Treatment of combat injuries to major arteries with extensive soft tissue defects

Abstract

Objective – to enhance the treatment outcomes of combat injuries to the lower extremities with damage to major arteries and extensive soft tissue defects by preventing complications and implementing an improved surgical algorithm.

Materials and methods. The study was conducted on a cohort of patients with gunshot and explosive wounds in the femoropopliteal segment of the lower extremities, affecting the major arteries. These patients sustained injuries during combat operations and received treatment at the National Military Medical Clinical Center «Main Military Clinical Hospital» between 2014 and 2024. The cohort was divided into two groups. The main group (n=29) included patients who underwent treatment using an improved surgical algorithm that involved selective use of methods for extra‑anatomic revascularization, ligation of the major arteries (in cases of complications in the reconstruction zone), and active application of rotational fasciocutaneous and muscle flaps to close soft tissue defects in the vascular reconstruction zone. The comparison group (n=41) included patients who received treatment using standard methods that involved staged surgical debridement, NPWT, and staged wound closure. All patients were males aged between 23 and 57, with gunshot wounds to the lower extremities that caused damage to major arteries and extensive soft tissue defects.

Results. The improved surgical algorithm focused on patients with extensive soft tissue defects in the area of the reconstructed artery (> 100 cm²), often accompanied by Gustilo‑Anderson grade IIIC gunshot fractures. The treatment strategy included the following key components: 1) Early wound closure using rotational fasciocutaneous and muscle flaps to ensure reliable coverage of the neurovascular bundle. 2) Extra‑anatomic bypass for complications such as erosion, thrombosis, or progression of infection in the reconstructed artery. 3) Ligation of major arteries followed by active monitoring of limb viability and delayed revascularization when feasible in cases of extra‑anatomic vascular restoration failure. The main group (treated using the improved algorithm) had a significantly higher limb preservation rate than the comparison group (treated with conventional methods), with 82.8% limb preservation and 17.2% amputations versus 53.7% limb preservation and 46.3% amputations, respectively. Statistical analysis using the χ²‑test and Fisher’s exact test confirmed the statistical significance of the improved surgical algorithm in amputation reduction rates (χ²‑test 5.16, p=0.023; Fisher’s exact test p=0.02).

Conclusions. The implementation of an improved surgical algorithm for the treatment of gunshot wounds to major arteries in the lower extremities, accompanied by extensive soft tissue defects, significantly reduced the amputation rate in our study, from 46.3% to 17.2% (p=0.02).