Being Prepared for the Next Conflict Part II: Case Analysis of a Military Level 1 Trauma Center.

INTRODUCTION: Combat-related injuries have declined substantially in recent years as we have transitioned to a low-volume combat casualty flow era. Surgeons must remain actively committed to training for the next engagement to maintain life and limb-saving skills. Soft tissue coverage procedures were imperative to the management of complex lower extremity trauma that occurred during recent conflicts. The purpose of this study was to evaluate advanced soft tissue coverage procedures performed on the lower extremity over the previous decade on military and civilian trauma patients at a Department of Defense Level 1 trauma center to provide data that can be used to guide future training efforts. MATERIALS AND METHODS: The electronic surgical record system was searched for cases that utilized advanced soft tissue coverage (rotational and free flaps) to the lower extremity. The date of treatment, indication, procedure performed, and military/civilian patient designation were recorded. The data was categorized between military and civilian cases, rotational versus free flap, and indication and then charted over time. It was assessed as moving averages over a 12-month period. Statistically distinct periods were then identified. RESULTS: From January 2006 to March 2015, 132 advanced soft tissue coverage procedures were performed on the lower extremity (100 military, 32 civilian). Military soft tissue coverage data demonstrated peaks in 2007 and late 2011 to late 2012, averaging 6.5 (3.5-9.6) and 4.5 (3.2-5.8) per quarter, respectively. There were two low periods, from 2008 to mid-2010 and from mid-2012 to the end of the study, averaging 1.1 (0.6-1.6) and 1.8 (1.1-2.6) cases per quarter, respectively. Civilian procedures averaged 0.9 per quarter (0.5-1.2) throughout the study, but notably were equal to the number of military procedures by the last quarter of 2013 at 2.0 (1.2-2.8 civilian, 0.8-3.1 military). CONCLUSIONS: This data supports prior identified trends in military cases correlating increased number of procedures with increased combat activity related to the conflicts in Iraq and Afghanistan in 2007 and 2011, respectively. The data showed relative stability in the numbers of civilian procedures with a slight uptrend beginning in mid-2012. A comparison after mid-2012 shows military procedures declining and civilian procedures increasing to eventually become equivalent at the end of the data collection. These trends follow previously reported data on tibia fracture fixation procedures and lower extremity amputations for the same time periods. These data demonstrate the importance of the civilian trauma mission for maintaining surgical skills relevant to limb salvage, such as rotational and free flaps, during a low-volume combat casualty flow era.

Can Sural Fasciocutaneous Flaps Be Effective in Patients Older Than 65?

BACKGROUND: Many studies have evaluated the reverse sural fasciocutaneous flap for coverage of wounds on the distal lower extremity, and many of these have focused on younger, healthy patients. However, to our knowledge, there has been no dedicated study focusing on older patients. We believe there is a generalized concern about performing these procedures in older patients because of microvascular changes associated with aging. QUESTIONS/PURPOSES: (1) What is the likelihood of flap survival in a small series of patients older than 64 years who underwent reverse sural artery fasciocutaneous flap for coverage of lower extremity wounds? (2) What additional procedures did patients undergo after treatment with this flap? METHODS: From 2009 to 2018, we identified 16 patients, 64 years or older, who underwent a retrograde sural fasciocutaneous flap. Patients were a mean (range) age of 71.5 years (64 to 87). The average size of the flaps was 30 cm (range 12 to 64 cm). The reverse sural artery flap was indicated when the skin could not be closed primarily and there was not a suitable vascularized bed of tissue for a split-thickness skin graft. All patients underwent a wide-based pedicle (3 cm to 4 cm), reverse sural artery fasciocutaneous flap with all but one completed in a "flap delay" manner, between 2 to 7 days, and without the use of microsurgery or doppler. Thirteen flaps were done to cover wounds that occurred over fractures while three were performed to cover chronic wounds. We performed a retrospective review of the electronic health record to ascertain patient comorbidities, age, timing of coverage, and size of the wound. RESULTS: In all, 94% of flaps (15 of 16) survived with 100% viability. One flap had 30% skin necrosis at the distal tip. The flap ultimately healed with in-office wound care, and epithelization occurred over the intact fascia. A total of five additional procedures were performed in five patients. Although the flap ultimately healed, an 87-year-old patient with partial flap necrosis ultimately elected for below-knee amputation for a persistent tibial infected nonunion. Another patient, despite a healed flap, eventually underwent a below-knee amputation 3 years later for a chronic osteomyelitis present before undergoing the reverse sural flap. One patient developed a pseudomonal infection of their Gustillo-Anderson IIIB open tibia fracture, resulting in a surgical procedure for débridement, after which the flap healed. Two patients underwent underlying hardware removal to relieve wound tension and allow for complete flap healing. No patients underwent further coverage procedures. CONCLUSIONS: In this small series, we found fewer complications than have been observed in prior studies, despite our series consisting solely of higher-risk, older patients. We believe this may have been attributable to the period of delay before placing the flap, which has been previously associated with higher flap survival and which allows for an extra recipient-site débridement. We believe this procedure can be performed by appropriately trained orthopaedic surgeons because it does not need microsurgery. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Being Prepared for the Next Conflict: A Case Analysis of a Military Level I Trauma Center.

BACKGROUND: As we transition to an interwar period, combat-related injuries are at their lowest levels in over a decade, yet we must continue to maintain our surgical skills and train new surgeons. During the recent wars, the importance of the treatment and care for amputations and complex extremity injuries became apparent. This study compares the number of these procedures performed during the treatment of civilian and military orthopaedic trauma patients at a Department of Defense Level I trauma center over the past 9 years. The need to evaluate this unique system is further highlighted by the recent recommendation from the National Academies of Sciences, Engineering, and Medicine's to combine civilian and military trauma systems. METHODS: Data derived through a retrospective review of electronic health records were charted and evaluated for statistically unique periods. RESULTS: There were significant fluctuations in the number of procedures performed within the military cohort, with peaks centered around 2007 and 2011-2012, whereas the number of civilian cases remained relatively steady. On average, the civilian cohort also produced a more consistent and greater number of tibia fractures than the military cohort. For the past 3 years, the civilian cohort has produced 22 more tibia fractures per quarter than the military cohort. Furthermore, although type III open tibia fractures were the most common classification within the military cohort, the civilian cohort provided comparable numbers of type III open fractures despite only being the second most common fracture classification in the civilian cohort. In fact, the civilian volume outpaced the military cohort the past 3 years in this metric. More importantly, the military cohort produced 6 type III fractures in 2013, and 3 in 2014, whereas the civilian cohort produced 14 and 25, respectively, during those years. DISCUSSION/IMPACT/RECOMMENDATIONS: Fluctuations in the military cohort's data mirrors surges in operational activity, whereas the civilian cohort demonstrates a higher and more predictable number of tibia fractures; with reliability and numbers being important factors in training new surgeons and maintaining surgical skills. Although this study focused on specific orthopaedic trauma cases deemed essential to combat casualty care, it highlights the universal reality facing U.S. Military Medicine: as combat trauma continues to decline, military medicine as a whole will have to look elsewhere for critical trauma experience. This study confirmed military case volumes fluctuate with operational demands and evaluated one method of supplementing the declining combat trauma volumes with a local civilian trauma mission. This indicates not only the need for a system that is able to quickly adapt to the increased patient load, but also depicts how little reliability there is within the system in terms of perpetuating physician experience when the civilian trauma mission is not considered.