Combat-related Extremity Injuries Research Articles

Venous thromboembolic complications in wounded with combat-related extremity injuries

Venous thromboembolic complications in wounded with combat-related extremity injuries

A Longitudinal Perspective on Conversion to Amputation for Combat-Related Extremity Injuries Treated with Flap-Based Limb Salvage.

To define the rate and primary drivers behind early and late amputation following flap-based limb salvage in the setting of combat extremity trauma. Retrospective review. Level II trauma center. Three hundred seven (303 men, 4 women) patients who underwent flap-based limb salvage treatment between 2003-2014. We reviewed patient medical records, radiographs, and clinical photographs. Early and late amputation rates, time to amputation, reason for amputation. 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. 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. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

The impact of bilateral injuries on the pathophysiology and functional outcomes of volumetric muscle loss

Volumetric muscle loss (VML)—defined as the irrecoverable loss of skeletal muscle tissue with associated persistent functional deficits—is among the most common and highly debilitating combat-related extremity injuries. This is particularly true in cases of severe polytrauma wherein multiple extremities may be involved as a result of high energy wounding mechanisms. As such, significant investment and effort has been made toward developing a clinically viable intervention capable of restoring the form and function of the affected musculature. While these investigations conducted to date have varied with respect to the species, breed, and sex of the chosen pre-clinical in-vivo model system, the majority of these studies have been performed in unilateral injury models, an aspect which may not fully exemplify the clinical representation of the multiply injured patient. Furthermore, while various components of the basal pathophysiology of VML (e.g., fibrosis and inflammation) have been investigated, relatively little effort has focused on how the pathophysiology and efficacy of pro-regenerative technologies is altered when there are multiple VML injuries. Thus, the purpose of this study was two-fold: (1) to investigate if/how the pathophysiology of unilateral VML injuries differs from bilateral VML injuries and (2) to interrogate the effect of bilateral VML injuries on the efficacy of a well-characterized regenerative therapy, minced muscle autograft (MMG). In contrast to our hypothesis, we show that bilateral VML injuries exhibit a similar systemic inflammatory response and improved muscle functional recovery, compared to unilateral injured animals. Furthermore, MMG treatment was found to only be effective at promoting an increase in functional outcomes in unilateral VML injuries. The findings presented herein add to the growing knowledge base of the pathophysiology of VML, and, importantly, reiterate the importance of comprehensively characterizing preclinical models which are utilized for early-stage screening of putative therapies as they can directly influence the translational research pipeline.

The effect of neuropathic pain on quality of life, depression levels, and sleep quality in patients with combat-related extremity injuries.

There is limited research on the effects of neuropathic pain (NP) on quality of life, depression levels, and sleep quality in patients with combat-related extremity injuries. This study evaluated whether patients with combat-related extremity injuries with and without NP had differences in quality of life, sleep quality, and depression levels. A total of 98 patients with combat-related extremity injuries, 52 with NP and 46 without, were included in this cross-sectional study. The presence of NP was determined using the Leeds Assessment of Neuropathic Symptoms and Signs questionnaire. The outcome measures were a visual analogue scale (VAS), the 36-Item Short Form Survey, the Beck Depression Inventory, and the Pittsburgh Sleep Quality Index (PSQI). The VAS subparameter scores for pain (all P<0.05), PSQI sleep duration subscale scores (P=0.025), PSQI sleep disturbance subscale scores (P=0.016), and PSQI total scores (P=0.020) were significantly higher in patients with NP than those without. Logistic regression analysis showed that VAS scores of 5 and above for average pain during the previous 4 weeks contributed independently to the prediction of NP. Patients with combat-related extremity injuries with NP had more pain and poorer sleep quality than those without NP. Sleep quality should be evaluated as part of the diagnostic work-up in patients with combat-related extremity injury with NP, and interventions to improve sleep quality may help manage NP in this patient group.

Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness.

As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.

A Focus on Non-Amputation Combat Extremity Injury: 2001-2018.

