Soft Tissue Reconstruction of Complex Blast Injuries in Military and Civilian Settings: Guidelines and Principles

  • Corinne E. Wee
  • Jason M. Souza
  • Terri A. Zomerlei
  • Ian L. Valerio
Chapter

Abstract

The increasing use of explosive devices in recent military operations has introduced complex patterns of injury requiring new reconstructive considerations. Proper initial management, staging, traditional and advanced reconstruction methods, and the use of regenerative medicine can have a drastic effect on outcomes. Even when limb salvage is not achieved, an understanding of residual limb length preservation and peripheral nerve techniques can improve functionality within the amputee patient. Surgery utilizing regenerative modalities and peripheral nerve techniques has shown promising results in military injuries with extensive soft tissue, orthopedic, and neurovascular damage. Improved understanding of the hybrid reconstructive ladder, the increased use of innovative surgical strategies, and further study into the benefits of regenerative medicine may lead to improvements in care for both military and nonmilitary trauma patients suffering from blast injuries.

Keywords

Blast injury Improvised explosive device Complex wound care Regenerative medicine Hybrid reconstructive ladder Targeted muscle reinnervation War trauma 

References

  1. 1.
    Schoenfeld AJ, Dunn JC, Bader JO, Belmont PJ Jr. The nature and extent of war injuries sustained by combat specialty personnel killed and wounded in Afghanistan and Iraq, 2003-2011. J Trauma Acute Care Surg. 2013;75:287–91.CrossRefGoogle Scholar
  2. 2.
    Cannon JW, et al. Dismounted complex blast injuries: a comprehensive review of the modern combat experience. J Am Coll Surg. 2016;223:652–664.e8.CrossRefGoogle Scholar
  3. 3.
    Kelly JF, et al. Injury severity and causes of death from Operation Iraqi Freedom and Operation Enduring Freedom: 2003–2004 versus 2006. J Trauma. 2008;64:S21–6; discussion S26–7.CrossRefGoogle Scholar
  4. 4.
    Grady D. Study Maps ‘Uniquely Devastating’ Genital Injuries Among Troops. The New York Times. 2017.Google Scholar
  5. 5.
    Doukas WC, et al. The military extremity trauma amputation/limb salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am. 2013;95:138–45.CrossRefGoogle Scholar
  6. 6.
    Zoroya G. How the IED changed the U.S. military. USA TODAY. 2013.Google Scholar
  7. 7.
    Lucy Rodgers Salim Qurashi. July London bombings: What happened that day? BBC News. 2015.Google Scholar
  8. 8.
    Burns TC, et al. Does the zone of injury in combat-related type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma. 2010;24:697–703.CrossRefGoogle Scholar
  9. 9.
    Shin EH, Sabino JM, Nanos GP 3rd, Valerio IL. Ballistic trauma: lessons learned from Iraq and Afghanistan. Semin Plast Surg. 2015;29:10–9.CrossRefGoogle Scholar
  10. 10.
    Mossadegh S, Tai N, Midwinter M, Parker P. Improvised explosive device related pelvi-perineal trauma: anatomic injuries and surgical management. J Trauma Acute Care Surg. 2012;73:S24–31.CrossRefGoogle Scholar
  11. 11.
    Han G, Ceilley R. Chronic wound healing: a review of current management and treatments. Adv Ther. 2017.  https://doi.org/10.1007/s12325-017-0478-y.
  12. 12.
    Venturi ML, Attinger CE, Mesbahi AN, Hess CL, Graw KS. Mechanisms and clinical applications of the vacuum-assisted closure (VAC) device: a review. Am J Clin Dermatol. 2005;6:185–94.CrossRefGoogle Scholar
  13. 13.
