Safe burn excision prior to military repatriation: an achievable goal?

Burn excision is the gold standard treatment for full thickness and some deep partial thickness burns. Early burn excision (24-96 hours) has been shown to improve patient outcomes. However, in the military setting, transporting the patient to a centre which can provide this procedure can be delayed. Especially as control of airspace in the future may be hampered due to the political landscape. For this reason, focus on how to achieve safer burn excision prior to repatriation should be addressed. This paper considers the barriers to early burn excision in the military setting and offers potential solutions for the future.

Comparing the surgical timelines of military and civilians traumatic lower limb amputations.

The care and challenges of injured service have been well documented in the literature from a variety of specialities. The aim of this study was to analyse the surgical timelines of military and civilian traumatic amputees and compare the surgical and resuscitative interventions. A retrospective review of patient notes was undertaken. Military patients were identified from the Joint Theatre Trauma Registry (JTTR) in 2009. Civilian patients were identified using the hospital informatics database. Patient demographics, treatment timelines as well as surgical and critical care interventions were reviewed. In total 71 military patients sustained traumatic amputations within this time period. This represented 11% of the total injury demographic in 2009. Excluding upper limb amputees 46 patients sustained lower extremity amputations. These were investigated further. In total 21 civilian patients were identified in a 7-year period. Analysis revealed there was a statistically significant difference between patient age, ITU length of stay, blood products used and number of surgical procedures between military and civilian traumatic amputees. This study identified that military patients were treated for longer in critical care and required more surgical interventions for their amputations. Despite this, their time to stump closure and length of stay were not statistically different compared to civilian patients. Such observations reflect the importance of an Orthoplastic approach, as well as daily surgical theatre co-ordination and weekly multi-disciplinary meetings in providing optimal care for these complex patients. This study reports the epidemiological observed differences between two lower limb trauma groups.

Management of complex abdominal wall defects associated with penetrating abdominal trauma.

INTRODUCTION: The paradigm of Damage Control Surgery (DCS) has radically improved the management of abdominal trauma, but less well described are the options for managing the abdominal wall itself in an austere environment. This article describes a series of patients with complex abdominal wall problems managed at the UK-led Role 3 Medical Treatment Facility (MTF) in Camp Bastion, Afghanistan. METHOD: Contemporaneous review of a series of patients with complex abdominal wall injuries who presented to the Role 3 MTF between July and November 2012. RESULTS: Five patients with penetrating abdominal trauma associated with significant damage to the abdominal wall were included. All patients were managed using DCS principles, leaving the abdominal wall open at the end of the first procedure. Subsequent management of the abdominal wall was determined by a multidisciplinary team of general and plastic surgeons, intensivists and specialist nurses. The principles of management identified included minimising tissue loss on initial laparotomy by joining adjacent wounds and marginal debridement of dead tissue; contraction of the abdominal wall was minimised by using topical negative pressure dressing and dermal-holding sutures. Definitive closure was timed to allow oedema to settle and sepsis to be controlled. Closure techniques include delayed primary closure with traction sutures, components separation, and mesh closure with skin grafting. DISCUSSION: A daily multidisciplinary team discussion was invaluable for optimal decision making regarding the most appropriate means of abdominal closure. Dermal-holding sutures were particularly useful in preventing myostatic contraction of the abdominal wall. A simple flow chart was developed to aid decision making in these patients. This flow chart may prove especially useful in a resource-limited environment in which returning months or years later for closure of a large ventral hernia may not be possible.

Prospective randomised controlled trial of nanocrystalline silver dressing versus plain gauze as the initial post-debridement management of military wounds on wound microbiology and healing.

