Extremity War Injuries Research Articles

Outcomes of Lower Extremity Injuries Sustained During Operation Iraqi Freedom and Operation Enduring Freedom

Lower extremity war injuries are complex because of changes in weaponry and ballistics. Outcomes of a functional lower extremity depend on early transport, early debridement and washout, and advanced surgical techniques such as microvascular procedures. The purpose of this article is to present evidence on the outcomes of lower extremity complex injuries and provide evidence-based factors that contribute to these outcomes.

Extremity War Injuries: Challenges in Definitive Reconstruction

The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft-tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft-tissue injury management, such as improvement in the use of free-tissue transfer and enhanced approaches to tissue-engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer-aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high-energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high-velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.

Influence of Adjuvant Hyperbaric Oxygen Therapy on Short-term Complications During Surgical Reconstruction of Upper and Lower Extremity War Injuries: Retrospective Cohort Study

To determine the effects of hyperbaric oxygen (HBO) therapy on short-term complications of complex war wounds to the upper and lower extremities in patients who were and those who were not treated according to North Atlantic Treaty Organization (NATO) emergency war surgery recommendations. We retrospectively analyzed data of 388 male patients undergoing reconstructive surgery for Gustilo type III A, B, and C war wounds to the extremities at the Department of Reconstructive Surgery, Split University Hospital Center, between 1991 and 1995. The occurrence of main wound complications (deep infection, osteomyelitis, skin grafts lyses, and flap necrosis) during hospitalization and time from wounding to granulation formation were analyzed with respect to the use of HBO therapy as a risk factor. Odds ratio (OR) with 95% confidence intervals (CI) was calculated for the occurrence of wound complications with respect to HBO therapy and adjusted for NATO surgical strategy by logistic regression. Of 388 patients, 310 (80%) were initially treated according to the NATO surgical strategy and 99 (25%) received HBO therapy. Deep soft-tissue infection developed in 196 (68%) patients who did not receive HBO therapy and in 35 (35%) who received it (P<0.001, xi(2) test). Osteomyelitis developed in 214 (74%) patients who did not receive HBO therapy and in 62 (63%) who received it (P=0.030). Skin graft lysis occurred in 151 (52%) patients who did not receive HBO therapy and in 23 (23%) who received it (P<0.001). Flap necrosis occurred in 147 (51%) patients who did not receive HBO therapy and in 15 (15%) who received it (P<0.001). Median time to granulation formation was 9 (5-57) days in patients who received HBO therapy, and 12 (1-12) days in those who did not (P<0.001, Mann-Whitney test). These results were consistent over the groups of patients stratified according to the wound severity and remained unaltered after the adjustment for NATO surgical strategy. The effect of HBO therapy was greater in non-NATO than in NATO treated patients in case of deep soft-tissue infection (OR, 10.7 vs OR, 3.8; P=0.031 for interaction). HBO therapy reduced the frequency of wound complications in patients with Gustilo type III wounds and shortened the time to granulation formation. HBO therapy was more effective in non-NATO than in NATO treated patients for the prevention of deep soft-tissue infection but not flap necrosis.

Extremity War Injuries: Development of Clinical Treatment Principles

The AAOS/OTA Extremity War Injuries: Development of Clinical Treatment Principles symposium, held in January 2007, was a follow-up to the first Extremity War Injuries symposium held a year earlier. Discussion focused on four specific areas: prehospital management of extremity wounds, initial débridement, early stabilization, and postoperative wound management during air evacuation. Liberal emergency use of field tourniquets likely is contributing to lower overall mortality and is associated with very low rates of complications. Additional tools for extremity hemorrhage control, such as chitosan-based patches and granular zeolite hemostat, were postulated to be effective. Consensus opinion was that necrotic, devitalized, and contaminated tissue must be removed although objective assessment of completeness of initial débridement is difficult. Definitive open reduction and internal fixation for US and Coalition forces in the theater of operations should be limited to fracture patterns associated with significant perceived risk of delay in treatment. Finally, primary skin closure should be avoided in theater. In addition, because of the time and complications involved in transporting patients to level 4 care facilities, surgeons should consider release of compartments prior to patient transport whenever significant perceived potential for compartment syndrome is present.

