed medical facilities of the German Armed Forces provide medical care to these patients as part of their humanitarian activities. Reconstructive techniques, for example, microvascular free tissue transfer, can be used only to a limited extent in such settings, which require safe and simple (outpatient) procedures. The focus of treatment is not on cosmetic aspects but on rapidly restoring function. Low-resource settings require ethical and medical compromises. It is still a topic of the discussion which reconstructive surgical procedures could be performed in a deployment mission and which should be in the portfolio of the deployed surgeon. We conducted a retrospective analysis of a sample of 550 patients who received definitive treatment from seven surgeons from a single German Armed Forces hospital during a total of 47 tours of duty (i.e., 94 months) with the International Security Assistance Force in Feyzabad, Kunduz, and Mazar-i-Sharif in Afghanistan. The deployed surgeons (authors) were given an Excel spreadsheet and were asked to enter details on the surgical procedures they had performed in the deployed setting on the basis of operative reports. Local and pedicled flaps were used in 73 cases to cover extensive soft-tissue defects and preserve the affected limbs. Improvised distraction osteogenesis was used in 18 patients to manage large bone defects. In 13 cases, bone defects were temporarily filled with a cement spacer (Masquelet technique). Fourteen patients required a combination of soft-tissue and bone reconstruction. Simple surgical reconstructive procedures are available that enable surgeons to preserve the shape and function of an injured limb with limited resources. This emphasizes the need either to make these techniques a mandatory part of training not only for surgeons who are deployed to combat zones and disaster areas but also for surgeons working for civilian relief organizations or to ensure that surgical teams are composed in such a way that these techniques are available.