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Background: Vascularized osteoseptocutaneous radial flap is commonly used in the reconstruction of composite bony and soft tissue defects of the lower third of the face due to the outstanding quality of its cutaneous component. The aim was to evaluate the primary and overall success in the reconstruction of mandibular defects, following war injuries, with vascularized osteoseptocutaneous radial flap., Methods: At the Department of Maxillofacial Surgery of the Military Medical Academy Belgrade, there were eight patients with this kind of defect following war injury, and the mandible was reconstructed with a vascularized osteoseptocutaneous radial flap. Bony compartment of the graft was harvested as up to 11 cm long segment of radial circumference., Results: The localization and structure of the defect, features of a harvested compound graft, the procedure of the reestablishment of the mandibular continuity was presented as well as immediate and late complications during the consolidation period, and the primary successful reconstruction in 87.5% of the patients., Conclusion: The primary and overall success in the mandibular defects reconstruction with a vascularized osteoseptocutaneous radial flap was equal or even better than those presented in the literature on the reconstruction of the similar defects after tumor resections.

Background: Missile-caused median nerve injuries have rarely been reported in current literature. We present repair outcome for all median nerve injuries in which the median nerve was severed either by missile injury or secondarily in the subsequent resection of a neuroma in continuity., Methods: Prospective study included 81 casualties with proximal, intermediate, or distal complete median nerve lesions, repaired by nerve graft or direct suture. Final outcome was defined at least 4 years postoperatively, on the basis of motor recovery, sensory recovery, neurophysiological recovery, and patient's judgment on the outcome, each estimated by 0 to 5 points and according to the total sum, as poor, insufficient, good, or excellent. The last 2 modalities were considered to be successful., Results: Successful outcome was obtained in 68.7% of distal, in 33.3% of intermediate, and in 10% of proximal repairs. Average outcomes were good, insufficient, and poor, respectively (P < .001). Nerve defect and preoperative interval were both significantly shorter on average for patients with successful outcome than for those with unsuccessful outcome (P < .001 and P = .007, respectively), but only preoperative interval and height of repair were independent predictors for successful outcome. Age of patient, associated ulnar nerve complete lesion, and manner of repair did not influence the outcome significantly (P > .05)., Conclusions: The level of repair, duration of preoperative interval, and length of nerve defect significantly influence outcome after median nerve repair, but only level of repair and duration of preoperative interval were independent predictors for successful outcome.

Background: Reports on missile-caused radial nerve injuries are relatively rare in current literature. We present the outcome after repair of such injuries as well as the factors influencing the result of treatment., Methods: Prospective study included 131 complete missile-caused radial nerve severances repaired with nerve graft or direct suture. Final outcome was defined 4 years postoperatively at least, on the basis of motor recovery (M), EMNG recovery (E) and patient's judgement on the quality of outcome (P). Recovery was estimated with 0-5 points and final outcome was defined according to the total sum (0-15 points) as: poor, insufficient, good or excellent. Both the good and the excellent outcomes were considered as successful, and both the poor and the insufficient outcome as unsuccessful., Results: Excellent outcome was noted in 38.2% and good outcome in 47.3% of all patients. Average point score was 9.9 +/- 3.3 points for the whole series (domain of good outcome) and 6.6 +/- 3.0, 10.1 +/- 3.2 and 10.9 +/- 2.2 points for high, intermediate and low repairs, respectively (p<0.01). Useful motor recovery (>or =M3), good EMNG recovery (> or =E3) and affirmative patient's judgement on the outcome (> or =P3) had similar frequencies for intermediate (83.2-89.7%) and low repairs (85.7-92.8%), but for high repairs, good EMNG recovery was more frequent (70%) than were useful motor recovery and affirmative patient's judgement (40%). Successful outcome was noted in 89.3% of direct sutures and in 82.7% of nerve grafts (p>0.05). Patients with a successful outcome had a significantly shorter nerve defect (p<0.001), shorter preoperative interval (p<0.001) and younger age (p<0.05) than patients with an unsuccessful outcome. Significant deterioration of results began with defects longer than 8 cm, preoperative interval longer than 6 months and age above 40 years., Conclusions: The outcome is significantly worse after high radial nerve repairs than after intermediate and low repairs. The length of nerve defect, duration of preoperative interval and age of the patient also influence the repair outcome. Correlation of motor recovery with EMNG recovery and with patient's judgement on the outcome is relatively good, but depends on the level of the repair.

