Reconstructive challenges in war wounds

ABSTRACT

War wounds are devastating with extensive soft tissue and osseous destruction and heavy contamination. War casualties generally reach the reconstructive surgery centre after a delayed period due to additional injuries to the vital organs. This delay in their transfer to a tertiary care centre is responsible for progressive deterioration in wound conditions. In the prevailing circumstances, a majority of war wounds undergo delayed reconstruction, after a series of debridements. In the recent military conflicts, hydrosurgery jet debridement and negative pressure wound therapy have been successfully used in the preparation of war wounds. In war injuries, due to a heavy casualty load, a faster and reliable method of reconstruction is aimed at. Pedicle flaps in extremities provide rapid and reliable cover in extremity wounds. Large complex defects can be reconstructed using microvascular free flaps in a single stage. This article highlights the peculiarities and the challenges encountered in the reconstruction of these ghastly wounds.

KEY WORDS

Delayed reconstruction - reconstructive challenges - war wound - wound debridement

• 1 Stanec Z, Skrbic S, Dzepina I. The management of war wounds to the extremities. Scand J Plast Reconstr Surg Hand Surg 1994;28:39-44.
• 2 Haywood I, Skinner D. Blast and gunshot injuries. BMJ 1990;301:1040-2.
• 3 Visnjic M, Petkovic A, Djenic N, Kovacevic P. Clinical experience in management of war injuries caused by armament during NATO aggression. Facta Universitatis, Series-Medicine & Biology2000;7:91-6.
• 4 Deitch EA, Grimas WR. Experience with 112 shotgun wounds of extremities. J Trauma 1984;24:600-3.
• 5 Kumar AR, Harshbanger R, Martin B. Plastic surgery challenges in war wounded. In: Sen CK, editor. Advances in wound care. Vol 1. Mary Ann Liebert, USA; 2010. p. 65-9.
• 6 Rozen N, Dudkiewicz I. Wound ballistics and tissue damage in armed conflict injuries to the extremities. In: Lerner A, Soudary M, editors. Berlin Heidelberg: Springer - Verley; 2011. p. 21-33.
• 7 Dougherty AL, Mohrle CR, Galaneau MR, Woodruff SI, Duye JL, Quinn KH. Battlefield extremity injuries in operation Iraqi Freedom. Injury 2009;40:772-7.
• 8 Hardaway RM. Vietnam wound analysis. J Trauma 1978;18:635-43.
• 9 Wangensteen OH, Wangensteen SD. Military surgeons and surgery, old and new: An instructive chapter in management of contaminated wounds. Surgery 1967;62:1102-24.
• 10 Granick M, Boykin J, Gamelli R, Schultz G, Tenenhaus M. Towards a common language: Surgical wound bed preparation and debridement. Wound Repair Regen 2006;14 Suppl 1:S1-10.
• 11 Guthrie HC, Clasper JC. Historical origins & current concepts of wound debridement. J R Army Med Corps 2011;157:130-2.
• 12 Jackson DS. Sepsis of soft tissue limb wounds in soldiers injured during Falklands campaign 1982. J R Army Med Corps 1984;130:97-9.
• 13 Siemers F, Stang FH, Namdar T, Senyaman O, Mailander P. Removal of accidental inclusions following blast injury by use of a hydrosurgery system. Injury Extra 2010;41:83-4.
• 14 Coupland RM. Technical aspects of war wound excision. Br J Surg 1989;76:603-7.
• 15 15 Lowry KF, Curtis GM. Delayed suture in the management of wounds. Am J Surg 1950;80:280-7.
• 16 Forsberg JA, Elster EA, Anderson RC, Nylen E, Brown TS, Rose MW, et al. Correlation of Procalcitonin and cytokinin expression with dehiscence of wartime extremity wounds. J Bone Joint Surg Am 2008;90:580-8.
• 17 Hawksworth JS, Stojadinovic A, Gage FA, Tadaki DK, Perdue PW, Forsberg J, et al. Inflammatory biomarkers in combat wound healing. Ann Surg 2009;250:1002-7.
• 18 Murray CK, Roop SA, Hospenthal DR, Dooley DP, Wenner K, Homock J, et al. Bacteriology of war wounds at the time of injury. Mil Med 2006;171:826-9.
• 19 Davis KA, Moran KA, McAllister K, Gray PJ. Multidrug resistant Acinetobacter extremity infections in soldiers. Emerg Infect Dis 2005;11:1218-24.
• 20 Godina M. Early microsurgical reconstruction of complex trauma of extremities. Plast Reconstr Surg 1986;78:285-92.
• 21 Coupland RM. The role of reconstructive surgery in the management of war wounds. Ann R Coll Surg Engl 1999;73:21-5.
• 22 Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8.
• 23 Marchaland JP, Ollat D, Mathieu L, Versier G. How to cover soft tissue defects after injuries to leg in precarious conditions. Eur J Trauma Emerg Surg 2009;35:3-9.
• 24 Stanec Z, Skrbic S, Dzepina I, Hulina D, Unksic I, Montani D, et al. High energy war wounds: Flap reconstruction. Ann Plast Surg 1993;31:97-102.
• 25 Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from operation Iraqi freedom: Successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg 2009;123:218-29.
• 26 Tintle SM, Gwinn DE, Andersen RC, Kumar AR. Soft tissue coverage of combat wounds. J Surg Orthop Adv 2010;19:29-34.
• 27 Argenta LC, Morykwas MJ. Vacuum-assisted closure: A new method for wound control and treatment: Clinical experience. Ann Plast Surg 1997;38:563-76.
• 28 Couch KS, Stojadinovic A. Negative - pressure wound therapy in Military: Lessons learnt. Plast Reconstr Surg 2011;127(S):117S-30.
• 29 Geiger S, McCormick F, Chou R, Wangel AG. War wounds: Lessons learned from Operation Iraqi Freedom. Plast Reconstr Surg 2008;122:146-53.
• 30 Swartz WM, Mears DC. The role of free tissue transfers in lower extremity reconstruction. Plast Reconstr Surg 1985;76:364-73.
• 31 Maghari A, Forootan KS, Emamia SA, Melow C. Microvascular reconstruction of soft tissue and bone loss in war wounds. Scand J Plast Reconstr Surg Hand Surg 1992;26:91-6.
• 32 Dzepina I, Stanec Z, Skrbic S, Hulia D, Ivriac R, Unusic J, et al. One stage reconstruction of war wounds with free osteocutaneous flap. Br J Plast Surg 1997;50:81-7.