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AIMS: The aim of the study is to evaluate the clinical outcome and complications from the initial cohort of blast injured bilateral lower limb, above knee amputees who underwent Direct Skeletal Fixation (DSF). PATIENTS AND METHODS: We undertook a retrospective analysis of a prospective data base identifying patients who had undergone implantation with the Australian Osseointegration Group of Australia-Osseointegration Prosthetic Limb (OGAP-OPL) prosthesis, with minimum 24 months follow up. Patient demographics, injury profile, and polymicrobial colonisation status were recorded. Physical functional performance measures recorded were the 6 minute Walk Test (6-MWT) and patient reported outcome measures were the Short Form Health Survey-36 (SF-36). Post operatively, complications including infection, re-operation, and fracture were recorded. RESULTS: 7 patients (14 femora) were identified (mean age 29.8yrs), all injured by dismounted blast. Mean follow up was 46 months. All were polytrauma patients and all had previous polymicrobial colonisation. Following surgery, all patients mobilised with significant improvement in 6-minute walk time, with a mean improvement of 154 m (248 m vs 402 m, p = 0.018). The physical component score for the SF-36 demonstrated a statistically significant improvement from 34.65 to 54.5 (p = 0.018) and the mental component score demonstrated a similar improvement (41.55-58.19 p = 0.018). At follow up, no patient required explantation of the implant. Each had been prescribed a minimum of 1 course of antibiotics with no evidence of deep infection. CONCLUSION: DSF is an option for amputees who, due to the nature of their injuries, may not be able to tolerate traditional suspension socket prostheses and have exhausted all other treatment options. At a minimum of 2 year follow up, the absence of significant infective complications suggests DSF may be utilised in the blast injured despite chronic polymicrobial colonisation. Longer term surveillance of these patients is required to assess the long-term suitability of this technique in this cohort of patients.
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Amputação Cirúrgica/reabilitação , Membros Artificiais , Traumatismos por Explosões/cirurgia , Fixação de Fratura/métodos , Perna (Membro)/cirurgia , Osseointegração , Adulto , Seguimentos , Humanos , Masculino , Medidas de Resultados Relatados pelo Paciente , Desenho de Prótese , Implantação de Prótese , Radiografia , Estudos Retrospectivos , Reino Unido , Teste de Caminhada , Caminhada , Adulto JovemRESUMO
[This corrects the article DOI: 10.1016/j.tcr.2017.10.021.].
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INTRODUCTION: The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan. METHODS: Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013. RESULTS: 566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK. CONCLUSIONS: The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury.
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Campanha Afegã de 2001- , Traumatismos por Explosões/cirurgia , Traumatismos Faciais/cirurgia , Medicina Militar , Militares , Procedimentos de Cirurgia Plástica , Ferimentos por Arma de Fogo/cirurgia , Adulto , Traumatismos por Explosões/psicologia , Traumatismos por Explosões/reabilitação , Traumatismos Faciais/psicologia , Traumatismos Faciais/reabilitação , Humanos , Escala de Gravidade do Ferimento , Militares/psicologia , Sistema de Registros , Estudos Retrospectivos , Reino Unido , Ferimentos por Arma de Fogo/psicologia , Ferimentos por Arma de Fogo/reabilitaçãoRESUMO
Patients that suffer multiple traumatic injuries often present with uncontrollable haemorrhage and rapidly descend into a viscous death triad consisting of hypothermia, coagulopathy and acidosis. Initial surgical intervention does not aim to provide conclusive repair, but instead strives to stop blood loss while priority is given to correct the patient's metabolic state (Duchesne et al., 2010). However in some cases of massive polytrauma, gaining surgical control of bleeding can be incredibly difficult. As a result a number of topical haemostatic agents were developed for use in military and civilian settings. This case details a successful intracavity use of the granular haemostatic agent, Quikclot™ (Z-Medica), in halting massive haemorrhage in a patient who sustained major blast injuries. Although not officially recommended, intracorporeal uses of Quikclot™ can be effective as a last resort in preventing loss of life in cases of severe polytrauma. However, users need to remain wary of complications which may arise due to its application.
