https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736%2815%2901063-6.pdf

The medical response to multisite terrorist attacks in Paris

Background. Terrorism, disease outbreaks, and other natural disasters and mass casualty events have pushed health care and public health systems to identify and refine emergency preparedness protocols for disaster response. Ethical guidance, alongside legal and medical frameworks, are increasingly common components of disaster response plans.Objectives. To systematically review the prevalence and content of ethical guidance offered for disaster response, specifically around crisis standards of care (CSCs).Search methods. We systematically indexed academic literature from PubMed, Google Scholar, and ISI Web of Science from 2012 to 2016.Selection criteria. We searched for peer-reviewed articles that substantively engaged in discussion of ethical guidance for CSCs.Data collection and analysis. Researchers screened potential articles for identification and discussion of ethical issues in CSC planning. We categorized and cataloged ethical concepts and principles.Main results. Of 580 peer-reviewed articles ment...

Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review

The optimal time for the second stage is between 4 and 8 weeks.Multiple tissue biopsy specimens must be sent for microbiological analysis during both stages of the procedure.Recurrence of infection requires debridement of the membrane and surrounding soft tissues and reinitiation of the technique (r

Bone Repair Using the Masquelet Technique

Bone Tissue engineering (BTE) has recently been introduced as an alternative to conventional treatments for large non-healing bone defects. BTE approaches mimic autologous bone grafts, by combining cells, scaffold, and growth factors, and have the added benefit of being able to manipulate these constituents to optimize healing. Electrical stimulation (ES) has long been used to successfully treat non-healing fractures and has recently been shown to stimulate bone cells to migrate, proliferate, align, differentiate, and adhere to bio compatible scaffolds, all cell behaviors that could improve BTE treatment outcomes. With the above in mind we performed in vitro experiments and demonstrated that exposing Mesenchymal Stem Cells (MSC) + scaffold to ES for 3 weeks resulted in significant increases in osteogenic differentiation. Then in in vivo experiments, for the first time, we demonstrated that exposing BTE treated rat femur large defects to ES for 8 weeks, caused improved healing, as indicated by increased bone formation, strength, vessel density, and osteogenic gene expression. Our results demonstrate that ES significantly increases osteogenic differentiation in vitro and that this effect is translated into improved healing in vivo. These findings support the use of ES to help BTE treatments achieve their full therapeutic potential.

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Combining electrical stimulation and tissue engineering to treat large bone defects in a rat model.

The induced membrane technique for reconstruction of bone defects has proved its effectiveness and is now widely accepted. The 2 stages procedure, implying a cement spacer in the first stage and a huge bone graft in the second stage, responds to rigorous technical details involving each phase of the procedure. Prerequisites for the technique, cement spacer, bone fixation, time between the 2 stages, grafting, and postoperative course are reported and discussed.

Induced Membrane Technique: Pearls and Pitfalls.

Summary Introduction The treatment of posttraumatic diaphyseal bone defects (BD) calls on a number of techniques including bone transport techniques: isolated shortening, compression-distraction at the fracture site, shortening followed by lengthening in a corticotomy distant from the site and segmental bone transport. Patients and methods The multicenter retrospective study combined 38 cases: 22 cases of initial diaphyseal bone defect and 16 cases of secondary diaphyseal BD, sometimes associated with metaphyseal or metaphyseal-epiphyseal BD, involving the humerus, the forearm, the femur and the tibia. These techniques were mainly used on the lower extremity (33 cases), for the most part on the tibia (22 cases) in young men. Results Bone healing was acquired in 37 cases out of 38 after a mean 14.9 months (range, 6–62 months). A mean 4.3 secondary interventions were required to obtain final union; most notably, a bone graft was necessary at the docking site for the segmental bone transport procedures. Discussion Many reconstruction techniques can be proposed to treat posttraumatic BD. None responds to all situations. Bone transport techniques have their place and their indications. Isolated shortening is intended for bone loss not exceeding 3 cm, notably in the humerus and to a lesser degree in the lower extremity. Shortening associated with lengthening is valuable in the femur and the tibia for bone loss up to 6 cm. Segmental bone transport is the only technique that can treat bone defects associated with shortening in the lower limb. For substantial bone loss beyond 10 cm, segmental bone transport is particularly indicated. However, these cases of substantial bone loss tend to be resolved by a hybridization of the procedures. The distraction gap of a bone segment can, for example, be prepared using an induced-membrane technique. Level of evidence Level IV. Retrospective study.

