Soft Tissue Injuries and Amputations

The wars in Iraq and Afghanistan have produced a devastating but survivable injury pattern termed dismounted complex blast injury (DCBI) which is characterized by proximal lower extremity amputations and peri-pelvic trauma. The potential for massive blood loss from major vessel hemorrhage requires expedient battlefield intervention and coordinated casualty evacuation that balances aggressive debridement and soft tissue management with forward-minded action to preserve limb length and maximize function. Despite and possibly as a result of these attempts, the limbs of DCBI patients are wrought with early and late complications. Infection mitigation remains difficult despite serial debridements, early antibiosis, and delayed closures that utilize negative pressure wound dressings and antibiotic- and antifungal-impregnated cement beads. Invasive fungal infection, in particular, has high mortality and requires aggressive debridement as a lifesaving measure. Efforts to preserve amputation level necessitate novel approaches to soft tissue management to include rotational and free flaps, tissue expanders, and regenerative xenograft tissue matrices that push the limits of the orthoplastic reconstructive ladder. Heterotopic ossification is nearly ubiquitous in the residual limbs of DCBI causalities and when symptomatic can delay rehabilitation and require morbid surgery making prophylaxis a primary focus of military surgeons and scientists. While the functional outcomes of combat amputees surpass those of civilian traumatic amputees, innovative treatments such as targeted muscle reinnervation and osseointegration offer promise for those amputees who are limited by neuromas and poorly tolerated conventional prostheses. These advances may have wide-reaching clinical application beyond military treatment facilities and veteran’s hospitals to those who sustain traumatic amputations from conventional trauma, natural disaster, or terrorism.