INTRODUCTION: Recent conflicts have been characterised by the use of improvised explosive devices causing devastating injuries, including heavily contaminated wounds requiring meticulous surgical debridement. After being rendered surgical clean, these wounds are dressed and the patient transferred back to the UK for on-going treatment. A dressing that would prevent wounds from becoming colonised during transit would be desirable. The aim of this study was to establish whether using nanocrystalline silver dressings, as an adjunct to the initial debridement, would positively affect wound microbiology and wound healing compared to standard plain gauze dressings. METHODS: Patients were prospectively randomised to receive either silver dressings, in a nanocrystalline preparation (Acticoat™), or standard of care dressings (plain gauze) following their initial debridement in the field hospital. On repatriation to the UK microbiological swabs were taken from the dressing and the wound, and an odour score recorded. Wounds were followed prospectively and time to wound healing was recorded. Additionally, patient demographic data were recorded, as well as the mechanism of injury and Injury Severity Score. RESULTS: 76 patients were recruited to the trial between February 2010 and February 2012. 39 received current dressings and 37 received the trial dressings. Eleven patients were not swabbed. There was no difference (p=0.1384, Fishers) in the primary outcome measure of wound colonisation between the treatment arm (14/33) and the control arm (20/32). Similarly time to wound healing was not statistically different (p=0.5009, Mann-Whitney). Wounds in the control group were scored as being significantly more malodorous (p=0.002, Mann-Whitney) than those in the treatment arm. CONCLUSIONS: This is the first randomised controlled trial to report results from an active theatre of war. Performing research under these conditions poses additional challenges to military clinicians. Meticulous debridement of wounds remains the critical determinant in wound healing and infection and this study did not demonstrate a benefit of nanocrystaline silver dressing in respect to preventing wound colonisation or promoting healing, these dressings do however seem to significantly reduce the unpleasant odour commonly associated with battlefield wounds.

Use of 3D photography in complex-wound assessment.

OBJECTIVE: To review the evidence to support three-dimensional (3D) photographic imaging in wound care and undertake a feasibility evaluation of one device in the clinical environment. METHOD: A literature review was undertaken of the role of stereophotogrammetry in wound care.Subsequently, a 3D imaging and data storage system was selected and evaluated in two representative case studies within the clinical environment of the Royal Centre for Defence Medicine. RESULTS: The review suggested that 3D imaging has the potential to provide more accurate data on which to base treatment decisions. In practice, the device was found to be relatively easy to operate and sufficiently robust to handle the demands of clinical practice. However, the high initial cost of the unit and the time taken to download images to the database meant that its benefits were limited to more complex wound types. CONCLUSION: Three-dimensional photography has the potential to play a role in management options;however, current technical issues limit its potential and the incorporation of a highly defined image (similar to that of a standard digital 2D photograph) within its 3D representation would make it more powerful.

Topical negative pressure and military wounds--a review of the evidence.

BACKGROUND: Topical negative pressure (TNP) has been used as a method of wound management for some years. Use of TNP is accepted best practice at Role 4. There are advocates of using TNP after initial wound surgery at Role 3 or 2E. The evidence to support forward use of TNP is not comprehensive, especially when considering this narrow cohort of patients and injury pattern. It is the aim of this review to evaluate the current evidence for the use of TNP in all wounds, and to find what evidence there is that may be applicable to military wounds. METHODS: A literature search of Cinahl, Embase, Medline, ProQuest and the Cochrane Library was conducted; references were cross-referenced. All Randomised Controlled Trials (RCTs) were included in all languages over a comprehensive time period. An interim review was conducted by the Wound Management Working Group of the Academic Department of Military Surgery and Trauma. A further literature review was conducted to find all papers relating to the use of TNP on military wounds. RESULTS: 17 reports were reviewed relating to 14 studies including 662 patients. Of these 131 were reported to have had traumatic injuries. Significant results were reported with respect to time to wound healing, patient comfort and reduction in wound volumes. Bacterial load was not affected, in the 3 trials which commented on this, but in 1 there was a significant reduction in wound infections in the TNP group. Several of the trials were small, methodology was not consistent therefore no meta-analysis was possible. 2 papers were found describing case series of military patients being treated with TNP. CONCLUSIONS: There is very little published evidence in the form of RCTs to support the use of TNP in the acute traumatic military setting. This review supports the requirement for further investigation to evaluate whether this method of wound management has a place forward of Role 4.

Advanced wound therapies in the management of severe military lower limb trauma: a new perspective.

OBJECTIVE: The purpose of this article is to describe the treatment of injuries resulting from land mine explosions using a holistic approach that includes gauze-based negative pressure wound therapy (NPWT) and encompasses wound bed preparation, exudate management, and infection control. METHOD: In the treatment of 3 traumatic injuries, each requiring limb amputation, we describe the application of NPWT using the Chariker-Jeter system, which uses a single layer of saline-moistened antimicrobial gauze laid directly onto the wound bed. A silicone drain is placed on the gauze and then more gauze is placed over the drain to fill the wound. This is then covered with a clear semipermeable film, cut so that there is a 2- to 3-cm border around the wound allowing it to be sealed onto healthy skin. RESULTS: In each of the cases described, we were able to achieve wound closure prior to successful skin grafting, and the patients have recovered well despite the severity of their injuries. CONCLUSION: We discuss the potential advantages of the Chariker-Jeter system over polyurethane foam as a method of delivering NPWT in highly extensive and irregular-shaped wounds created by land mine explosions while stressing the importance of thorough and effective wound bed preparation.