The results of below-knee amputations in 36 war wounded (mean age 35.42) were reviewed. The majority of the patients was wounded by land mines (94.4%). Most of them were between 25 and 35 years old. Bilateral amputation was done in 2.8% of cases. The amputation was performed on the day of wounding (primary below-knee amputation) in 30 (83.3%) amputees. Secondary amputation after the attempt to save the severely injured lower-limb was performed in 6 patients (16.7%) average 4.61 +/- 11.67 days after wounding. Reamputation was necessary in 6 cases (16.7%). Time period from the beginning of rehabilitation to the fitting of prosthesis, was 36.25 +/- 14.97 days for primary amputations, 32 +/- 17.8 days for secondary amputations and 68.66 +/- 33.52 days for reamputations. There was no significant correlation between the duration of rehabilitation to prosthetic management and the period between wounding and amputation (r = -0.102). The attempt to save the limb after severe below-knee injuries and the secondary amputation afterwards, did not significantly influence the ensuing rehabilitation and prosthetic works.

The 67th Combat Support Hospital at Camp Bondsteel, Kosovo, treated victims of trauma on an almost daily basis at the beginning of U.S. peacekeeping efforts in the region. Military health care personnel must respond quickly and efficiently when confronted with patient wounds resulting in massive blood losses. The limited medical resources of a field hospital often complicate efforts to treat the most severe injuries. One such case involved a young farmer riddled with gunshot wounds. Early volume/blood resuscitation before, during, and after surgery led to a massive blood coagulopathy. This case study describes the actions the physicians and nurses initiated to save this victim of violence. The subsequent discussion delineates methods to reduce intraoperative blood losses, blood transfusion alternatives, and technological advances in trauma resuscitation.

An urgent blood drive in which active duty military field surgical hospital personnel volunteered to donate whole blood was conducted, and administration of warm, whole blood prevented the exsanguination of a normothermic coagulopathic patient who had received a massive transfusion. In austere care settings in which full blood banking capability may not be available, physicians should consider that exsanguinating hemorrhage can potentially be controlled surgically, but nonsurgical bleeding requires specific replacement therapy, and whole blood may be the best selection for repleting deficiencies of components that are otherwise unavailable.

Presented are the results of primary surgical treatment of war injuries of the foot in 250 patients wounded in the territory of former Yugoslavia in the period June 1991-October 1995. Total number of feet treated was 275. Aetiologically, the most frequent injuries were those inflicted by the effect of mine blasts (65.2%) and by bullets from firearms (30.8%). Injuries to a single foot were present in 140 (56.0%), combined injuries in 107 (42.8%) and associated with burn injuries in three (1.2%) patients. Soft tissue injuries were present in 25 (9.1%) and injuries to bone structures and joints in 250 (90.9%) feet. Injuries resulting from solid blasts were found in nine (3.2%) feet. Postoperative bone fragment stabilization was required in 115 (41.8%) feet. Stabilization was by plaster of Paris in 87 (75.6%) and by external fixation in 23 (20. 0%) feet. Amputations were performed in 73 (26.5%) feet. Covering of soft tissue and bone defects was required in 84 (33.6%) patients.

