Top

Published in:

01-12-2019 | Wound Debridement | Original Paper

Risk factors and failures in the management of limb injuries in combat casualties

Authors: Antoine Grosset, Georges Pfister, Nicolas de l’Escalopier, Soryapong Plang, Anne-Pauline Russo, James-Charles Murison, Laurent Mathieu, Sylvain Rigal

Published in: International Orthopaedics | Issue 12/2019

Abstract

Introduction

Treatment of war wounds is based on a sequential surgical strategy, which frequently faces therapeutic failures, which then burden the final functional result. The aim of this study was to identify risk factors of failure of the different treatments to prevent the therapeutic failure.

Methods

A monocentric case–control study was done on French war-wounded soldiers treated for an open fracture caused by an invasive war weapon. The primary end point was the treatment failure three months after the injury. The risk factors of failure studied were the traumatic mechanism, the general and local lesional assessment, and the surgery performed.

Results

Between January 1, 2004 and December 31, 2016, 57 soldiers were included, with an average follow-up of 3.42 years. On 81 limb segments studied, the most injured segment was the leg (37.0%). A vital or urgent surgery requirement (OR = 1.56; p = 0.02) and bone loss substance (OR = 5.45; CI95% = 1.54–20.09) were risk factors of failure for limb salvage treatment. Improvised explosive device traumatic mechanism (OR = 1.56; p = 0.02) and the persistence of surgical site contamination after two debridement procedures (OR = 1.20; p = 0.04) were risk factors of failure for amputation procedures.

Conclusions

Two main risk factors of treatment failure are highlighted: those in relation to traumatic mechanisms and general lesional assessment and those in relation to surgical site conditions. There is no over risk of failure in relation to surgical procedure and treatment.

Rigal S, Mathieu L, de l’ Escalopier N (2018) Temporary fixation of limbs and pelvis. Orthop Traumatol Surg Res 104(1S):S81–S88. https://doi.org/10.1016/j.otsr.2017.03.032 CrossRefPubMed

Rigal S (2012) Extremity amputation: how to face challenging problems in a precarious environment. Int Orthop 36(10):1989–1993. https://doi.org/10.1007/s00264-012-1548-z CrossRefPubMedPubMedCentral

Murison JC, Rigal S, Niang CD (2015) Severe leg trauma in a resource-poor environment: indications for amputation in emergencies. Med Sante Trop 25(3):267–272. https://doi.org/10.1684/mst.2015.0444 CrossRefPubMed

Mathieu L, Bazile F, Barthélémy R, Duhamel P, Rigal S (2011) Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers. Orthop Traumatol Surg Res 97(8):852–859. https://doi.org/10.1016/j.otsr.2011.05.014 CrossRefPubMed

Eid HO, Abu-Zidan FM (2015) New Injury Severity Score is a better predictor of mortality for blunt trauma patients than the Injury Severity Score. World J Surg 39(1):165–171. https://doi.org/10.1007/s00268-014-2745-2 CrossRefPubMed

Chandler H, MacLeod K, Penn-Barwell JG, Penn-Barwell JG, Bennett PM, Fries CA et al (2017) Extremity injuries sustained by the UK military in the Iraq and Afghanistan conflicts: 2003–2014. Injury. 48(7):1439–1443. https://doi.org/10.1016/j.injury.2017.05.022 CrossRefPubMed

Penn-Barwell JG, Sargeant ID, Severe Lower Extremity Combat Trauma (SeLECT) Study Group (2016) Gun-shot injuries in UK military casualties - features associated with wound severity. Injury 47(5):1067–1071. https://doi.org/10.1016/j.injury.2016.02.004 CrossRefPubMed

Ramasamy A, Harrisson SE, Clasper JC, Stewart MPM (2008) Injuries from roadside improvised explosive devices. J Trauma 65(4):910–914. https://doi.org/10.1097/TA.0b013e3181848cf6 CrossRefPubMed

Zheng W, Hu Y, Xin H (2016) Successful implementation of thirty five major orthopaedic procedures under poor conditions after the two thousand and fifteen Nepal earthquake. Int Orthop 40(12):2469–2477. https://doi.org/10.1007/s00264-016-3284-2 CrossRefPubMed

10.

Choufani C, Barbier O, Grosset A, Murison JC, Ollat D, Rigal S et al (2017) Initial management of complex hand injuries in military or austere environments: how to defer and prepare for definitive repair? Int Orthop 41(9):1771–1775. https://doi.org/10.1007/s00264-017-3439-9 CrossRefPubMed

11.