Extremity injuries have comprised the majority of battlefield injuries in modern U.S. conflicts since World War II. Most reports have focused on serious injuries only and, to date, no reports have described the full extent of combat extremity injuries, from mild to severe, resulting from post-9/11 conflicts. This study aims to identify and characterize the full spectrum of non-amputation combat-related extremity injury and extend the findings of previous reports. The Expeditionary Medical Encounter Database was queried for all extremity injured service members (SMs) deployed in support of post-9/11 conflicts through July 2018. Only injuries incurred during combat operations were included in this report. Major amputations were excluded as well as SMs killed in action or who died of wounds. Extremity injuries were categorized by body region, nature of injury, and severity. Demographics and injury event characteristics are also presented. A total of 17,629 SMs sustained 42,740 extremity injuries during 18,004 separate injury events. The highest number of SMs were injured in 2004 (n = 3,553), 2007 (n = 2,244), and 2011 (n = 2,023). Injured SMs were mostly young (78% under 30 years), male (97%), junior- to mid-level enlisted (89%), in the Army (69%) or Marine Corps (28%), active duty (84%), serving as infantry and gun crew (59%), and injured in support of Operation Iraqi Freedom (60%). Blast weaponry was responsible for 75% of extremity injuries. Injuries were similarly distributed between the lower (52%) and upper (48%) extremities. The most common sites of lower extremity injury were the lower leg/ankle complex (40%) and thigh (26%). The most common upper extremities sites were the shoulder and upper arms (37%), and the hand, wrist, and fingers (33%). Nearly half (48%) of all extremity injuries were open wounds (48%), followed by fractures (20%) and contusions/superficial injuries (16%). SMs sustained an average of 2.4 extremity injuries per event and 56% of injuries were considered mild, with a median Injury Severity Score (ISS) of 3. This study is the first publication to capture, review, and characterize the full range, from mild to severe, of non-amputation combat-related extremity injuries resulting from post-9/11 conflicts. The high prevalence of extremity injury, particularly in such a young population, and associated short- and long-term health outcomes, will impact military health care systems for decades to come.

Patency of arterial repairs from wartime extremity vascular injuries

BackgroundExtremity vascular injury (EVI) causes significant disability in Veterans of the Afghanistan/Iraq conflicts. Advancements in acute trauma care improved survival and decreased amputations. The study of wartime EVI has relied...

Lower Limb Posture Affects the Mechanism of Injury in Under-Body Blast

Over 80% of wounded Service Members sustain at least one extremity injury. The ‘deck-slap’ foot, a product of the vehicle’s floor rising rapidly when attacked by a mine to injure the limb, has been a signature injury in recent conflicts. Given the frequency and severity of these combat-related extremity injuries, they require the greatest utilisation of resources for treatment, and have caused the greatest number of disabled soldiers during recent conflicts. Most research efforts focus on occupants seated with both tibia-to-femur and tibia-to-foot angles set at 90°; it is unknown whether results obtained from these tests are applicable when alternative seated postures are adopted. To investigate this, lower limbs from anthropometric testing devices (ATDs) and post mortem human subjects (PMHSs) were loaded in three different seated postures using an under-body blast injury simulator. Using metrics that are commonly used for assessing injury, such as the axial force and the revised tibia index, the lower limb of ATDs were found to be insensitive to posture variations while the injuries sustained by the PMHS lower limbs differed in type and severity between postures. This suggests that the mechanism of injury depends on the posture and that this cannot be captured by the current injury criteria. Therefore, great care should be taken when interpreting and extrapolating results, especially in vehicle qualification tests, when postures other than the 90°–90° are of interest.

Combat Injury of the Sciatic Nerve - An Institutional Experience.

Combat injury of the sciatic nerve tends to be severe with variable but often profound consequences, is often associated with widespread soft tissue and bone injuries, significant neurologic impairment, severe neuropathic pain, and a prolonged recovery time. There is little contemporary data that describes the treatment and outcome of this significant military acquired peripheral nerve injury. We describe our institution's experience treating patients with combat-acquired sciatic nerve injury in the recent Iraq and Afghanistan wars. IRB approval was obtained, and a retrospective review was performed of the records of 5,137 combat-related extremity injuries between June 2007 and June 2015 to identify patients with combat-acquired sciatic nerve injury without traumatic amputation of the injured leg. The most common mechanisms of injury were gunshot wound to the upper thigh or pelvis, followed by blast injury. Thirteen patients were identified that underwent sciatic nerve exploration and repair. Nine patients had nerve repair using long-length acellular cadaveric allografts. Five patients underwent nerve surgery within 30 d of injury and eight had surgery on a delayed basis. The postoperative follow-up period was at least 2 yr. Reduction of neuropathic pain was significant, 7/10 points on the 11-point pain intensity numerical rating scale. Eight patients displayed electrodiagnostic evidence of reinnervation distal to the injury zone; however, functional recovery was poor, as only 3 of 10 patients had detectable motor units distal to the knee, and recovery was only in tibial nerve innervated muscles. There were no serious surgical complications, in particular, wound infection or graft rejection associated with long-length cadaver allograft placement. Early surgery to repair sciatic nerve injury possibly promotes significant pain reduction, reduces narcotic usage and facilitates a long rehabilitation process. Allograft nerve placement is not associated with serious complications. A follow-up period longer than 3 yr would be required and is ongoing to assess the efficacy of our treatment of patients with combat-acquired sciatic nerve injury.