Bone transport techniques in posttraumatic bone defects

Summary Introduction The purpose of this study was to analyze the use of temporary external fixation within the perspective of a damage control orthopedics attitude in the management of battlefield extremity injuries Hypothesis Damage control orthopaedics (DCO) is a valuable treatment option for easy and rapid limb fracture stabilization in an unfavorable surgical environment Methods Sixteen French soldiers wounded on the battlefield between 2004 and 2009 and managed by damage control orthopedics were included in this retrospective series All patients were males with a mean age of 30 years (20–53 years) Eighteen external fixators were applied on the theater of operations for multiple injuries (five cases), closed fractures of the pelvis or long bones (three cases) and open osteoarticular lesions (ten cases) Results After medical evacuation from original theater, conversion to internal fixation was possible in five cases External fixation was maintained in thirteen cases due to the severity of the lesions or infectious complications Bone union was achieved in all cases The mean time for bone union was 28 months (2 to 3 months) in case of conversion to internal fixation, and 63 months (15 to 17 months) when external fixation was extended To achieve bone union, three devices were removed after a three or four month period and converted to rigid internal fixation associated with bone grafting No case of septic complication was observed after early conversion The only case of post-conversion infection occurred after three months of external fixation After a mean follow-up of 19 months (6 to 49 months) all patients recovered functional autonomy and thirteen could return to duty Conclusion When possible, early conversion from external to internal fixation improves bone union and functional recovery after war limb injuries in properly selected patients Level of evidence Level IV

Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers.

Introduction The composition of a French Forward Surgical Team (FST) has remained constant since its creation in the early 1950s: 12 personnel, including a general and an orthopaedic surgeon. The training of military surgeons, however, has had to evolve to adapt to the growing complexities of modern warfare injuries in the context of increasing subspecialisation within surgery. The Advanced Course for Deployment Surgery (ACDS)—called Cours Avance de Chirurgie en Mission Exterieure (CACHIRMEX)—has been designed to extend, reinforce and adapt the surgical skill set of the FST that will be deployed. Methods Created in 2007 by the French Military Health Service Academy (Ecole du Val-de-Grâce), this annual course is composed of five modules. The surgical knowledge and skills necessary to manage complex military trauma and give medical support to populations during deployment are provided through a combination of didactic lectures, deployment experience reports and hands-on workshops. Results The course is now a compulsory component of initial surgical training for junior military surgeons and part of the Continuous Medical Education programme for senior military surgeons. From 2012, the standardised content of the ACDS paved the way for the development of two more team-training courses: the FST and the Special Operation Surgical Team training. The content of this French military original war surgery course is described, emphasising its practical implications and future prospects. Conclusion The military surgical training needs to be regularly assessed to deliver the best quality of care in an context of evolving modern warfare casualties.

https://militaryhealth.bmj.com/content/jramc/162/5/343.full.pdf

The French Advanced Course for Deployment Surgery (ACDS) called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects.

Purpose
Indications for amputation in natural disasters are not the same compared to our daily practice. They must be determined by those with great surgical experience and good knowledge of military or disaster surgical doctrine. Unfortunately, nowadays few surgeons have this experience. In fact, some volunteer surgeons may be interested in providing care for civilian victims of war or disaster in developing countries. However, there are significant differences between the type and the management of cases seen in this context versus those seen at home. The problems of amputations cannot be solved schematically. Amputation will depend on several factors: the form of warfare or disaster, the conditions for surgery, the skill of the surgical team and the experience of the surgeon, and the length or duration of the mission.

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Extremity amputation: how to face challenging problems in a precarious environment

Purpose
The authors made a retrospective analysis of three triage situations of war wounded in Chad and Rwanda in which mass casualties overwhelmed available medical facilities.

Sylvain Rigal

Papers

Bone transport techniques in posttraumatic bone defects

Damage control orthopaedics in the context of battlefield injuries: the use of temporary external fixation on combat trauma soldiers.

The French Advanced Course for Deployment Surgery (ACDS) called Cours Avancé de Chirurgie en Mission Extérieure (CACHIRMEX): history of its development and future prospects.

Extremity amputation: how to face challenging problems in a precarious environment

Triage of mass casualties in war conditions: realities and lessons learned.