Clarke JE, Davis PR (2012) Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010–April 2011. Mil Med 177(11):1261–1266. https://doi.org/10.7205/MILMED-D-11-00120 CrossRefPubMed

12.

Dubost C, Goudard Y, Soucanye de Landevoisin E, Contargyris C, Evans D, Pauleau G (2016) Combat casualties from two current conflicts with the Seventh French Forward Surgical Team in Mali and Central African Republic in 2014. J R Army Med Corps 162(6):450–455. https://doi.org/10.1136/jramc-2015-000557 CrossRefPubMed

13.

Owens BD, Kragh JF, Macaitis J, Svoboda SJ, Wenke JC (2007) Characterization of extremity wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma 21(4):254–257. https://doi.org/10.1097/BOT.0b013e31802f78fb CrossRefPubMed

14.

Penn-Barwell JG, Bennett PM, Kay A, Sargeant ID, Severe Lower Extremity Combat Trauma (SeLECT) Study Group (2014) Acute bilateral leg amputation following combat injury in UK servicemen. Injury. 45(7):1105–1110. https://doi.org/10.1016/j.injury.2014.01.025 CrossRef

15.

Lerner A, Fodor L, Soudry M (2006) Is staged external fixation a valuable strategy for war injuries to the limbs? Clin Orthop 448:217–224. https://doi.org/10.1097/01.blo.0000214411.60722.f8 CrossRefPubMed

16.

Ware JE, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30(6):473–483CrossRef

17.

Murray CK, Hsu JR, Solomkin JS, Keeling JJ, Andersen RC, Ficke JR et al (2008) Prevention and management of infections associated with combat-related extremity injuries. J Trauma 64(3 Suppl):S239–S251. https://doi.org/10.1097/TA.0b013e318163cd14 CrossRefPubMed

18.

Horst K, Andruszkow H, Weber C, Dienstknecht T, Hildebrand F, Tarkin I et al (2015) Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion. Injury 46(Suppl 3):S13–S18. https://doi.org/10.1016/S0020-1383(15)30005-X CrossRefPubMed

19.

Tintle SM, Shawen SB, Forsberg JA, Gajewski DA, Keeling JJ, Andersen RC et al (2014) Reoperation after combat-related major lower extremity amputations. J Orthop Trauma 28(4):232–237. https://doi.org/10.1097/BOT.0b013e3182a53130 CrossRefPubMed

20.

Mathieu L, Marty A, Ramaki A, Najib A, Ahmadzai W, Fugazzotto DJ et al (2014) Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul. Eur J Trauma Emerg Surg 40(3):387–393. https://doi.org/10.1007/s00068-013-0334-y CrossRefPubMed

21.

Covey DC (2015) Conversion from limb salvage to late amputation: lessons learned from recent battlefields with application to civilian trauma. J Surg Orthop Adv 24(3):170–173CrossRef

22.

Murray CK, Wilkins K, Molter NC, Li F, Yu L, Spott MA et al (2011) Infections complicating the care of combat casualties during operations Iraqi Freedom and Enduring Freedom. J Trauma 71(1 Suppl):S62–S73. https://doi.org/10.1097/TA.0b013e3182218c99 CrossRefPubMed

Title: Risk factors and failures in the management of limb injuries in combat casualties
Authors: Antoine Grosset
Georges Pfister
Nicolas de l’Escalopier
Soryapong Plang
Anne-Pauline Russo
James-Charles Murison
Laurent Mathieu
Sylvain Rigal
Publication date: 01-12-2019
Publisher: Springer Berlin Heidelberg
Keyword: Wound Debridement
Published in: International Orthopaedics / Issue 12/2019
Print ISSN: 0341-2695
Electronic ISSN: 1432-5195
DOI: https://doi.org/10.1007/s00264-019-04329-7

2024 ASCO Annual Meeting

Springer Medicine

Risk factors and failures in the management of limb injuries in combat casualties

Abstract

Introduction

Methods

Results

Conclusions

2024 ASCO Annual Meeting

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 12/2019

Clinical experience with combined reconstruction of the anterior cruciate and anterolateral ligaments of the knee in sportsmen

Social determinants associated to chronic pain after total knee arthroplasty

Patient-specific cutting guides for open-wedge high tibial osteotomy: safety and accuracy analysis of a hundred patients continuous cohort

Three-dimensional computed tomography analysis and functional results of calcaneal fractures treated by an intramedullary nail

A comparative study about the incidence of dislocation and peri-prosthetic fracture between dual mobility versus standard cups after primary total hip arthroplasty

Perceived skills for sports performance after primary hip arthroplasty: a cross-sectional study