The Importance of Medical Readiness Training Exercises: Maintaining Medical Readiness in a Low-Volume Combat Casualty Flow Era.

Ringed external fixation has demonstrated promising results in the management of severe combat-related extremity injuries. The purpose of this study was to identify and compare rates of wartime-related surgical cases at times of high and low casualty time periods, and then compare these case numbers with those performed during a 2-week Medical Readiness Training Exercise (MEDRETE) in Honduras. A retrospective review was performed of patients treated at a single Military Treatment Facility with definitive ringed external fixators during a 2-year period of high-volume combat casualty flow (January 2009-December 2010) and a subsequent 2-year period of low-volume combat casualty flow (January 2013-December 2014). These data were then compared with cases performed over a 2-week period during a MEDRETE in 2011 to Honduras. Sixty-one cases were identified as having definitive treatment using ringed external fixation at the Military Treatment Facility during the high- and low-volume eras. During the high-volume era, 47 ringed external fixators were used as a definitive treatment. During the low-volume era, only 14 of the definitive ringed external fixation were identified. Of the 32 total cases performed during the 2-week MEDRETE to Honduras, 11 cases of definitive ringed external fixator placement were performed. This accounted for 34.4% of all cases performed during this 2-week period. Appropriately planned MEDRETEs can provide a concentrated case volume to allow maintenance of complex surgical skills related to the management of severe combat-related extremity injuries. These training exercises will be vital to maintain surgical skills during a low-volume combat casualty flow era.

Exploratory study on the effect of osteoactivin on muscle regeneration in a rat volumetric muscle loss model.

Wounds causing extensive injury loss of muscle, also known as volumetric muscle loss (VML), are frequently associated with high-energy civilian trauma and combat-related extremity injuries. Currently, no effective clinical therapy is available for promoting de novo muscle tissue regeneration to restore muscle function following VML. Recent studies have shown evidence that osteoactivin (OA), a transmembrane glycoprotein, has the ability to prevent skeletal muscle atrophy in response to denervation. Therefore the objective of this study is to investigate the potential regenerative effect of OA embedded and delivered via a cross-linked gelatin hydrogel within a volumetric tibialis anterior muscle defect in a rat model. After 4 weeks, however, no evidence for muscle formation was found in defects treated with either low (5 μg/ml) or high (50 μg/ml) OA. It is possible that a different delivery scaffold, delivery kinetics, or OA concentration may have yielded an alternate outcome, or it is also possible that the spaciostructural environment of VML, or the local (versus systemic) delivery of OA, simply does not support any potential regenerative activity of OA in VML. Together with prior work, this study demonstrates that an efficacious and scalable therapy for regenerating muscle volume and function in VML remains a veritable clinical challenge worthy of continued future research efforts.

Improving Outcomes Following Extremity Trauma: The Need for a Multidisciplinary Approach.

Extremity injuries contribute a significant amount to the overall disability of combat-injured soldiers. Tracking patient outcomes allows military health care providers to gain a better understanding of the disability associated with various injury patterns. Only recently have orthopedic surgeons begun to collect functional outcome measures, and perhaps even more importantly, have begun to collect patient-reported outcomes. There is a growing body of evidence demonstrating the importance of a multidisciplinary approach to optimize outcomes in patients following severe extremity trauma. Tracking the outcomes of these interventions longitudinally will ultimately provide the military surgeon with an evidence-based plan to treat severe combat-related extremity injuries, leading to optimal care for future combat injured patients. "However beautiful the strategy, you should occasionally look at the results."-Winston Churchill.

Free-Tissue Transfer for the Reconstruction of War-Related Extremity Injuries: A Systematic Review of Current Practice.

