Plastic Surgery Challenges in War Wounded II: Regenerative Medicine

Abstract

Background: A large volume of service members have sustained complex injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF). These injuries are complicated by contamination with particulate and foreign materials, have high rates of bacterial and/or fungal infections, are often composite-type defects with massive soft tissue wounds, and usually have multisystem involvement. While traditional treatment modalities remain a mainstay for optimal wound care, traditional reconstruction approaches alone may be inadequate to fully address the scope and magnitude of such massive complex wounds. As a result of these difficult clinical problems, the use of regenerative medicine therapies, such as autologous adipose tissue grafting, stem cell therapies, nerve allografts, and dermal regenerate templates/extracellular matrix scaffolds, is increased as adjuncts to traditional reconstructive measures. Basic and Clinical Science Advances: The beneficial applications of regenerative medicine therapies have been well characterized in both in vitro studies and in vivo animal studies. The use of these regenerative medicine techniques in the treatment of combat casualty injuries has been increasing throughout the recent war conflicts. Clinical Care Relevance: Military medicine has shown positive results when utilizing certain regenerative medicine modalities in treating complex war wounds. As a result, multi-institution clinical trials are underway to further evaluate these observations and reconstruction measures. Conclusion: Successful combat casualty wound care often requires a combination of traditional aspects of the reconstructive ladder/elevator with adoption of various regenerative medicine therapies. Due to the recent OIF/OEF conflicts, a high volume of combat casualties have benefited from adoption of regenerative medicine therapies and increased access to innovative clinical trials. Furthermore, many of these patients have had long-term follow-up to report on clinical outcomes that substantiate current treatment paradigms and concepts within regenerative medicine, reconstructive, and rehabilitation care. These results are applicable to not only combat casualty care but also to nonmilitary patients.

Keywords: complex wound care; limb salvage; regenerative medicine; war trauma.

Ian L. Valerio, MD, MS, MBA, FACS

Figure 1.

(a, b) Clinical example of massive soft tissue and polyextremity injuries commonly seen in combat casualties secondary to blast exposure. (a) Shows left upper extremity (LUE) severe composite and soft tissue injury; (b) illustrates bilateral lower extremity injuries, including a left lower extremity traumatic amputation. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 2.

The hybrid reconstructive ladder that integrates regenerative medicine therapies to traditional reconstruction measures. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 3.

(a) LUE blast injury illustrating large soft tissue injury of nearly entire volar forearm extending proximally to the brachial region. (b) Same LUE injury after lib salvage with free ALT flap coverage proximally and a dermal regenerate template (DRT)/extracellular matrix (ECM) placement to distal forearm. (c) LUE appearance 2 years postreconstruction and after liposuction contouring of proximal ALT flap. Note appearance of distal forearm DRT/ECM and skin graft 2 years after initial operative events. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 4.

(a) Lower extremity combat casualty injury before hybrid reconstruction. (b, c) Same lower extremity injury after hybrid reconstruction with flap coverage of tibia fracture and open knee joint, DRT/ECM placement, and secondary skin grafting 2 years after reconstruction. (b) Left Lower Extremity in extension; (c) LLE in flexion. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 5.

(a) Right Upper Extremity radiograph showing extensive orthopedic injuries. (b) RUE massive soft tissue injuries in face of severe orthopedic injuries with DRT in place for regeneration of dermal substitute in preparation of second stage Split Thickness Skin Graft. (c) RUE hybrid reconstruction with STSG after DRT incorporation. (d) RUE hybrid reconstruction and function illustrating patient throwing first pitch at professional baseball game 2 years postreconstruction. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound