Soft tissue management of war wounds to the foot and ankle

Terrorist attacks: common injuries and initial surgical management

Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.

Innervation of an engineered muscle graft for reconstruction of muscle defects

Autologous muscle flaps are commonly used to reconstruct defects that involve muscle impairment. To maintain viability and functionality of these flaps, they must be properly vascularized and innervated. Tissue-engineered muscles could potentially replace autologous muscle tissue, but still require establishment of sufficient innervation to ensure functionality. In this study, we explored the possibility of innervating engineered muscle grafts transplanted to an abdominal wall defect in mice, by transferring the native femoral nerve to the graft. Six weeks posttransplantation, nerve conduction studies and electromyography demonstrated increased innervation in engineered grafts neurotized with the femoral nerve, as compared to non-neurotized grafts. Histologic assessments revealed axonal penetration and formation of neuromuscular junctions within the grafts. The innervation process described here may advance the fabrication of a fully functional engineered muscle graft that will be of utility in clinical settings.

Early Reconstructions of Complex Lower Extremity Battlefield Soft Tissue Wounds

BACKGROUND

Severe lower extremity trauma as a devastating combat related injury is on the rise and this presents reconstructive surgeons with significant challenges to reach optimal cosmetic and functional outcomes. This study assessed early reconstructions of complex lower extremity battlefield soft tissue wounds.

METHODS

This was a prospective case series study of battled field injured patients which was done in the Department of Plastic Surgery, Baqiyatallah University of Medical Sciences hospitals, Tehran, Iran between 2013-2015. In this survey, 73 patients were operated for reconstruction of lower extremity soft tissue defects due to battlefield injuries.

RESULTS

Seventy-three patients (65 men, 8 womens) ranging from 21-48 years old (mean: 35 years) were enrolled. Our study showed that early debridement and bone stabilization and later coverage of complex battlefields soft tissue wounds with suitable flaps and grafts of lower extremity were effective method for difficult wounds managements with less amputation and infections.

CONCLUSION

Serial debridement and bone stabilization before early soft tissue reconstruction according to reconstructive ladder were shown to be essential steps.

Complex Foot Injury: Early and Definite Management

Complex foot injuries occur infrequently, but are life-changing events. They often present with other injuries as the result of a high-energy trauma. After initial stabilization, early assessment should be regarding salvagability. All treatment strategies are intensive. The initial treatment includes prevention of progression ischemia/necrosis, prevention of infection, and considering salvage or amputation. Definitive treatment for salvage includes anatomic reconstruction with stable internal fixation and early soft tissue coverage followed by aggressive rehabilitation. Prognosis after complex injuries is hard to predict. The various stages of the treatment are reviewed and recommendations are made.

Role of integrin α7β1 signaling in myoblast differentiation on aligned polydioxanone scaffolds

The aligned structural environment in skeletal muscle is believed to be a crucial component in functional muscle regeneration. Myotube formation is increased on aligned biomaterials, but we do not fully understand the mechanisms that direct this enhanced fusion. Previous studies indicate that the α7 integrin subunit is upregulated during myoblast differentiation, suggesting that signaling via α7β1 mediates the effect of alignment. To test this hypothesis, we took advantage of an in vitro model using random and aligned polydioxanone (PDO) matrices and C2C12 myoblasts. We measured expression and production of myoblast markers: paired box-7 (Pax7), myogenic differentiation factor-1 (MyoD), myogenin (MyoG), myogenic factor-6 (Myf6), and myosin heavy chain (MyHC). To examine the role of α7β1 signaling, we measured expression and production of α7, α5, and β1 and myoblast markers in wild type cells and in cells silenced for α7 and assessed effects of silencing on myogenic differentiation. Downstream signaling via ERK1/2 mitogen activated protein kinase (MAPK) was examined using a specific MEK1/2 inhibitor. Alignment increased mRNAs and protein for early (MyoD) and late (MyoG, MyHC) myoblast markers in comparison to non-aligned matrices, and these levels corresponded with increased α7 protein. α7-silencing reduced MyoG and MyHC protein in cells cultured on tissue culture polystyrene and aligned PDO matrices compared to wild type cells. Inhibition of ERK1/2 blocked effects of alignment. These data suggest that alignment regulates myogenic differentiation via α7β1 integrin signaling and ERK1/2 mediated gene expression.

