A differentiated approach to comprehensive surgical treatment of combined combat thermomechanical injuries





combined combat thermomechanical injury, perfusion index, syndrome of mutual aggravation of injuries


In recent years, there has been a notable increase in the incidence of thermomechanical injuries, which frequently manifest as a combination of various types of damage. The majority of these injuries require long‑term treatment and result in the development of decompensated (critical) conditions during the early stages, with a substantial death rate ranging from 75% to 80%.

Objective —  to improve the results of surgery for combined combat thermomechanical injuries by developing and implementing a differentiated surgical approach that incorporates the assessment of injury severity within the context of medical support.

Materials and methods. A retrospective‑prospective study was carried out to determine the effectiveness of medical care provided for wounded individuals with combined combat thermomechanical injuries sustained during combat operations between 2017 and 2023. The study included a cohort of 97 wounded individuals, who were subsequently divided into two separate clinical groups. The main group (n=56) underwent treatment according to a differentiated surgical approach that included the assessment of the severity of the patient’s condition using the admission trauma scale (AdTS) and the perfusion index (PI). The control group (n=41) received treatment based on established protocols using conventional treatment approaches for combined combat thermomechanical injuries without considering prioritisation.

Results. A differentiated surgical strategy for managing combined combat thermomechanical injuries, which included an objective assessment of injury severity using the AdTS and the perfusion index (PI), allowed for a notable decrease in the occurrence of late purulent‑septic complications as well as a significant reduction in the mortality rate in the main group to 21.4%, compared to 38.8% in the control group (p=0.038). This was related to a decrease in the frequency of fatal outcomes among individuals with serious injuries: 21.2% in the main group, 37.0% in the control group (p=0.013). Furthermore, surgical treatment improved anatomical and functional outcomes in the main group compared to the control group. Group 1 had a higher specific weight of favourable outcomes 52.0±14.2% and a lower specific weight of unsatisfactory outcomes (17.6), [8.7;28.7] %, compared to group 2 20.6±13.4% and 47.3±14.7%. The difference was statistically significant at p=0.001.

Conclusions. The implementation of a differentiated surgical approach with an objective assessment of injury severity resulted in a reduction in mortality from 7.3% to 1.8%, specific weight of amputations from 34.2% to 8.9%, and contractures from 26.8% to 10.5% (p<0.05). Early vacuum therapy in the surgical treatment of combined combat thermomechanical injuries reduced treatment time and allowed for early reconstructive and restorative operations, leading to better functional outcomes. The specific weight of favourable outcomes increased from 20.6% to 52.0%, while the relative number of unsatisfactory outcomes decreased from 47.3% to 17.6% (p<0.05).




Bukowski J, Nowadly CD, Schauer SG, Koyfman A, Long B. High risk and low prevalence diseases: Blast injuries. Am J Emerg Med. 2023 Aug;70:46-56. http://doi.org/10.1016/j.ajem.2023.05.003. Epub 2023 May 5. PMID: 37207597.

Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, Dubose JJ, Fox EE, Inaba K, Rodriguez CJ, Holcomb JB, Duchesne JC. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2017 Mar;82(3):605-617. http://doi.org/10.1097/TA.0000000000001333. PMID: 28225743.

Clemens MS, Janak JC, Rizzo JA, Graybill JC, Buehner MF, Hudak SJ, Thompson CK, Chung KK. Burns to the genitalia, perineum, and buttocks increase the risk of death among U.S. service members sustaining combat-related burns in Iraq and Afghanistan. Burns. 2017 Aug;43(5):1120-1128. http://doi.org/10.1016/j.burns.2017.01.018. Epub 2017 Apr 21. PMID: 28438352.

Ghosh S, Kulkarni S, More N, Singh NK, Velyutham R, Kumar NR, Kapusetti G. Cellulose-based bioabsorbable and antibiotic coated surgical staple with bioinspired design for efficient wound closure. Int J Biol Macromol. 2023 Sep 1;248:126477. http://doi.org/10.1016/j.ijbiomac.2023.126477. Epub 2023 Aug 26. PMID: 37640182.

