Clinical guidelines for complex extremity war wound management: update and consensus using a mixed-method approach

BACKGROUND: Extremity trauma is a common and significant injury sustained by military and civilian casualties of war. Civilian management has evolved, adopting a multidisciplinary orthoplastics approach. Accurate and timely management of open fractures and complex war wounds is required to minimize complications and optimize outcomes. The Lower Limb Debridement for Operations Working Group is part of the UK Defence Medical Services and aimed to provide updated guidelines to support deployed surgeons, given the modern nature of conflict. METHODS: The working group formed a panel of military consultants (attendings) in Trauma and Orthopaedics and Plastics and Reconstructive Surgery. The literature was systematically reviewed for new evidence. A modified Delphi technique was adopted, and an initial survey was circulated to the working group to gain its opinion on current guidance. Responses were used by the steering group chairs to formulate updated guidance on combat wound management. A consensus meeting with consultants (attendings) was then used to agree the final guidance. RESULTS: Eight previous recommendations were removed and 21 new recommendations were formed, providing updated guidelines. Recommendations relate to timing, location, and technique of wound excision including irrigation and requirements for wound closure. CONCLUSIONS: Civilian and military combat casualties require well prepared surgeons and evidence-based guidance to save life and limb. These recommendations represent a consensus, utilizing up-to-date literature and expert opinions of both orthopaedic and plastic surgeons. In large-scale combat operations, NHS surgeons working in the UK may be required to treat large numbers of patients repatriated from conflict. These guidelines may form a useful part of their preparation.