STATEMENT OF SIGNIFICANCE

Muscle regeneration in severe muscle injuries is complex, requiring a sequence of events to promote healing and not fibrosis. Aligned biomaterials that recapitulate muscle environments hold potential to facilitate regeneration, but it is important to understand cell-substrate signaling to form functional muscle. A critical component of muscle signaling is integrin α7β1, where mice lacking α7 exhibit a dystrophic phenotype and impaired regeneration. Here, we report the role of α7β1 signaling in myoblast differentiation on aligned biomaterials. α7-silenced myoblasts were found to regulate myogenic differentiation and demonstrate defective fusion. Our data shows reduced levels of myogenin and myosin heavy chain protein, while MyoD remains unchanged. These results support the hypothesis that α7β1 signaling plays a role in substrate-dependent tissue engineering strategies.

Blurred front lines: triage and initial management of blast injuries

Recent armed conflicts and the expanded reach of international terror groups has resulted in an increased incidence of blast-related injuries in both military and civilian populations. Mass-casualty incidents may require both on-scene and in-hospital triage to maximize survival rates and conserve limited resources. Initial evaluation should focus on the identification and control of potentially life-threatening conditions, especially life-threatening hemorrhage. Early operative priorities for musculoskeletal injuries focus on the principles of damage-control orthopaedics, with early and aggressive debridement of soft-tissue wounds, vascular shunting or grafting to restore limb perfusion, and long-bone fracture stabilization via external fixation. Special considerations such as patient transport, infection control and prevention, and amputation management are also discussed. All orthopedic surgeons, regardless of practice setting, should be familiar with the basic principles of evaluation, resuscitation, and initial management of explosive blast injuries.

Extremity injuries in soldiers during the conflict in Mali: experience of Togo Level two Hospital

PURPOSE

The aim of this study was to analyse war-related and non-war-related extremity injuries in soldiers in the Mali conflict.

MATERIALS AND METHODS

This prospective study was performed from 1 May 1 to 31 December 2014. It concerned extremity injuries in soldiers treated at Togo Level 2 Hospital.

RESULTS

Seventy-nine patients with an average age of 31.19 years were assessed. Among them, 50 were admitted after war injury and 29 from nonwar injury. Most war-related injuries were due to improvised explosive devices (IEDs) (36 %); road traffic accidents (51.72 %) were the main mechanism of non-war injury. A total of 125 injuries were analysed. Limb fractures were identified in 37 patients (29.6 %), and 22 cases (59.46 %) were open fractures. Twenty-six (20.8 %) patients had soft tissue wounds. The other injuries were sprains (18.4 %), muscle contusions (15.2 %), dislocations (8.8 %), traumatic amputations (4 %) and burns (3.2 %). Surgical debridement and external fixator application were the most frequently performed surgical procedures. Thirty-nine per cent of patients were evacuated to a level 3 hospital for better care.

CONCLUSION

The severity of injuries and their rapid treatment require orthopaedic surgeons to have high levels of surgical experience and knowledge pertaining to military or disaster surgical doctrine.

The ortho-plastic approach to soft tissue management in trauma

Fractures with associated soft tissue injuries, or those termed 'open,' are not uncommon. There has been much discussion regarding there management, with the guidance from the combined British Orthopaedic Association and British Association and Aesthetic Surgeons teams widely accepted as the gold level of therapy. We aim to discuss the current evidence about the initial management of this group of injuries, taking a journey from arrival in the accident and emergency department through to the point of definitive closure. Other modes of therapy are also reviewed.

French surgical experience in the role 3 medical treatment facility of KaIA (Kabul International Airport, Afghanistan): the place of the orthopedic surgery

INTRODUCTION

In 2009, the French took command of the Medical Hospital (MH) or Role 3 Hospital at KaIA (Kabul International Airport) within the framework of its role in the military mission Operation Pamir in Afghanistan. The goal of this study was to analyze the volume of orthopedic surgical activity for the last four years, to identify its specificities and to improve training of military orthopedic surgeons.

