A04 Implementing early limb reconstruction as part of ‘advanced prolonged field care’

Background The emergence of large-scale combat operations (LSCOs), as seen in the Russo-Ukrainian war, challenges conventional limb injury management developed during asymmetric conflicts. 1 In LSCOs, delays in casualty evacuation and surgical care often lead to postponed wound debridement and soft tissue coverage. These delays contribute to high infection rates with multidrug-resistant organisms, compromising limb salvage and functional outcomes. 1 2 To address these challenges, we advocate for damage control orthopaedics (DCO) initiation at Role 1, followed by early limb reconstruction at Role 2/3, within an ‘Advanced Prolonged Field Care’ (Advanced PFC) concept (figure 1). This approach follows as far as possible the structured ‘6/7/8/9’ timeline developed by the French Military Health Service: life and limb salvage within 6 hours, soft tissue coverage by day 7, bone and nerve reconstruction within 8 weeks, and functional restoration within 9 months. 3 4 Prehospital Damage Control Orthopaedics at Role 1 Since it may take up to 24 hours for casualties to reach a stabilization point, wound decontamination must begin at Role 1, under sedation or regional anaesthesia. This includes wound cleaning, marginal debridement with deep irrigation, and specific antibiotic prophylaxis protocols. 5 Fractures can be stabilized non-invasively using plaster splints or improvised skeletal traction. Advanced Prolonged Field Care at Role 2/3 At Role 2/3, DCO continues with further debridement, bacteriological sampling when possible, and temporary external fixation of long bones. 3 Given potential delays of days or weeks before evacuation to higher-level care, early limb reconstruction must begin in forward surgical units, adapting the 6/7/8/9 framework to the advanced PFC context. 4 This strategy is based on three core principles: Aggressive Wound Decontamination Serial marginal debridement every 48–72 hours is the cornerstone of infection prevention, combined with copious saline irrigation. Between sessions, negative pressure wound therapy helps isolate wounds from environmental contamination. Systemic antibiotics should be maintained until skin closure or flap coverage and can be supplemented with local delivery using antibiotic-loaded cement beads. 3 4 Prompt Soft Tissue Coverage Soft tissue reconstruction within 7 days is critical, especially for Gustilo type III B injuries. 6 In forward settings, pedicled flaps are preferred for their simplicity and reliability. They can be combined to address large defects. We demonstrated that orthopaedic surgeons with basic knowledge of local vascular anatomy can safely harvest local, regional, or distant flaps to manage most combat-related defects without requiring microsurgical expertise. 3 4 7 Early Bone Reconstruction To avoid complications associated with prolonged external fixation, early conversion to internal fixation is preferred. In cases of bone loss, the induced membrane technique is the method of choice, using reinforced spacer tactics whenever possible. 3 4 8 A polymethylmethacrylate (PMMA) spacer, reinforced with minimal intramedullary support, is placed during soft tissue coverage to preserve the reconstruction space, provide stability during evacuation, and enable local antibiotic delivery. When PMMA is unavailable, polypropylene syringe bodies can be used as spacers if stable fixation is ensured. 8 Conclusion Preventing infection is key to improving outcomes for limb injuries in LSCOs. This requires adapting conventional approaches by expanding the PFC concept to include DCO at Role 1 and early reconstruction at Role 2/3. With minimal additional training, deployed orthopedic surgeons can apply this protocol. Dedicated training in operational reconstructive surgery is essential to support this pragmatic and cost-effective approach. References Lawry LL, Korona-Bailey J, Kanagaratnam A, Maddox J, Hamm TE, Janvrin M, Juman L, Berezyuk O, Amowitz Z, Schoenfeld AJ, Koehlmoos TP. Qualitative assessment of point of injury to role 2+ combat casualty care in Ukraine. Trauma Surg Acute Care Open . 2025; 10 (2):e001674. Kazmirchuk A, Yarmoliuk Y, Lurin I, Gybalo R, Burianov O, Serhii Derkach S, et al . Ukraine’s experience with management of combat casualties using NATO’s four-tier « changing as needed » healthcare system. World J Surg . 2022; 46 (12):2858–62. Mathieu L, Choufani C, Andro C, de l’Escalopier N. Management of combat-related extremity injuries in modern armed conflicts. Orthop Traumatol Surg Res . 2025; 111 (Suppl 1):104055. Mathieu L, Durand M, de L’escalopier N, Bertani A, Rongieras F, Collombet JM. Challenges and solutions for reconstruction of combat extremity injuries encountered during high-intensity warfare. Eur J Trauma Emerg Surg . 2024; 50 :1183–4. Causbie JM, Wisniewski P, Maves RC, Mount CA. Prophylactic antibiotic use for penetrating trauma in prolonged casualty care: a review of the literature and current guidelines. J Trauma Acute Care Surg . 2024; 97 (Suppl 1):S126–37. Mody RM, Zapor M, Hartzell JD, Robben PM, Waterman P, Wood-Morris R, et al . Infectious complications of damage control orthopedics in war trauma. J Trauma . 2009; 67 :758–61. Mathieu L, Plang S, de l’Escalopier N, Murison JC, Gaillard C, Bertani A, Rongiéras F. Correction to: Extremity soft tissue coverage in the combat zone: use of pedicled flap transfers by the deployed orthopedic surgeon. Mil Med Res. 2021; 218 :4. Mathieu L, Mourtialon R, Durand M, de Rousiers A, de l’Escalopier N, Collombet JM. Masquelet technique in military practice: specificities and future directions for combat-related bone defect reconstruction. Mil Med Res. 2022; 9 :48. Statement and declarations Ethics approval : Not applicable. Consent for publication : Not applicable. Availability of data and materials : Not applicable. Competing interest : The authors declare that they have no competing interest. Funding : There is no funding source. Authors contribution : All co-authors contributed to the writing of the manuscript. Abstract A04 Figure 1 Adaptation of the 6/7/8/9 timeline to the concept of Advanced Prolonged Field Care in high-intensity conflicts. ATB = Antibiotic; Bact. = Bacterial; DCO = Damage Control Orthopaedics; D LS = Limb Salvage; NPWT = Negative Pressure Wound Therapy