Greydanus DJ, Hassmann LL, Butler FK Jr. Quality Assurance in Tactical Combat Casualty Care for Medical Personnel Training 16 April 2020. J Spec Oper Med. 2020 Summer;20(2):95-103. http://doi.org/10.55460/T63H-3OXX. PMID: 32573744.

Gurney J, Tadlock MD, Cancio LC. Burn Injuries from a military perspective. Current Trauma Reports. 2022;8(3):113-126. https://doi.org/10.1007/s40719-022-00232-6.

Huang CH, Tsai CS, Tsai YT, Lin CY, Ke HY, Chen JL, Tzeng YS, Liu HH, Lai CY, Hsu PS. Extracorporeal Life Support for Severely Burned Patients with Concurrent Inhalation Injury and Acute Respiratory Distress Syndrome: Experience from a Military Medical Burn Center. Injury. 2023 Jan;54(1):124-130. http://doi.org/10.1016/j.injury.2022.08.063. Epub 2022 Sep 7. PMID: 36163205; PMCID: PMC9448699.

Janak JC, Clemens MS, Howard JT, Le TD, Cancio LC, Chung KK, Gurney JM, Sosnov JA, Stewart IJ. Using the injury severity score to adjust for comorbid trauma may be double counting burns: implications for burn research. Burns. 2018 Dec;44(8):1920-1929. http://doi.org/10.1016/j.burns.2018.03.012. Epub 2018 Sep 17. PMID: 30236816.

Kauvar DS, Wolf SE, Wade CE, Cancio LC, Renz EM, Holcomb JB. Burns sustained in combat explosions in Operations Iraqi and Enduring Freedom (OIF/OEF explosion burns). Burns. 2006 Nov;32(7):853-7. http://doi.org/10.1016/j.burns.2006.03.008. Epub 2006 Aug 8. PMID: 16899341.

Perez KG, Eskridge SL, Clouser MC, Cancio JM, Cancio LC, Galarneau MR. Burn injuries in US service members: 2001-2018. Burns. 2023 Mar;49(2):461-466. http://doi.org/10.1016/j.burns.2022.03.011. Epub 2022 Mar 23. PMID: 35400523.

Penn-Barwell JG, Roberts SA, Midwinter MJ, Bishop JR. Improved survival in UK combat casualties from Iraq and Afghanistan: 2003-2012. J Trauma Acute Care Surg. 2015 May;78(5):1014-20. http://doi.org/10.1097/TA.0000000000000580. PMID: 25909424.

Reda F, Kjartansson H, Jeffery SLA. Use of Fish Skin Graft in Management of Combat Injuries Following Military Drone Assaults in Field-Like Hospital Conditions. Mil Med. 2023 Nov 3;188(11-12):e3377-e3381. http://doi.org/10.1093/milmed/usad028. PMID: 36794813; PMCID: PMC10629988.

Kronstedt S, Boyle J, Fisher AD, April MD, Schauer SG, Grabo D. Male Genitourinary Injuries in Combat - A Review of United States and British Forces in Afghanistan and Iraq: 2001-2013. Urology. 2023 Jan;171:11-15. http://doi.org/10.1016/j.urology.2022.07.018. Epub 2022 Jul 23. PMID: 35882303.

Tien H, Beckett A, Garraway N, Talbot M, Pannell D, Alabbasi T. Advances in damage control resuscitation and surgery: implications on the organization of future military field forces. Can J Surg. 2015 Jun;58(3 Suppl 3):S91-S97. http://doi.org/10.1503/cjs.001815. PMID: 26100784; PMCID: PMC4467505.

Tien H, Beckett A. Medical support for future large–scale combat operations. Journal of Military, Veteran and Family Health. 2022;8(2):18-28. https://jmvfh.utpjournals.press/doi/10.3138/jmvfh-2022-0006.

Zheng XF, Zhu F, Fang H, Xu DY, Xu L, Chen TS, Zheng YJ, Xiao SC, Xia ZF. Management of combined massive burn and blast injury: A 20-year experience. Burns. 2020 Feb;46(1):75-82. http://doi.org/10.1016/j.burns.2018.11.010. Epub 2019 Dec 15. PMID: 31852619.






Original Research