HYPOTHESIS

Orthopedic surgery is the most important activity in the field and surgeons must adapt to situations and injuries that are different from those encountered in France.

PATIENTS AND METHODS

All patients operated on between July 2009 and June 2013 were prospectively included in an electronic database. The analysis included the number of surgical acts and patients, the types of injuries and the surgical procedures.

RESULTS

Forty-three percent (n=1875) of 4318 procedures involved orthopedic surgery. Half of these were emergencies. French military personnel represented 17% of the patients, local civilians 47% and children 17%. Half of the procedures involved the soft tissues, 20% were for bone fixation and 10% for surgery of the hand. The rate of amputation was 6%. The diversity of the surgical acts was high ranging from emergency surgery to surgical reconstruction.

DISCUSSION

The activity of this Role 3 facility is comparable to that of other Role 3 facilities in Afghanistan, with an important percentage of acts involving medical assistance to the local population and scheduled surgeries as well as primary and/or secondary management of the wounded. The diversity of surgical acts confirms the challenge of training military orthopedic surgeons within the context of the hyperspecialization of the civilian sector. Specific training has been organized in France by the École du Val de Grâce. Specific continuing education is also necessary.

LEVEL OF EVIDENCE

IV (retrospective review).

Microvascular reconstructive surgery in Operations Iraqi and Enduring Freedom: the US military experience performing free flaps in a combat zone

BACKGROUND

Local nationals with complex wounds resulting from traumatic combat injuries during Operations Iraqi Freedom and Enduring Freedom usually must undergo reconstructive surgery in the combat zone. While the use of microvascular free-tissue transfer (free flaps) for traumatic reconstruction is well documented in the literature, various complicating factors exist when these intricate surgical procedures are performed in a theater of war.

METHODS

The microvascular experiences of six military surgeons deployed during a 30-month period between 2006 and 2011 in Iraq and Afghanistan were retrospectively reviewed.

RESULTS

Twenty-nine patients presented with complex traumatic wounds. Thirty-one free flaps were performed for the 29 patients. Location of tissue defects included the lower extremity (15), face/neck (8), upper extremity (6). Limb salvage was successful in all but one patient. Six of eight patients with head and neck wounds were tolerating oral intake at the time of discharge. There were three flap losses in 3 patients; two patients who experienced flap loss underwent a successful second free or regional flap. Minor complications occurred in six patients.

CONCLUSION

Microvascular free tissue transfer for complex tissue defects in a combat zone is a critically important task and can improve quality of life for host-nation patients. Major US combat hospitals deployed to a war zone should include personnel who are trained and capable of performing these complex reconstructive procedures and who understand the many nuances of optimizing outcomes in this challenging environment.

Total posterior leg open wound management with free anterolateral thigh flap: case and literature review

Soft tissue coverage of the exposed Achilles tendon is a unique reconstructive challenge. In this report, we describe the management of a large posterior leg wound with exposed Achilles tendon using a free anterolateral thigh (ALT) flap. A careful review of alternative reconstructive options is included, along with their respective advantages and disadvantages. A 32-year-old white man suffered a fulminant right lower extremity soft tissue infection requiring extensive debridement of the entire posterior surface of the right leg. The resulting large soft tissue defect included exposure of the Achilles tendon. Reconstruction of the defect was achieved with an ALT flap and split-thickness skin graft for coverage of the Achilles tendon and gastrocnemius muscle, respectively. The patient was able to ambulate independently within 2 months of the procedure.

