Reconstructive closure of soft tissue defects in battlefield trauma

Introduction

Following Russia"s full-scale invasion of Ukraine in 2022, the Ukrainian medical service faced major challenges. Extremity injuries in combat trauma account for over 50% of cases, with many complex limb injuries requiring amputation or reconstruction. Treating forearm and shin injuries is challenging due to anatomical constraints and limited soft tissue availability, often leading to infection and delayed bone union. Rapid debridement and defect closure, typically achievable only through flap reconstruction, are essential for optimal outcomes.

Materials and Methods

The sural flap was used to close distal shin defects in 18 patients and foot defects in 4. Proximal shin defects were managed with the medial head of the gastrocnemius in 10 cases and the lateral head in 6 cases. Soft tissue defects in the distal forearm were closed using the SCIP (superficial circumflex iliac artery perforator) flap on a vascular pedicle in 6 patients. In cases with bone defects (14 sural flap, 16 gastrocnemius flap, 2 SCIP flap), the Masquelet technique was employed.

Results

Among the 22 patients closured by sural flaps, necrosis was observed in 2 cases (up to 25% of the flap surface) in distal shin closures, and in foot closures, 50% necrosis in one case and total necrosis in another. Causes included venous stasis and hematoma under the flap. In the 16 patients closured with gastrocnemius flaps, there was 1 case of total necrosis with the lateral head. All 6 SCIP flap cases achieved successful integration without complications.

Conclusions

Reconstructive soft tissue closure is effective but carries risks. These techniques enable rapid defect coverage with functional tissue, support bone healing, and reduce infection risks. Optimal reconstructive choice should be based on the patient"s individual characteristics and the specifics of the defect.

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