The Revised "Reconstructive Ladder" for High-Energy War Injuries to the Extremities

We tried to evaluate the merits of the classic "reconstructive ladder" and other reconstructive tools, such as acute shortening followed by distraction osteogenesis and a vacuum-assisted closure device, for the treatment of high-energy war injuries.

We have treated hundreds of patients suffering from high-velocity injuries to the extremities caused by war weapons and blast injuries during the last four and half years. Massive irrigation and immediate thorough soft tissue debridement and hemorrhage control, followed by axial realigning and skeletal stabilization using the tubular external fixators was performed. In all patients, the soft tissue defects were left uncovered after primary radical debridement and locally treated with antiseptic solutions. A second-look procedures and repeated surgical debridement was performed at 24-48 hour intervals. Extensive soft tissue defects at most patients were managed using NPWT, followed by skin grafting. Abdominal skin-fascial flaps were used for only three patients suffered from extensive soft tissue loss on wrist and elbow joints. Temporary acute shortening or shortening with angulation were performed for 12 patients with extensive hard and soft tissue defects. The wounds were successfully closed in all the patients.

We suggest that the classic reconstructive ladder, starting from direct closure and ending with a free flap, should be revised and extended for high energy traumas and include acute shortening with or without angulation, followed by distraction osteogenesis and the VAC system.