The Role of Military Plastic Surgeons in the Management of Modern Combat Trauma: An Analysis of 645 Cases

The integration of ortho-plastic limb salvage teams in the humanitarian response to violence-related open tibial fractures: evaluating outcomes in the Gaza Strip

BACKGROUND

Limb salvage by ortho-plastic teams is the standard protocol for treating open tibial fractures in high-income countries, but there's limited research on this in conflict settings like the Gaza Strip. This study assessed the clinical impact of gunshot-related open tibial fractures, compared patient management by orthopedic and ortho-plastic teams, and identified the risk factors for bone non-union in this context.

METHODS

A retrospective review of medical records was conducted on Gaza Strip patients with gunshot-induced-open tibial fractures from March 2018 to October 2020. Data included patient demographics, treatments, and outcomes, with at least one year of follow-up. Primary outcomes were union, non-union, infection, and amputation.

RESULTS

The study included 244 injured individuals, predominantly young adult males (99.2%) with nearly half (48.9%) having Gustilo-Anderson type IIIB fractures and more than half (66.8%) with over 1 cm of bone loss. Most patients required surgery, including rotational flaps and bone grafts with a median of 3 admissions and 9 surgeries. Ortho-plastic teams managed more severe muscle and skin injuries, cases with bone loss > 1 cm, and performed less debridement compared to other groups, though these differences were not statistically significant. Non-union occurred in 53% of the cases, with the ortho-plastic team having the highest rate at 63.6%. Infection rates were high (92.5%), but no significant differences in bone or infection outcomes were observed among the different groups. Logistic regression analysis identified bone loss > 1 cm, vascular injury, and the use of a definitive fixator at the first application as predictors of non-union.

CONCLUSIONS

This study highlights the severity and complexity of such injuries, emphasizing their significant impact on patients and the healthcare system. Ortho-plastic teams appeared to play a crucial role in managing severe cases. However, further research is still needed to enhance our understanding of how to effectively manage these injuries.

Understanding progressive tissue loss and wound burden in combat casualties: lessons learnt for future operational capability

Understanding tissue loss following injury is important due to its prevalence among the war-wounded and the impact it has on subsequent treatment and rehabilitation. Progressive tissue loss is a type of tissue loss that has complicated extremity injury in recent conflicts. It has resulted in more proximal residual limb lengths and has influenced rehabilitation. Quantifying wound burden in combat casualties remains a challenge due to poor quality of data sets that lack the capacity for detailed analysis. The aims of this article are to outline the current hurdles in attempting to quantify wound burden in combat casualties and to propose simple interventions to improve data capture for future analysis.

Analysis of 983 civilian blast and ballistic casualties and the generation of a template of injury burden: An observational study

Background

Terrorism and armed conflict cause blast and ballistic casualties that are unusual in civilian practice. The immediate surgical response to mass casualty events, with civilians injured by these mechanisms, has not been systematically characterised. Standardising an approach to reacting to these events is challenging but is essential to optimise preparation for them. We aimed to quantify and assesses the surgical response to blast and ballistic injuries managed in a world-class trauma unit paradigm.

Methods

This was an observational study conducted at the UK-led military Medical Treatment Facility, Camp Bastion, Afghanistan from original theatre log-book entries between Nov 5, 2009, and Sept 21, 2014; a total of 10,891 consecutive surgical cases prospectively gathered by surgical teams were catalogued. Patients with combatant status/wearing body-armour to various degrees including interpreters were excluded from the study. Civilian casualties that underwent primary trauma surgery for blast and ballistic injuries were included (n=983). Surgical activity was analysed as a rate per 100 casualties, and patients were grouped according to adult vs. paediatric and ballistic vs. blast injury mechanisms to aid comparison.

Findings

The three most common surgical procedures for civilian blast injuries were debridement, amputation, and laparotomy. For civilian ballistic injuries, these were debridement, laparotomy and vascular procedures. Blast injuries generated more amputations in both adults and children compared to ballistic injuries. Blast injuries generated more removal of fragmentation material compared to ballistics injuries amongst adult casualties. Ballistic injuries lead to more chest drain insertions in adults. As a rate per 100 casualties, adults injured by blast underwent significantly more debridement (63·5); temporary skeletal stabilisation (13·2) and vascular procedures (12·8) compared to children (43·4, z=4·026, p=0·00007; 5·7, z=2·230, p=0·022; 4·9, z=2·468, p=0·014). Adults injured by ballistics underwent significantly more debridement (63·4); chest drain (12·3) and temporary skeletal fixation procedures (11·4) compared to children (50·0, z=2·058, p=0.040, p<0·05; 2·9, z=2·283, p=0.0230; 2·9, z=2·131, p=0.034 respectively). By comparison, children injured by ballistics underwent significantly more removal of fragmentation and ballistic materials (20·6) when compared to adults (7·7, z=-3·234; p=0.001).