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INTRODUCTION: Improvised explosive device (IED) blasts cause serious injury. Survivors are left with multiple amputations, considerable soft tissue loss and open fractures with gross contamination. We present our early experience of Integra™ in the acute management of military wounds. METHOD: The clinical records of all patients with IED injuries who underwent early reconstruction with Integra™ during the six month period between August and December 2009 in our unit were reviewed and data gathered prospectively. RESULTS: There were 7 male soldiers, aged 21-31 years (mean=26). All sustained trunk and limb injuries, including multiple amputations. Number of procedures prior to application of Integra™ was 4-10 (mean=5). Application of Integra™ took place 6-24 days post-injury (mean=13). Size of wounds covered with Integra™ was 1-11.5% TBSA (mean=5%). Anatomical sites reconstructed included amputation stumps, and both upper and lower limbs. There was partial take of Integra in 3 wounds in 2 patients. All wounds were eventually treated with delayed split skin grafting and healed satisfactorily. CONCLUSION: IEDs produce a large zone of injury with massive soft tissue damage, multiple discontinuous wounds which are significantly contaminated. The physiological insult is equivalent to a large cutaneous burn and there is a paucity of available donor sites. Multiple amputees also have a greater energy and power requirement(1-4) and cannot spare remaining functional muscles as donors. The literature suggests that microvascular flaps have a high failure rate in military patients.(5) Reconstruction began as soon as wounds were considered sufficiently clean. Integra™ was applied with the aim of providing higher quality coverage than that provided by split skin grafting alone (particularly for amputation stumps) whilst minimising operative time and morbidity. Integra™ allows timely closure of battlefield wounds with minimal operative time and morbidity. The procedure can begin whilst still in the acute phase and certainly before one would consider lengthy complex operations such as free flaps. Our experience suggests that Integra™ can allow early closure with robust tissue, promoting early rehabilitation and return to duties.
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Amputação Traumática/cirurgia , Traumatismos por Explosões/cirurgia , Sulfatos de Condroitina/uso terapêutico , Colágeno/uso terapêutico , Militares , Pele Artificial , Adulto , Campanha Afegã de 2001- , Cotos de Amputação/cirurgia , Traumatismos do Braço/cirurgia , Explosões , Humanos , Traumatismos da Perna/cirurgia , Masculino , Transplante de Pele , Lesões dos Tecidos Moles/cirurgia , Adulto JovemRESUMO
There is little data in the literature on the reconstruction of combat related lower genitourinary trauma. Published reports document patterns of injury, which is useful for epidemiological analysis of military trauma, but very few describe the reconstructive management. We aim to describe a systematic multidisciplinary approach to planning the challenging reconstruction of the severely injured male perineum.
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Traumatismos por Explosões/cirurgia , Militares , Pênis/cirurgia , Períneo/cirurgia , Procedimentos de Cirurgia Plástica , Escroto/cirurgia , Uretra/cirurgia , Explosões , Humanos , Masculino , Equipe de Assistência ao Paciente , Pênis/lesões , Períneo/lesões , Escroto/lesões , Uretra/lesõesRESUMO
The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.
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Extremidades/lesões , Medicina Militar/métodos , Traumatismos dos Nervos Periféricos , Procedimentos de Cirurgia Plástica/métodos , Guerra , Infecção dos Ferimentos/prevenção & controle , Ferimentos e Lesões/cirurgia , Ferimentos e Lesões/terapia , Extremidades/cirurgia , Humanos , Medicina Militar/tendências , Militares , Ossificação Heterotópica/patologia , Ossificação Heterotópica/prevenção & controle , Reino Unido , Infecção dos Ferimentos/microbiologiaRESUMO
INTRODUCTION: Inguinal lymphadenectomy is performed for the treatment of nodal metastases from squamous cell carcinoma of the penis and other tumors of the trunk and lower extremity. Malignant skin infiltration requires wide resection, producing a defect requiring complex soft-tissue reconstruction. We have used a pedicled anterolateral thigh flap as our first-choice flap for these cases. We report a prospective series of cases using this recently described flap for reconstruction of groin defects after radical groin dissection. TECHNICAL CONSIDERATIONS: From May 2001, 6 patients with locally advanced inguinal disease underwent wide skin excision and en bloc nodal resection with immediate reconstruction using a pedicled anterolateral thigh flap. Data were collected prospectively, and the data of 4 of 6 patients were reviewed at 6 months postoperatively. No flap losses occurred. Complete healing was achieved in all patients. The mean hospital stay was 18 days. The median time to complete healing was 33.5 days. The complications were seroma leading to flap congestion, wound dehiscence, wound infection, and delayed healing. The donor sites were either closed primarily or split skin grafted. CONCLUSIONS: Reconstruction using a pedicled anterolateral thigh flap in patients with advanced inguinal nodal disease is a useful adjunct in selected patients. We present our indications for the procedure, our rational for the choosing this technique over other methods of reconstruction, and the difficulties we experienced.