Serial debridement appropriate for war-wounded amputation patients

Jowan Penn-Barwell

GLASGOW – A British military trauma surgeon presented findings here that support the current practice for the management of unsalvageable war-wounded lower limbs.

The current practice involves maximizing stump length through serial debridement rather than undertaking early amputation, according to Surg Lt Cdr Jowan Penn-Barwell, MRCS, RN.

“The idea is to give the surviving casualty the maximum stump function at the end of the day,” Penn-Barwell said at the 12th Meeting of the Combined Orthopaedic Associations. “When I say end of the day I mean probably in about 18 months time.”

Serial debridement

Penn-Barwell and colleagues performed a regression analysis on data from 51 men with 70 lower limb amputations — 48 of whom sustained their injuries from improvised explosive device blasts.

As part of their research, they sought to determine whether serial debridement was resulting in sequential amputations.

“We were also keen to identify patient groups and characteristics that are identifiable early that would be better managed with a much more aggressive earlier approach,” Penn-Barwell said.” “So perhaps rather than performing a stump salvage [in those patients], we should get in there and do a traditional two-stage amputation and get the patient up and out sooner rather than later, and possibly end up with the same height of amputation as if you had spent 2 weeks performing serial debridement procedures.”

Fungal infections

Penn-Barwell reported that the men in the study underwent an average of 4.1 debridement procedures, and amputation height increased in 30% of the patients.

Fungal infections, particularly Zygomycetes, were found to result in an early return to the surgery, therefore, Penn-Barwell recommended an early aggressive surgical approach in these cases.

“In general, the strategy we use is appropriate. We think that the surgical burden we are placing on both the patients and the medical system is justified in terms of salvaging these stumps, increasing the length, and hopefully by the kinds of outcomes we achieve down the line,” Penn-Barwell concluded, noting that military surgeons should be aware of the dangers of infection in areas where Zygomycota is present.

Reference:

Penn-Barwell JG, et al. Combat lower-limb amputation: the contemporary British military experience. Presented at the 2010 Meeting of the Combined Orthopaedic Associations. September 12-17. Glasgow.

Jowan [Penn-Barwell] looked into how many times we took a patient back for serial debridement procedures, and whether that was detrimental to the patient and whether or not we could identify when it was perhaps better to debride higher, or more, at the time of the injury than successive revisits.

He looked at several aspects, including the nature of the injury, whether a tourniquet was used, and infections. Some of the infections he identified are certainly seasonal, and it is really dependent on where the soldiers are injured, in what situation, and how their evacuation occurs, in my opinion.

Therefore, you cannot say strictly that each person should have x, y and z done to them. It is a variable feat, and that is the problem. Within a military situation, we have to give an overall plan of how a patient like this should be managed. Several of us are going out repeatedly to determine an overall management strategy, and that strategy must be planned and repeated over a significant period of time and considered by experts that have had a lot of experience and looked into these certain aspects in detail.

Jowan’s presentation actually showed us that we are doing the right thing still – that sequential debridement is still the way ahead, which I think is comforting to those of us who have to do this on a regular basis.

– Sarah Stapley, MBChB, FRCS(TR&Orth), DM
Session Moderator

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