The influence of platelet-rich plasma on myogenic differentiation

The ability to expand and direct both precursor and stem cells towards a differential fate is considered extremely advantageous in tissue engineering. Platelet-rich plasma (PRP) possesses a milieu of growth factors and cytokines, which have the potential to have either a differentiative or proliferative influence on the cell type tested. Here, we investigated the effect of PRP on C2C12 myoblasts. A range of PRP concentrations in differentiation media was used to determine whether a concentration dependence existed, while PRP embedded in fibres of aligned electrospun polydioxanone and polycaprolactone was used to determine whether this presence of fibres would cause any differences in response. In both cases, it was found that late myogenic markers were suppressed after 7 days in culture. However, an early differentiation marker, MyoD, was upregulated during this same time period. The results from this study represent the ability of PRP to have an influence over both myogenic proliferation and differentiation, a factor which could prove useful in future studies involved with skeletal muscle tissue engineering.

Functional recovery of completely denervated muscle: implications for innervation of tissue-engineered muscle

Tissue-engineered muscle has been proposed as a solution to repair volumetric muscle defects and to restore muscle function. To achieve functional recovery, engineered muscle tissue requires integration of the host nerve. In this study, we investigated whether denervated muscle, which is analogous to tissue-engineered muscle tissue, can be reinnervated and can recover muscle function using an in vivo model of denervation followed by neurotization. The outcomes of this investigation may provide insights on the ability of tissue-engineered muscle to integrate with the host nerve and acquire normal muscle function. Eighty Lewis rats were classified into three groups: a normal control group (n=16); a denervated group in which sciatic innervations to the gastrocnemius muscle were disrupted (n=32); and a transplantation group in which the denervated gastrocnemius was repaired with a common peroneal nerve graft into the muscle (n=32). Neurofunctional behavior, including extensor postural thrust (EPT), withdrawal reflex latency (WRL), and compound muscle action potential (CMAP), as well as histological evaluations using alpha-bungarotoxin and anti-NF-200 were performed at 2, 4, 8, and 12 weeks (n=8) after surgery. We found that EPT was improved by transplantation of the nerve grafts, but the EPT values in the transplanted animals at 12 weeks postsurgery were still significantly lower than those measured for the normal control group at 4 weeks (EPT, 155.0±38.9 vs. 26.3±13.8 g, p<0.001; WRL, 2.7±2.30 vs. 8.3±5.5 s, p=0.027). In addition, CMAP latency and amplitude significantly improved with time after surgery in the transplantation group (p<0.001, one-way analysis of variance), and at 12 weeks postsurgery, CMAP latency and amplitude were not statistically different from normal control values (latency, 0.9±0.0 vs. 1.3±0.7 ms, p=0.164; amplitude, 30.2±7.0 vs. 46.4±26.9 mV, p=0.184). Histologically, regeneration of neuromuscular junctions was seen in the transplantation group. This study indicates that transplanted nerve tissue is able to regenerate neuromuscular junctions within denervated muscle, and thus the muscle can recover partial function. However, the function of the denervated muscle remains in the subnormal range even at 12 weeks after direct nerve transplantation. These results suggest that tissue-engineered muscle, which is similarly denervated, could be innervated and become functional in vivo if it is properly integrated with the host nerve.

Improved vascular organization enhances functional integration of engineered skeletal muscle grafts

Severe traumatic events such as burns, and cancer therapy, often involve a significant loss of tissue, requiring surgical reconstruction by means of autologous muscle flaps. The scant availability of quality vascularized flaps and donor site morbidity often limit their use. Engineered vascularized grafts provide an alternative for this need. This work describes a first-time analysis, of the degree of in vitro vascularization and tissue organization, required to enhance the pace and efficacy of vascularized muscle graft integration in vivo. While one-day in vitro was sufficient for graft integration, a three-week culturing period, yielding semiorganized vessel structures and muscle fibers, significantly improved grafting efficacy. Implanted vessel networks were gradually replaced by host vessels, coupled with enhanced perfusion and capillary density. Upregulation of key graft angiogenic factors suggest its active role in promoting the angiogenic response. Transition from satellite cells to mature fibers was indicated by increased gene expression, increased capillary to fiber ratio, and similar morphology to normal muscle. We suggest a "relay" approach in which extended in vitro incubation, enabling the formation of a more structured vascular bed, allows for graft-host angiogenic collaboration that promotes anastomosis and vascular integration. The enhanced angiogenic response supports enhanced muscle regeneration, maturation, and integration.