title: Current issues with lower extremity amputations in a country at war: experience from the National Military Hospital of Kabul.
abstract: OBJECTIVE
  Management practices associated with war-related amputations in countries at war may be different from the recommendations of occidental Health Force Services due to the high numbers of wounded persons to treat in precarious conditions. This observational retrospective study documents the current management of local lower extremity amputees in Afghanistan. Surgical practices, with or without delayed primary closure (DPC), and prosthetic rehabilitation issues are analyzed.
  
  
  METHODS
  This retrospective study was conducted in the National Military Hospital (NMH) of Kabul from May 2011 to November 2011. Fifty-four Afghan patients who underwent a lower extremity combat-related amputation were included. Ten of them sustained a bilateral amputation.
  
  
  RESULTS
  Injuries were caused by improvised explosive devices (IEDs) or mines in 48 cases, bullets in three cases, and exploding shell fragments in three cases. Of the 64 amputations studied, 46 were open length preserving amputations and primary closure (PC) was applied in 18 cases. Patients were reviewed with a mean follow-up of 5.4 months (range 1-28 months). In the DPC group, secondary closure was performed with a mean time of 18.7 days (range 4-45 days) from injury. The proportion of infectious complications seemed to be higher in the PC group (5/18) than in the DPC group (3/46), but it was only a statistical trend (p = 0.1). Forty-three patients were not prosthetic fitted at the last follow-up.
  
  
  CONCLUSIONS
  This study supports the surgical strategy of a two-stage procedure for lower limb amputations in countries at war, but underlines the problems of late secondary closure and prosthetic fitting related to decreased sanitary conditions.
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Desgenettes Military Hospital, Lyon, France. laurent.mathieu69@yahoo.fr.
authors.forename: L
authors.initials: L
authors.lastname: Mathieu
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Legouest Military Hospital, Metz, France.
authors.forename: A
authors.initials: A
authors.lastname: Marty
authors.affiliation: Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan.
authors.forename: A
authors.initials: A
authors.lastname: Ramaki
authors.affiliation: Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan.
authors.forename: A
authors.initials: A
authors.lastname: Najib
authors.affiliation: Department of Orthopaedic and Trauma Surgery, National Military Hospital, Kabul, Afghanistan.
authors.forename: W
authors.initials: W
authors.lastname: Ahmadzai
authors.affiliation: Afghan National Security Forces, Health System Development, ISAF Joint Command, Kabul, Afghanistan.
authors.forename: D J
authors.initials: DJ
authors.lastname: Fugazzotto
authors.affiliation: Department of Orthopaedic and Trauma Surgery, Percy Military Hospital, Clamart, France.|Department of Surgery, French Military Medical Academy, Ecole du Val-de-Grâce, Paris, France.
authors.forename: S
authors.initials: S
authors.lastname: Rigal
authors.affiliation: National Military Hospital, Kabul, Afghanistan.
authors.forename: N
authors.initials: N
authors.lastname: Shirzai
keywords: Amputation; Combat; Countries at war; Lower extremity
references.citation: Philos Trans R Soc Lond B Biol Sci. 2011 Jan 27;366(1562):219-30
references.pmid: 21149357
references.citation: Plast Reconstr Surg. 2011 Jan;127 Suppl 1:117S-130S
references.pmid: 21200282
references.citation: J R Army Med Corps. 2009 Dec;155(4):265-72
references.pmid: 20397601
references.citation: J Trauma. 2011 Jul;71(1 Suppl):S52-7
references.pmid: 21795879
references.citation: Br J Surg. 1989 Jul;76(7):663-7
references.pmid: 2670049
references.citation: J Trauma. 2011 Jul;71(1 Suppl):S47-51
references.pmid: 21795878
references.citation: JAMA. 2003 Aug 6;290(5):650-3
references.pmid: 12902369
references.citation: J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S438-44
references.pmid: 23192067
references.citation: Med Arh. 2011;65(3):188-90
references.pmid: 21776887
references.citation: Injury. 1996 Sep;27(7):477-9
references.pmid: 8977832
references.citation: J Trauma. 2008 Mar;64(3 Suppl):S211-20
references.pmid: 18316965
references.citation: J R Army Med Corps. 2007 Sep;153(3):172-4
references.pmid: 18200912
references.citation: J Bone Joint Surg Am. 2010 Dec 1;92(17):2852-68
references.pmid: 21123616
references.citation: Int Orthop. 2012 Oct;36(10):1989-93
references.pmid: 22552430
references.citation: Med Trop (Mars). 2011 Dec;71(6):565-71
references.pmid: 22393622
references.citation: Philos Trans R Soc Lond B Biol Sci. 2011 Jan 27;366(1562):204-18
references.pmid: 21149356
references.citation: J Trauma. 2008 Feb;64(2):295-9
references.pmid: 18301189
references.citation: J Bone Joint Surg Br. 2012 Apr;94(4):536-43
references.pmid: 22434472