Introduction Extremity War Injuries: Development of Clinical Treatment Principles

Introduction Extremity War Injuries: Development of Clinical Treatment Principles

Timing of Wound Coverage in Extremity War Injuries

Although several studies have been done on the timing of débridement of open fracture, none has specifically examined the effect of timing of soft-tissue coverage on outcome in the types of lower extremity injury being encountered in Iraq and Afghanistan, namely, injuries associated with the detonation of improvised explosive devices. Complex limb salvage requiring free tissue transfer or rotational flap coverage for soft-tissue defects has been commonly performed during the recent military conflicts in Iraq and Afghanistan. Current treatment protocols favor the inclusion of timely and stable axial limb fixation, radical débridement of all compromised soft tissues and osseous structures, and early wound closure with healthy, well-vascularized autologous tissue. In an attempt to minimize overall morbidity, a comprehensive plan must be made to sequentially reconstruct the involved extremity in order to achieve the highest level of function possible, with a durable construct, in the shortest period of time. Prospective studies are necessary to evaluate the effect of timing of coverage on outcome and on limb salvage.

Extremity War Injuries: State of the Art and Future Directions. Prioritized Future Research Objectives

Extremity War Injuries: State of the Art and Future Directions. Prioritized Future Research Objectives

Introduction

Introduction

Standard Wound Coverage Techniques for Extremity War Injury

Reconstruction of extremity war injuries begins with aggressive forward resuscitative care and stabilization of the trauma patient. After serial care in progressively better supported medical environments, definitive management is done at the level V military treatment facility. Aggressive forward care coupled with rapid air transport has enabled increasingly complex care to be administered at the continental United States military facilities; however, it has also made the decision between limb salvage and amputation more challenging. Yet to be determined are (1) the optimal timing of definitive wound closure or coverage in coordination with fracture stabilization and (2) the optimal types of flap for both upper and lower extremity reconstruction. Records of patients with complex lower and upper extremity wounds who were treated at the National Naval Medical Center between September 2004 and June 2006 reveal useful short-term data. Longer-term data, such as fracture union rate, time to ambulation, range of motion and global function of salvaged limbs, patient satisfaction with limb salvage, and average cost, are not yet available.

A Review of 41 Upper Extremity War Injuries and the Protective Gear Worn during Operation Enduring Freedom and Operation Iraqi Freedom

Forty-one patients with upper extremity war injuries sustained during combat operations Operation Enduring Freedom and Operation Iraqi Freedom were reviewed to report on protective gear availability and usage at the time of injury. Participants treated at the Madigan Army Medical Center occupational therapy clinic from August 2004 until February 2005 completed a questionnaire regarding injuries sustained during deployment. Overall, 6 injuries were to upper extremity regions that were covered with issued protective gear; 21 injuries were to areas not covered with issued protective gear (i.e., participant was not wearing issued gear), and 22 injuries were to regions that were not covered because no protective gear was issued for that body area. Although this study is limited, future research would provide valuable insights about the efficacy of current body armor and the need for additional or modified gear.

Rehabilitation of extremity war injuries with lesion of peripheral nerves in "PRAXIS" Centre for Physical Medicine and Rehabilitation, Sarajevo

Polytrauma with significant lesion of peripheral nerves is a specific war injury. It is also one of the most delicate problems in rehabilitation treatment because it requires a close cooperation with surgeon and timely surgical interventions. Based on our experience, the best results in the treatment of injured persons with lesion of peripheral nerves have been accomplished after the surgical treatment. Results in the neurolysis were better than those accomplished in neurorrhaphy. Total of 436 patients with lesion of peripheral nerves were recorded and 56 patients with plexus lesion. Out of this number, 78 patients (about 15%) had surgical treatment (41 neurorrhaphy and 37 neurolysis). Due to lack of adequate ENMG diagnostics, the objective valorisation of treatment outcome was not possible.