The retrospective analysis of 1,514 cases treated at the Clinic for Plastic Surgery and Burns of the Military Medical Academy in the period between 1991 and 1995, established that the percentage of the injuries caused by gunshots and those caused by explosives during the conflict in former Yugoslavia, was more or less the same. The injuries caused by gunshot more often occurred on the head, neck, arms and trunk. The injuries of the legs caused by the explosives were more frequent, and they occurred in 83% of the cases. All the plastic surgeons who took part in the treatment of patients and in preparing the surgeons of other specialties for the treatment applied the original classification of the war injuries according to the structure of the defects that had occurred, to standardize the approach to the planning of treatment and the treatment itself of the wounded. In the delayed primary or secondary treatment of the injuries with the tissue defects all known plastic and reconstructive methods were applied. In the cases requiring the covering of the the tissue defect with the full thickness skin, local skin, fasciocutaneous, fascioadipose or muscle flap was chosen. Distant pedicled direct flaps were used in cases when it was not possible to use a more suitable reconstructive method. Free skin, myocutaneous or complex microvascular flaps were applied in cases of more extensive defects or if a more suitable solution could not be found. Our experience in surgical treatment of war injuries with skin defects during the civil war in former Yugoslavia has shown that over 50% of all the injured patients required the treatment of a plastic surgeon in a definite surgical treatment of a war injury. A multidisciplinary approach is necessary in the majority of the injured, and the surgical team is composed according to the affected area and the extent of the injury.

The work of the Vinkovci General Hospital in the 1991-1992 war in Croatia is described. Because the hospital was only 400 m from the front line and the enemy shelled it incessantly (it is estimated that the hospital was hit by 5,000-7,000 heavy artillery shells), the surgical services worked in the cellar. Between May 1, 1991, and July 1, 1992, 1,211 patients were admitted and subsequently operated on. Of these, 51 died (4.3%), 12 of them on admission. Bullet wounds were found in 41 patients (3%), and 1,092 (90%) were wounded by shell explosions, 53 (4%) by mine explosions, and 25 (2%) contracted burns. Most of the patients were adults, but 50 children, half of them with serious wounds, were also treated. Almost two-thirds of our patients were soldiers or policemen, and one-third were civilians. Four of the patients were prisoners of war. The proportions of heavy and light wounds among the soldiers and civilians were almost exactly 50%. At almost all sites, the ratio of penetrating to nonpenetrating injuries was rather high. With regard to wounds to the head, 38% of the wounds were penetrating. We operated on 181 patients with thorax injuries, of which 80 were penetrating. A high proportion of the injuries were on the arms and legs, the latter accounting for more than 45% of all wounds. A relatively high proportion of traumatic amputations, as well as blast contusions and fractures, were attributable to the fact that most of the wounds were caused by explosions (90%). Their seriousness required a total of 70 surgical amputations on upper extremities and 156 amputations on lower extremities. There were many more vessel injuries on lower extremities than on upper extremities. In our work, we applied the war medical doctrine used through-out the country, which essentially adhered to the NATO doctrine. The differences with NATO doctrine stemmed from the fact that Croatian military medicine emerged from civilian prewar medicine and worked fully integrated with it throughout the war. Yet, our results correspond to the results and experiences of other authors belonging to developed military medical services.

We present the results of primary surgical treatment of war injuries of major joints in 339 patients, wounded in the territory of the former Yugoslavia in the period June 1991-October 1995. The total number of surgically treated joints was 358. The injuries were inflicted by the fragments of explosive devices in 176 (51.9%) patients and by bullets in 125 (36.9%) patients. A single wound was present in 160 (47.2%) and several wounds in 176 (51.9%) patients; 276 (77.1%) patients had injuries of articular bone. The most frequently injured joints were knee joint 167 (46.6%) and elbow joint 72 (20.1%). Associated neurovascular injuries were present in 68 (18.9%) patients. Postoperative bone fragment stabilization was required in 254 (70.9%) joints. Stabilization was by plaster of Paris in 148 (58.2%) and external fixation in 85 (33.4%) patients. Postoperative course was uneventful in 262 (77.3%) while postoperative complications occurred in 77 (22.7%) patients. Amputations were performed in 15 (4.4%) patients. After the primary surgical treatment 254 (74.9%) patients were discharged and directed to rehabilitation or home care and 81 (23.9%) patients required additional reconstructive surgery for bone and soft tissue defects.