    Bowler PG, Jones SA, Walker M, Parsons D. Microbicidal properties of a silver-containing hydrofiber?? Dressing against a variety of burn wound pathogens. J Burn Care Rehabil. 2004;25:192–6.CrossRefGoogle Scholar
  14. 14.
    Wright JB, Lam K, Burrell RE. Wound management in an era of increasing bacterial antibiotic resistance: a role for topical silver treatment. Am J Infect Control. 1998;26:572–7.CrossRefGoogle Scholar
  15. 15.
    Wolvos T. Wound instillation – the next step in negative pressure wound therapy. Lessons learned from initial experiences. Ostomy Wound Manage. 2004;50:56–66.PubMedGoogle Scholar
  16. 16.
    Ollat D, Tramond B, Nuzacci F, Barbier O, Marchalan JP, Versier G. Vacuum-assisted closure: an alternative low cost method without specific components. About 32 cases reports and a review of the literature. Bull Acad Natl Chir Dent. 2008;7:10–5.Google Scholar
  17. 17.
    Maurya S, Bhandari PS. Negative pressure wound therapy in the management of combat wounds: a critical review. Adv Wound Care. 2016;5:379–89.CrossRefGoogle Scholar
  18. 18.
    Mathieu L, et al. Soft tissue coverage of war extremity injuries: the use of pedicle flap transfers in a combat support hospital. Int Orthop. 2014;38:2175–81.CrossRefGoogle Scholar
  19. 19.
    Tintle SM, Wilson K, McKay PL, Andersen RC, Kumar AR. Simultaneous pedicled flaps for coverage of complex blast injuries to the forearm and hand (with supplemental external fixation to the iliac crest for immobilization). J Hand Surg Eur Vol. 2010;35:9–15.CrossRefGoogle Scholar
  20. 20.
    Webster D. Clinical applications for muscle and musculocutaneous flaps. S. J. Mathes and F. Nahai. 285 × 215 mm. Pp. 733 xvi with 1052 illustrations. 1982. London: Year Book. £102.00. Br J Surg. 1983;70:451–2.CrossRefGoogle Scholar
  21. 21.
    Valerio IL, et al. Sequential free tissue transfers for simultaneous upper and lower limb salvage. Microsurgery. 2013;33:447–53.CrossRefGoogle Scholar
  22. 22.
    Cho MS, et al. Functional outcome following nerve repair in the upper extremity using processed nerve allograft. J Hand Surg Am. 2012;37:2340–9.CrossRefGoogle Scholar
  23. 23.
    Ray WZ, Mackinnon SE. Management of nerve gaps: autografts, allografts, nerve transfers, and end-to-side neurorrhaphy. Exp Neurol. 2010;223:77–85.CrossRefGoogle Scholar
  24. 24.
    Valerio IL, Campbell P, Sabino J, Dearth CL, Fleming M. The use of urinary bladder matrix in the treatment of trauma and combat casualty wound care. Regen Med. 2015;10:611–22.CrossRefGoogle Scholar
  25. 25.
    Cuadra A, et al. Functional results of burned hands treated with Integra®. J Plast Reconstr Aesthet Surg. 2012;65:228–34.CrossRefGoogle Scholar
  26. 26.
    Hodde JP, Badylak SF, Brightman AO, Voytik-Harbin SL. Glycosaminoglycan content of small intestinal submucosa: a bioscaffold for tissue replacement. Tissue Eng. 1996;2:209–17.CrossRefGoogle Scholar
  27. 27.
    McPherson TB, Badylak SF. Characterization of fibronectin derived from porcine small intestinal submucosa. Tissue Eng. 1998;4:75–83.CrossRefGoogle Scholar
  28. 28.
    Mostow EN, Davin Haraway G, Dalsing M, Hodde JP, King D. Effectiveness of an extracellular matrix graft (OASIS Wound Matrix) in the treatment of chronic leg ulcers: a randomized clinical trial. J Vasc Surg. 2005;41:837–43.CrossRefGoogle Scholar
  29. 29.
    Badylak SF. In: Tissue Engineering. 1993. p. 179–89.CrossRefGoogle Scholar
  30. 30.
    Badylak SF, Lantz GC, Coffey A, Geddes LA. Small intestinal submucosa as a large diameter vascular graft in the dog. J Surg Res. 1989;47:74–80.CrossRefGoogle Scholar