Extremity injuries in combat zones have devastating sequelae. The increasing survival of war-zone casualties, combined with rapid advances in microsurgery, means that there is a growing role for free-tissue reconstruction. We systematically reviewed the current practices in microsurgical reconstruction of combat-related extremity injuries, focusing on free-flap types, timing of surgery, and outcomes. We conducted a PubMed search of the terms "War" and "Reconstruction," identifying 21st century studies on subacute/delayed free-flap repair, to reflect the idiosyncrasies of modern warfare. Case reports and studies exclusively describing craniofacial and thoracoabdominal injuries were excluded. A total of 11 studies fulfilled our inclusion criteria. In 9 studies, patients were repatriated/transferred to specialist facilities for treatment; in 2 studies, reconstruction was performed within combat/austere environments. The number of free-flaps described per study ranged from 6 to 233 (Total = 501). Latissimus dorsi flaps were most commonly used (43.7%). The average time to definitive reconstruction ranged from 9.6 days to 3 years, being delayed to address life-threatening injuries. The average free-flap success rate was 95.5% (range = 88.9%-100%). Combat-associated extremity injuries are characterized by extensive tissue loss and gross contamination. Despite this, microsurgical reconstruction results in minimal morbidity and successful outcomes. Large, multicenter studies are necessary to corroborate these findings and establish definitive management guidelines.

Reliability of the mangled extremity severity score in combat-related upper and lower extremity injuries.

Background:Decision of limb salvage or amputation is generally aided with several trauma scoring systems such as the mangled extremity severity score (MESS). However, the reliability of the injury scores in the settling of open fractures due to explosives and missiles is challenging. Mortality and morbidity of the extremity trauma due to firearms are generally associated with time delay in revascularization, injury mechanism, anatomy of the injured site, associated injuries, age and the environmental circumstance. The purpose of the retrospective study was to evaluate the extent of extremity injuries due to ballistic missiles and to detect the reliability of mangled extremity severity score (MESS) in both upper and lower extremities.Materials and Methods:Between 2004 and 2014, 139 Gustillo Anderson Type III open fractures of both the upper and lower extremities were enrolled in the study. Data for patient age, fire arm type, transporting time from the field to the hospital (and the method), injury severity scores, MESS scores, fracture types, amputation levels, bone fixation methods and postoperative infections and complications retrieved from the two level-2 trauma center's data base. Sensitivity, specificity, positive and negative predictive values of the MESS were calculated to detect the ability in deciding amputation in the mangled limb.Results:Amputation was performed in 39 extremities and limb salvage attempted in 100 extremities. The mean followup time was 14.6 months (range 6–32 months). In the amputated group, the mean MESS scores for upper and lower extremity were 8.8 (range 6–11) and 9.24 (range 6–11), respectively. In the limb salvage group, the mean MESS scores for upper and lower extremities were 5.29 (range 4–7) and 5.19 (range 3–8), respectively. Sensitivity of MESS in upper and lower extremities were calculated as 80% and 79.4% and positive predictive values detected as 55.55% and 83.3%, respectively. Specificity of MESS score for upper and lower extremities was 84% and 86.6%; negative predictive values were calculated as 95.45% and 90.2%, respectively.Conclusion:MESS is not predictive in combat related extremity injuries especially if between a score of 6–8. Limb ischemia and presence or absence of shock can be used in initial decision-making for amputation.

Outcomes after Long-Term Follow-Up of Combat-Related Extremity Injuries in a Multidisciplinary Limb Salvage Clinic

Although the incidence of casualties from the Global War on Terror is decreasing, there remains a focus on the long-term sequelae from injuries sustained in the combat. Patients with prior significant limb injuries remain at risk of future complications. This study examines our institution's experience with a multidisciplinary team approach toward this challenging patient population. A retrospective review was performed on all patients treated in a single institution Limb Preservation Clinic over a 2-year period. Those patients who sustained a combat-related injury in theater were examined. Patient demographics, mechanism of injury, amputation rates, time to amputation, and reasons for failure were examined. Ninety-four patients were evaluated in our multidisciplinary Limb Preservation Clinic over a 2-year period. Twenty patients (21%) were seen for combat-related injuries. Sixteen patients were evaluated and treated for chronic complications at a median of 13 months from their injury. All 16 patients were male with a median age of 24 years (range, 20-35). Ten patients sustained injuries secondary to a dismounted improvised explosive device (IED). All 16 patients had extensive soft tissue injuries and associated fractures. Only 2 patients sustained a vascular injury. The median number of prior surgeries to the affected limb was 8 (range, 3-19). The limb salvage rate of 37% was lower than our noncombat cohort (47%). The most common reasons for delayed amputation included chronic pain, osteomyelitis, and soft tissue infections. The high secondary amputation rates seen in this cohort underscores the need for long-term follow-up. Despite successful initial outcomes, many patients eventually progress to limb loss. Patients who sustain a dismounted IED are at greatest risk for a delayed amputation. Identifying and addressing those factors which lead to delayed amputation should be a priority for returning war veterans and focus of future studies.

Flap coverage outcomes following vascular injury and repair: chronicling a decade of severe war-related extremity trauma.

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. 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. 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. 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. Therapeutic, III.