Missile injuries of the sciatic nerve are not common in civil practice. We analysed a war series of 55 cases operated on in a period from 1991 to 1995. Nerve continuity was preserved at least partially in 76.4% of cases, but only 13.3% of cases had preserved some nerve function. Surgical results were analysed in 45 cases followed for more than two years. The rates of useful functional recovery were 86.7% for tibial division, 53.3% for peroneal division and 86.7% for the sciatic nerve complex. On the basis of the obtained results we were able to make the following conclusions: (1) missile injuries to the sciatic nerve are characterised by partially preserved nerve continuity and complete functional loss in the majority of cases, (2) surgery should be performed 3 to 6 months after injury, (3) reconstruction of tibial division is the major goal of surgical repair, (4) the extent and severity of nerve damage and the type of surgical procedure are the main prognostic factors and (5) failures of surgical repair are usually related to nerve grafting at gluteal level.

The treatment results of subtrochanteric missile fractures of the femur in 41 casualties are analyzed. The wounds were inflicted by infantry weapon missiles in 29 (70.7%) and by fragments of mine or explosive devices in 12 (29.3%) casualties. The associated neurovascular bundle injuries were present in 11 (26.8%) patients. Fracture stabilization was done by external fixation in 25 (62.5%): group A; and by plaster of Paris in 15 (37.5%) patients: group B. The postoperative period was uneventful in 14 (35.0%) and early or late complications occurred in 26 (65.0%) patients. Bone infection developed in six (15.0%) and fractures did not heal in four (10.0%) patients. Complications were present in 13 (52.0%) patients from group A and in 13 (86.7%) patients from group B. Delayed fracture healing and fracture nonunion were present in group A and contractures of large joints in group B. Subtrochanteric missile fractures of the femur present very severe injuries where the treatment is followed by a very high percentage of complications. External fracture fixation in this region facilitates the care, stability, early covering of soft tissue defects and early physical therapy.

The aim of this study was to prove the advantage of the limited lung resection vs. suture in the primary management of penetrating lung war wounds. A prospective clinical study was presented about the results of primary surgical treatment of 50 injured with penetrating lung wounds, operated at the Military Medical Academy. The patients were divided into two groups: primary group was comprised of the wounded with limited resection, and the control group of the wounded with lung suture. Among the observed parameters, special attention had been paid to the specific postoperative complications, observed in 48% of the wounded from the group with lung suture (p < 0.01). The results of the investigation have demonstrated the significant advantage of limited resection vs. suture, and the method itself revealed all the features of radical and definite management of severe lung injuries. Precise indications for the use of both treatment methods are given.

In the period from 1990 to 1994, 52 facial nerve injuries caused by fragments firearm projectiles were managed. Their features (localization, severity and extensiveness) were correlated with 37 nerve injuries in blunt head injuries with fracture of temporal bone. In blunt head injuries, 81.1% patients were with the nerve lesion in the area of geniculate ganglion (labyrinthine and tympanic segment). Compression of nerve with bone fragments of fallopian tube was found in 56.8% cases, the cleft of neural sheath and intraneural hematoma were rarer, while the nerve tear was not found in any injured. The distal part of mastoid and beginning part of parotid nerve segment were injured in over 70% cases of gunshot injuries, and in 38.5% cases the injury was multiple. Direct suture was performed in 8 nerve injuries, neuroplasty in 6, and the other injuries were managed by skeletization of fallopian tube, nerve decompression or some other microsurgical procedure. Micro-surgery was performed 7-14 days after the injury.

Objective: Gunshot wounds to the brachial plexus present a specific problem in peripheral nerve surgery. The purpose of this study is to analyze the characteristics of these injuries and the possibilities for functional recovery after their surgical treatment., Design: Retrospective analysis of nerve lesions and results of surgery., Materials and Methods: The series consists of 54 patients operated on, with 148 injured nerve elements, i.e., with 163 injured nerve elements when individual components of complex brachial plexus structures are included. Surgical procedures involved exploration, neurolysis, and nerve grafting, or their combination, depending on intraoperative findings. The surgical results were analyzed in 46 patients (85.1%) with 119 (80.1%) of the 148 nerve elements, with follow-up periods of more than 24 months. Standard grading scores for motor and sensory function were used and ranged according to functional priorities in the surgery of brachial plexus and individual nerves., Measurements and Main Results: Neurolysis and nerve grafting generally gave similar rates of functional recovery, 90.2 and 87.8%, respectively. They were successful in all cases with injuries to the upper spinal nerves, the upper trunk, the lateral and posterior cord, and the musculocutaneous and axillary nerves. The failures were related to neurolysis or grafting of the ulnar and radial nerve lesions., Conclusion: Compared with previous studies, the number of lesions with complete functional loss and complete anatomic loss of continuity is larger. In cases that were prognostically favorable according to the location of injury, the results are similar regardless of the type of nerve repair.

