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.
Similar content being viewed by others
References
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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):473–483
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
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
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
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
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):170–173
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
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Additional information
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Grosset, A., Pfister, G., de l’Escalopier, N. et al. Risk factors and failures in the management of limb injuries in combat casualties. International Orthopaedics (SICOT) 43, 2671–2680 (2019). https://doi.org/10.1007/s00264-019-04329-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00264-019-04329-7