Måns Muhrbeck1,2, Kaspar Holmgren3, Zaher Osman4, Johan von Schreeb5, Andreas Wladis6,7, Peter Andersson8,9. 1. Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, 603 79, Norrköping, Sweden. mans.muhrbeck@liu.se. 2. Center for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden. mans.muhrbeck@liu.se. 3. Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark. 4. International Committee of the Red Cross, Geneva, Switzerland. 5. Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. 6. Center for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden. 7. Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden. 8. Department of Surgery, and Department of Clinical and Experimental Medicine, Linköping University, 603 79, Norrköping, Sweden. 9. International Medical Programme, Center for Teaching and Research in Disaster Medicine and Traumatology, University Hospital, Linköping, Sweden.
Abstract
BACKGROUND: In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. METHODS: Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. RESULTS: Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. CONCLUSION: In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.
BACKGROUND: In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. METHODS: Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. RESULTS: Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. CONCLUSION: In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.
Authors: Philip P Goodney; Massimo Tarulli; Adrienne E Faerber; Andreas Schanzer; Robert M Zwolak Journal: JAMA Surg Date: 2015-01 Impact factor: 14.766
Authors: Maximilian P Nerlander; Rawand Musheer Haweizy; Moayad Abdullah Wahab; Andreas Älgå; Johan von Schreeb Journal: World J Surg Date: 2019-02 Impact factor: 3.352