Interpretation

This is the first evidence-based, template of the immediate response required to manage civilians injured by blast and ballistic mechanisms. The template presented can be applied to similar conflict zones and to prepare for terror attacks on urban populations.

Funding

The work was supported in part by a grant to LM from School of Medicine, University of St Andrews.

Planning for UK terror attacks: Analysis of blast and ballistic injuries

Terrorist attacks have become more acute, less predictable and frequently involve use of explosives and gunfire to inflict mass casualty to civilians. Resource demand has been reported in Role 3 Medical Facilities but the continued resource required to manage blast and ballistic injuries has not been quantified. This study aimed to assess the resource required for blast and ballistic injuries at the United Kingdom's Role 4 Medical Facility. Military patients admitted to the Queen Elizabeth Hospital (Role 4 Medical Facility) from Afghanistan with blast or ballistic injuries during the 2012 calendar year were retrospectively reviewed. Injury pattern, theatre resource, length of stay and cost analysis were performed. This study included 99 blast and 53 gunshot wound (GSW) patients. Blast patients were more likely to suffer polytrauma than GSW (53% vs 23%), underwent more surgical procedures and utilized double the theatre time. Blast injury patients had a longer length of stay in hospital. The average cost per patient for blast patients was double that of the GSW injury cohort. The Queen Elizabeth experience represents a continuous flow of severely injured military casualties whilst managing concurrent civilian trauma over a long period. This workload has encouraged systematic advancements in managing high numbers of injured patients from point of wounding to rehabilitation. Distribution of resource, theatre planning and multi-disciplinary team working are critical in effectively managing Major Incidents such as terror attacks. Drawing on previous Role 4 Medical Facility experience can aid UK hospitals in terms of strategy and resource distribution.

Plastic Surgery at War: A Scoping Review of Current Conflicts

INTRODUCTION

The scope of military plastic surgery and location where care is provided has evolved with each major conflict. To help inform plastic surgeon utilization in future conflicts, we conducted a review of military plastic surgery-related studies to characterize plastic surgeon contributions during recent military operations.

MATERIALS AND METHODS

Using a scoping review design, we searched electronic databases to identify articles published since September 1, 2001 related to military plastic surgery according to a defined search criterion. Next, we screened all abstracts for appropriateness based on pre-established inclusion/exclusion criteria. Finally, we reviewed the remaining full-text articles to describe the nature of care provided and the operational level at which care was delivered.

RESULTS

The final sample included 55 studies with most originating in the United States (54.5%) between 2005 and 2019 and were either retrospective cohort studies (81.8%) or case series (10.9%). The breadth of care included management of significant upper/lower extremity injuries (40%), general reconstructive and wound care (36.4%), and craniofacial surgery (16.4%). Microsurgical reconstruction was a primary focus in 40.0% of published articles. When specified, most care was described at Role 3 (25.5%) or Roles 4/5 facilities (62.8%) with temporizing measures more common at Role 3 and definite reconstruction at Roles 4/5. Several lessons learned were identified that held commonality across plastic surgery domain.

CONCLUSIONS

Plastic surgeons continue to play a critical role in the management of wounded service members, particularly for complex extremity reconstruction, craniofacial trauma, and general expertise on wound management. Future efforts should evaluate mechanisms to maintain these skill sets among military plastic surgeons.

The role of plastic surgery in major trauma in the United Kingdom and workforce recommendations

INTRODUCTION

The 22 major trauma centres (MTCs) in England were appointed in 2012 to provide care to severely injured patients despite variation in existing infrastructure, resources, culture and skillset. Six MTCs remain unsupported by a co-located plastic surgery department. We describe the plastic surgical major trauma workload in England, the plastic surgical workforce and skillset available in each centre, and suggest what plastic surgical skills are required in an MTC.

METHODS

A multi-centre, prospective cohort study was performed to collect operative workload data. Eleven MTCs in England submitted complete datasets. Workforce data were provided by the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS).

RESULTS

Fifty-three percent (n = 1582) of Trauma and Audit Research Network (TARN)-eligible patients admitted during the study period underwent at least one operation during their index admission. Of these, 14% (n = 227) required plastic surgery. The majority of plastic surgical operative work involved the extremities: 62% of index procedures involved the lower limb and 38% involved the upper limb. The number of full-time plastic surgical consultants per MTC ranged from 1 to 22. Only 10 MTCs had at least one plastic surgeon with a primary interest in lower limb trauma.

CONCLUSION

Plastic surgery contributes substantially to major trauma care and the majority of this workload relates to extremity trauma. However, there is significant variability in the size, accessibility and skillset of the workforce available. On the basis of these data, we suggest a plastic surgical skillset which should be represented in plastic surgical departments supporting an MTC.

Prolonged deployed hospital care in the management of military eye injuries

BACKGROUND/OBJECTIVES

Prolonged hospital care is described as deployed medical care, applied beyond doctrinal planning timelines and military medical planning envisages that in future conflicts, patients will have to be managed for up to 5 days without evacuation to their home country. We aimed to investigate the effect of prolonged hospital care on visual outcomes in the management of open and closed globe injures.

METHODS

We conducted a retrospective cohort study in the setting of British military operations in Afghanistan. We included consecutive UK military patients with ocular trauma evacuated from Afghanistan between December 2005 and April 2013. We assessed outcome using best-corrected visual acuity (VA) 6-12 months after injury.

RESULTS

All patients were male, with a mean age of 25. Outcomes adjusted for ocular trauma score (OTS) at presentation were similar to previous reports of military ocular trauma. The mean time to arrival at a centre with an ophthalmologist was 1.74 days. Both patients with penetrating open globe injuries and patients with hyphaema and an OTS of 3 or less displayed an association between worsening 6-12 month VA and time between injury and repair or assessment by an ophthalmologist.

CONCLUSION

Time to specialist ophthalmic care contributes to outcome after military open and closed globe injuries, supporting deployment of ophthalmologists on military operations.

Facial injury management undertaken at US and UK medical treatment facilities during the Iraq and Afghanistan conflicts: a retrospective cohort study

OBJECTIVES

To perform the first direct comparison of the facial injuries sustained and treatment performed at USA and UK deployed medical treatment facilities (MTFs) in support of the military campaigns in Iraq and Afghanistan.

SETTING

The US and UK Joint Theatre Trauma Registries were scrutinised for all patients with facial injuries presenting alive to a UK or US deployed MTF between 1 March 2003 and 31 October 2011.

PARTICIPANTS

US and UK military personnel, local police, local military and civilians.

PRIMARY AND SECONDARY OUTCOME MEASURES

An adjusted multiple logistic regression model was performed using tracheostomy as the primary dependent outcome variable and treatment in a US MTF, US or UK military, mandible fracture and treatment of mandible fracture as independent secondary variables.

RESULTS

Facial injuries were identified in 16 944 casualties, with the most common being those to skin/muscle (64%), bone fractures (36%), inner/middle ear (28%) and intraoral damage (11%). Facial injuries were equally likely to undergo surgery in US MTF as UK MTF (OR: 1.06, 95% CI 0.4603 to 1.142, p=0.6656); however, variations were seen in injury type treated. In US MTF, 692/1452 (48%) of mandible fractures were treated by either open or closed reduction compared with 0/167 (0%) in UK MTF (χ²: 113.6; p≤0.0001). US military casualties who had treatment of their mandible fracture (open reduction and internal fixation or mandibulo-maxillary fixation) were less likely to have had a tracheostomy than those who did not undergo stabilisation of the fractured mandible (OR: 0.61, 95% CI 0.44 to 0.86; p=0.0066).

CONCLUSIONS

The capability to surgically treat mandible fractures by open or closed reduction should be considered as an integral component of deployed coalition surgical care in the future.

The state of microsurgical practice in French forward surgical facilities from 2003 to 2015

Microsurgery is an unusual procedure in the theatres of military operations. We sought to analyze the state of microsurgical practices in the French medical treatment facilities (MTFs) deployed around the world in the 21st century. A retrospective study was conducted among all patients who were operated on in French forward surgical facilities between 2003 and 2015. Those who underwent microsurgical procedures for nerve injury, vascular injury, or extremity reconstruction were included. Only early vascular results were assessed. Among the 2589 patients operated on for an extremity injury during the study period, 56 (2.1%) were included, with the group composed of 29 patients with isolated nerve injuries, 28 patients with nerve and arterial injuries, and two patients with isolated arterial injuries, mostly at the hand level. Nerve procedures predominantly consisted of direct suturing, although autografting and nerve transfers were also performed. Thirteen microvascular repairs were carried out, including nine cases of proximal or digital revascularization; revascularization was successful in six of the nine cases. These procedures were completed by orthopedic surgeons trained in microsurgery, mostly under loupes magnification. Routine nerve repair in the field seems to be specific to French MTFs. Salvage of amputated or devascularized fingers in the combat zone had never been reported before. Such emphasizes the need to train deployed orthopedic surgeons to perform microsurgical procedures and to equip all MTFs with basic microsurgical sets and magnification means.

Digital replantation in forward surgical units: a cases study

INTRODUCTION

Noncombat-related hand injuries are common in current theatres of operations. Crushing is one of the most frequent mechanisms that may cause traumatic amputations of digits. In the military setting, management of these digital amputations is challenging regarding limitation in microsurgical means in medical treatment facilities and aeromedical evacuation delays out of the combat zone.