  31. 31.
    Badylak SF, et al. The use of xenogeneic small intestinal submucosa as a biomaterial for Achilles tendon repair in a dog model. J Biomed Mater Res. 1995;29:977–85.CrossRefGoogle Scholar
  32. 32.
    Aiken SW, Badylak SF, Janas W, Boop FA. Small intestinal submucosa as an intra-articular ligamentous graft material: a pilot study in dogs. Vet Comp Orthop Traumatol. 1994;7.Google Scholar
  33. 33.
    Cobb MA, Badylak SF, Janas W, Boop FA. Histology after dural grafting with small intestinal submucosa. Surg Neurol. 1996;46(4):389–93; discussion 393.CrossRefGoogle Scholar
  34. 34.
    Prevel CD, et al. Small intestinal submucosa: utilization as a wound dressing in full-thickness rodent wounds. Ann Plast Surg. 1995;35:381–8.CrossRefGoogle Scholar
  35. 35.
    Prevel CD, et al. Small intestinal submucosa: utilization for repair of rodent abdominal wall defects. Ann Plast Surg. 1995;35:374–80.CrossRefGoogle Scholar
  36. 36.
    Gravante G, et al. A randomized trial comparing ReCell system of epidermal cells delivery versus classic skin grafts for the treatment of deep partial thickness burns. Burns. 2007;33:966–72.CrossRefGoogle Scholar
  37. 37.
    Wood FM, Stoner ML, Fowler BV, Fear MW. The use of a non-cultured autologous cell suspension and Integra® dermal regeneration template to repair full-thickness skin wounds in a porcine model: a one-step process. Burns. 2007;33:693–700.CrossRefGoogle Scholar
  38. 38.
    Sood R, et al. A comparative study of spray keratinocytes and autologous meshed split-thickness skin graft in the treatment of acute burn injuries. Wounds. 2015;27:31–40.PubMedGoogle Scholar
  39. 39.
    Graham JS, et al. Medical management of cutaneous sulfur mustard injuries. Toxicology. 2009;263:47–58.CrossRefGoogle Scholar
  40. 40.
    Bowen B, et al. Targeted Reinnervation for the amputee: a multi-cohort analysis. J Am Coll Surg. 2016;223:S102–3.CrossRefGoogle Scholar
  41. 41.
    Souza JM, et al. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014;472:2984–90.CrossRefGoogle Scholar
  42. 42.
    Tintle LTSM, Keeling CJJ, Shawen LSB, Forsberg LJA, Potter MBK. Traumatic and trauma-related amputations. J Bone Joint Surg Am Vol. 2010;92:2852–68.CrossRefGoogle Scholar
  43. 43.
    Aszmann OC, et al. Bionic reconstruction to restore hand function after brachial plexus injury: a case series of three patients. Lancet. 2015;385:2183–9.CrossRefGoogle Scholar
  44. 44.
    Tartarini D, Mele E. Adult stem cell therapies for wound healing: biomaterials and computational models. Front Bioeng Biotechnol. 2015;3:206.PubMedGoogle Scholar
  45. 45.
    Bueno EM, et al. Vascularized composite allotransplantation and tissue engineering. J Craniofac Surg. 2013;24:256–63.CrossRefGoogle Scholar
  46. 46.
    Gonfiotti A, et al. The first tissue-engineered airway transplantation: 5-year follow-up results. Lancet. 2014;383:238–44.CrossRefGoogle Scholar
  47. 47.
    Siemionow M. Vascularized composite allotransplantation: a new concept in musculoskeletal regeneration. J Mater Sci Mater Med. 2015;26:266.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Corinne E. Wee
    • 1
  • Jason M. Souza
    • 2
  • Terri A. Zomerlei
    • 1
  • Ian L. Valerio
    • 1
    • 2
  1. 1.Department of Plastic & Reconstructive SurgeryThe Ohio State University Wexner Medical CenterColumbusUSA
  2. 2.Department of Plastic & Reconstructive SurgeryWalter Reed National Military Medical CenterBethesdaUSA

Personalised recommendations