The results of the use of the vascularized fibular graft for the reconstruction of posttraumatic defects of the mandible are presented. Different surgical procedures were applied in reconstruction of the mandibular defects in 120 wounded. In the last four years vascularized fibular graft was used in 11 mandibular reconstructions. Taking into account the survival rate of 100%, long vascular pedicle, strength, length and the possibilities of adaptation of the bone make this graft suitable for mandibular reconstruction. The functional and esthetic results obtained by the use of this graft were satisfactory, with minimal donor site morbidity.

Authors presented their own experiences in treating 735 wounded in high-intensity combat zones in the territories of former Yugoslavia during 1991 to 1992. The mobile field hospital with surgical crews was situated 5 to 10 km from the front line, and its basic task had been continuous triage, immediate resuscitation with vital surgical aid, as well as organization of adequate primary and secondary air evacuation. At the field hospital level, fresh wounds were explored according to principles of war surgery, and major surgical interventions were performed in 3.3% of the wounded. Patients with massive hematothorax were treated with autotransfusion. Mortality at this primary level, field hospital was 0.75% with primary immediate resuscitation and 1.9% with immediate evacuation. We concluded that immediate resuscitation with delayed transport had advantages, compared with fast evacuation of only the wounded.

The results of retrospective analysis in the treatment of 189 wounded with colorectal lesions treated at the Military Medical Academy from July 1991 to December 1993 were presented. Primary surgical management was performed in 33 (17.5%) wounded. The others were transported into this hospital for further treatment after primary surgical management in war hospitals in the combat zone. Colorectal lesions (46.0%) were primarily inflicted by bullets of various calibers and high kinetic energy. The time interval between wounding and surgery was less than 6 hours for 39.6% of the wounded, whereas 80.1% were operated on within 12 hours. Multiple or combined colonic and rectal injuries were found in 91.5% of the wounded. Different surgical procedures were performed in accordance with the surgical war doctrine. Postoperative complications (colorectal cause) were found in 40 (21.2%) wounded. Reoperation was performed in 35 (18.5%) wounded. Total mortality rate was 10.1% (19 wounded).

Ninety frontoethmoidal fractures, as a result of war injuries from 1991 to 1994, produced 0.7% of all war injuries (i.e., 9% of head and neck injuries treated in the Military Medical Academy, Belgrade). These injuries were mainly part of complex endocranial, orbital, and zygomaticomaxillary injuries, and were rarely isolated. The central part of these injuries were in the ethmoidal region, which was isolatedly injured in 23.3% of the cases. There was 53.3% injuries with small fragments of explosive devices inside the wound, and 16.7% of through-and-through wounds were caused by sniper bullets. The priority over all definitive operative procedures belonged to osteoplasties whenever possible, because the primary goal was protection of life. About 3.3% of the patients died because of severe hemorrhagic shock and endocranial injury. There was only one case of recurrent meningitis. Most of the patients had multiple injuries and were mutually operated on by two different surgical teams.

The results of retrospective analysis in the treatment of 155 wounded with colorectal lesions treated at the Military Medical Academy from July 1991 to December 1992 were presented. Primary surgical management was performed in 29 (18.7%) wounded and the others were transported into this hospital for further treatment after primary surgical management in war hospitals in the combat zone. Colorectal lesion (42.6%) were mostly inflicted by bullets of various caliber and high kinetic energy. Time interval between the wounding and surgery was less than 6 hours for 38.2% of wounded while 78.6% were operated within 12 hours. Multiple or combined colonic or rectal injuries were found in 91.6% of the wounded. Different surgical procedures were performed in accordance with the surgical war doctrine. Postoperative complications (colorectal cause) were found in 30 (19.3%) wounded. Reoperation was performed in 25 (16.1%) wounded and total mortality rate was 9.0% (14 wounded).