Device related tangential excision in burns.

Tangential excision in burns serves to preserve uninjured tissue in order to maximise cosmesis and function. Excision of all necrotic tissue remains absolutely necessary prior to reconstruction, and the choice of debridement method will depend on the injury, the condition of the patient and the experience of the surgeon. A problem with tangential excision has been that the amount of tissue excised is often greater than the amount of necrotic tissue. Techniques of tangential excision are described. Those using a guard, such as the Goulian or Watson knife, allow the depth of the gap between the blade and the guard to be varied. However, there remains the issue of precision, and a variance between the shape of the blade and of certain parts of the body. "Shelving" can occur as variances in the depth of excision slopes conflict with the uniform thickness of split thickness grafts or Integra, and may lead to an excess of tissue at the periphery of a wound, or "stuck on" appearance. Dermatome debridement may result in less loss of tissue, but this technique can difficult to perform due to the amount of blood loss. The Versajet (Smith & Nephew, Hull, UK) hydrosurgery system enables a more precise removal of unhealthy tissue, as it allows the narrowest excision margin currently available. As with many new techniques, the debridement may take longer at first, but the improved results will justify the extra time. In addition to greater precision in tangential excision, a better and smoother surface for future grafting may be created.

Darier's disease, an unusual problem and solution.

A 46-year-old woman with Darier's disease was referred suffering from severe nail involvement. The patient suffered constant nail infections and an intolerable cycle of progressively more deformity. On examination the patient's nails and nail folds were badly deformed. Initially, as a test, a procedure was undertaken on the thumb alone. The operation was performed under tourniquet control with a digital nerve block. An eponychial flap was raised and nail complex excised. A full thickness skin graft was obtained from the groin. This was sutured into place with the proximal border of graft tucked under the eponychial fold. The results were excellent both surgically and cosmetically. Subsequently, procedures were performed on the remaining nine digits. Darier's disease is extremely variable in its degree of nail involvement. This case highlights a surgical intervention that may help people with intractable associated nail disease.

Patient satisfaction with cleft lip and palate services in a regional centre.

We sent a questionnaire to the parents of 478 children aged between 3 and 14 years who are under the care of the cleft team at the Queen Victoria Hospital, East Grinstead, and received 341 replies. A wide variety of questions were asked about aspects of patient satisfaction, and the results are reported and discussed. There was a high level of satisfaction with the service provided but 30% of parents would like to be more involved in treatment-planning decisions; 33% thought they had either not enough or no knowledge about cleft lip and palate and its treatment. Only 8% of parents would rather have seen the specialists separately than together in the joint clinic.

Use of cartilage grafts for closure of cleft palate fistulae.

We describe the results of using a free cartilage graft in the closure of cleft palate fistulae in 14 patients with a mean follow-up of 8.6 months. Complete closure of the fistula was achieved in 11 patients (79%), with partial closure in the remaining three patients. This technique is simple, causes relatively little discomfort, involves little tissue dissection and can be performed as a day-case procedure. The success rate is comparable with or better than other methods, and we consider it the treatment of choice for small cleft palate fistulae.

Left or right hand dominance in children with cleft lip and palate.

The relationship between unilateral cleft lip, bilateral cleft lip, palatal clefting and left-right hand dominance was studied in 337 patients with cleft lip and/or palate aged between 3 and 14 years. There was no statistically significant difference in the laterality of handedness between different types of cleft nor between unilateral left and right sided cleft lip with or without cleft palate.

Use of the homodigital adipofascial turnover flap for dorsal cover of distal interphalangeal joint defects.

The homodigital adipofascial turnover flap was originally described by Voche and Merle (1994) for dorsal cover of the proximal interphalangeal joint. We present three patients in whom this flap was used to cover dorsal defects of the distal interphalangeal joint, and describe an adaptation to allow greater flap mobility.