METHODS

Two cases of digital replantation performed in French forward surgical units are described. The first case was a complete distal amputation of the medius which was successfully replanted in the operating theatre of an aircraft carrier. No complication was observed after evacuation. Functional and aesthetic results were excellent. The second case was a ring finger avulsion revascularized in a role 2 facility in Central African Republic. Unfortunately, revascularization failed due to arterial thrombosis during evacuation.

RESULTS

Digital, hand or more proximal upper extremity replantation may be considered for isolated amputations due to work-related accidents within the combat zone. For a surgeon trained to microsurgery, a microsurgical set and magnification loupes enable to attempt such procedures in austere conditions.

DISCUSSION

The authors propose an algorithm of management in the field according to the type and level of amputation.

Microbiological and functional outcomes after open extremity fractures sustained overseas: The experience of a UK level I trauma centre

Background

Open extremity fractures carry a high risk of limb loss and poor functional outcomes. Transfer of extremity trauma patients from developing countries and areas of conflict adds further layers of complexity due to challenges in the delivery of adequate care. The combination of extensive injuries, transfer delays and complex microbiology presents unique challenges.

Methods

A retrospective review was conducted to analyse the surgical and microbiological themes of patients with open extremity fractures transferred from overseas to our institution (Imperial College NHS Trust) between January 2011 and January 2016.

Results

Twenty civilian patients with 21 open extremity fractures were referred to our unit from 11 different countries. All patients had poly-microbial wound contamination on initial surveillance cultures. Five patients (25%) underwent amputation depending on the extent of osseous injury; positive surveillance cultures did not preclude limb reconstruction, with seven patients undergoing complex reconstruction and eight undergoing simple reconstruction to achievewound coverage. Hundred percent of patients demonstrated infection-free fracture union on discharge.

Conclusion

Patients with open extremity fractures transferred from overseas present the unique challenge of poly-microbial infection in addition to extensive traumatic wounds. Favourable outcomes can be achieved despite positive microbiological findings on tissue culture with adequate antimicrobial therapy. The decision to salvage the limb and the complexity of reconstruction used should be based on the chance of achieving meaningful functional recovery, mainly determined by the extent of bony injury. The complexity of reconstruction was based on the predicted long-term functionality of the salvaged limb.

Plastic Surgery Management of Victims of Terrorist Violence in Ankara, Turkey

Terror attacks have been progressively increasing worldwide through the present era. The management of the consequences of terrorism events is under debate in almost every scientific area. The organization and advancement of health services constitute important components of the crisis management. Similar to other specialty areas in medicine, the medical management of terrorist attacks is becoming important in terms of plastic and reconstructive surgery.Ankara, the capital of Turkey, has been subject to 2 terrorist events in public places within a year. The total number of patients involved in both cases was 434. Ankara Numune Training and Research Hospital is a tertiary health care institution and one of the most important trauma centers in the region. A total of 178 Patients exposed to these events referred to our hospital. Of the total, 34 patients were completely or partially treated in the plastic and reconstructive surgery clinic. In this study, we tried to discuss the difficulties encountered in the classification of patients and plastic surgery during the treatment period of patients who experienced these attacks.Data were obtained from The National News Agency, hospital, and our own clinic registries. Patient classification was based on the injured parts of the body. Statistical analysis was performed for all data. In conclusion, the role and the importance of plastic surgery department especially in trauma management have been emphasized in the light of our findings.

Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: A retrospective cohort study

INTRODUCTION

The introduction of major trauma centres (MTCs) in England has led to 63% reduction in trauma mortality.(1) The role of plastic surgeons supporting these centres has not been quantified previously. This study aimed to quantify plastic surgical workload at an urban MTC to determine the contribution of plastic surgeons to major trauma care.

METHODS

All Trauma Audit and Research Network (TARN)-recorded major trauma patients who presented to an urban MTC in 2013 and underwent an operation were identified retrospectively. Patients who underwent plastic surgery were identified and the type and date of procedure(s) were recorded. The trauma operative workload data of another tertiary surgical specialty and local historical plastics workload data from pre-MTC go-live were collected for comparison.

RESULTS

Of the 416 major trauma patients who required surgical intervention, 29% (n = 122) underwent plastic surgery. Of these patients, 43% had open lower limb fractures, necessitating plastic surgical involvement according to British Orthopaedic Association Standards for Trauma (BOAST) 4 guidance. The overall plastic surgery operative workload increased sevenfold post-MTC go-live. A similar proportion of the same cohort required neurosurgery (n = 115; p = 0.589).

DISCUSSION

This study quantifies plastic surgery involvement in major trauma and demonstrates that plastic surgical operative workload is at least on par with other tertiary surgical specialties. It also reports one centre's experience of a significant change in plastic surgery activity following designation of MTC status. The quantity of plastic surgical operative workload in major trauma must be considered when planning major trauma service design and workforce provision, and for plastic surgical postgraduate training.