Limb salvage after vascular reconstruction followed by tissue transfer during the Global War on Terror

Combat extremity wounds are complex and frequently require an immediate vascular reconstruction in the operational environment followed by delayed tissue coverage at a stateside medical treatment facility. The purpose of this study was to evaluate limb salvage outcomes after combat-related vascular reconstruction that subsequently required delayed soft tissue coverage during the Global War on Terror. Patients who incurred a war-related extremity injury necessitating an immediate vascular intervention followed by definitive limb reconstruction requiring flap coverage from combat injuries were reviewed. Patient demographics, types of vascular and extremity injuries, and surgical interventions were examined. Outcomes included limb salvage, primary and secondary graft patency, flap outcomes, and complications. Differences between upper extremities (UEs) and lower extremities (LEs) were compared. From 2003 to 2012, 27 patients were treated for combat-related extremity injuries with an immediate vascular reconstruction followed by delayed tissue coverage. Fifteen LEs and 12 UEs were treated. The mean age was 24 years. An explosion was the cause in 77% of patients, with a mean Injury Severity Score (ISS) of 19. An autogenous vein bypass was the most common reconstruction performed in 20 patients (74%). Other vascular repairs included a primary repair, a patch angioplasty with bovine pericardium, and a bypass with use of a prosthetic graft. Eight patients (30%) had a concomitant venous injury, and 23 (85%) had a bone fracture. Thirty flaps were performed at a mean of 33 days from the original injury. Pedicle flaps were used in 24 limbs and free tissue flaps in six limbs. Muscle, fasciocutaneous, bone, and composite flaps were used for tissue coverage. At a mean follow-up of 16 months, primary patency rates of all arterial reconstructions were 66% in the UE and 53% in the LE (P = .69). Secondary patency rates were 100% in the UE and 86% in the LE (P = .48). The overall limb salvage rate was 81%. Limb salvage rates were 66% in the LE and 100% in the UE (P = .04). Three amputated lower limbs (60%) had inline flow to the foot. The flap success rate was 96%. Reasons for amputation included arterial thrombosis, flap failure, persistent soft tissue infection, osteomyelitis, and debilitating peripheral nerve injuries with associated chronic pain. Immediate vascular repair followed by delayed tissue coverage can be performed with a high (>80%) limb salvage rate after combat trauma. Limb salvage rates were higher in the UE despite equivocally high arterial patency rates. Wounded warriors can expect limb salvage by use of this international algorithm.

Soft tissue coverage of war extremity injuries: the use of pedicle flap transfers in a combat support hospital.

Definitive management of extremity injuries including soft tissue coverage is seldom achieved in battlefield medical treatment facilities due to limited resources and operational constraints. The purpose of this study was to analyse the French Army Medical Service experience performing such reconstructive surgery in a Combat Support Hospital (CSH) in Afghanistan. A clinical study was performed in the KaIA (Kabul International Airport) CSH from July 2012 to January 2013. During this period 23 Afghan patients treated for soft tissue coverage of combat-related extremity injuries were included. They totalled 28 extremity injuries including 18 blast trauma (BT) and ten non blast trauma (NBT). Overall, 35 extremity pedicled flaps were performed. There were 26 fasciocutaneous flaps, eight muscle flaps and one composite flap. Soft tissue coverage was achieved on all patients reviewed with a mean follow-up of 59days. Five postoperative complications occurred including two deep infections, one partial flap necrosis and two flap failures, without difference according to injury mechanism. Reconstruction of traumatic soft tissue defect can be achieved in CSHs for local nationals. Pedicle flap transfers provide simple and safe coverage for war extremity injuries in this challenging environment whatever the injury mechanism.

Evolution of Orthopaedic Rehabilitation Care

Rehabilitation following surgical reconstruction for combat-related extremity injuries sustained in the current conflicts in Iraq and Afghanistan has been challenging. The goal of rehabilitation is to restore limb function to facilitate the reintegration of patients with these severe injuries into society. The US Department of Defense has developed a network of rehabilitation centers of excellence within the military healthcare system in collaboration with the US Department of Veterans Affairs to optimize outcomes using technologic and systemic advances in prostheses in patients who have undergone limb salvage procedures or amputation. Managing pain during rehabilitation and optimizing function following high bilateral lower extremity amputation remains a clinical challenge. However, continued research is likely to improve outcomes in this severely injured patient population. To that end, two research consortia, the Bridging Advanced Developments for Exceptional Rehabilitation and the Center for Rehabilitation Sciences Research, have recently been created to address identified knowledge gaps.