Remember the Importance of the Civilian Trauma Mission for Maintaining Surgical Skills relevant to Limb Salvage during a Low-volume Combat Casualty Flow Era

Research Paper Title

Being Prepared for the Next Conflict Part II: Case Analysis of a Military Level 1 Trauma Center.


Combat-related injuries have declined substantially in recent years as we have transitioned to a low-volume combat casualty flow era.

Surgeons must remain actively committed to training for the next engagement to maintain life and limb-saving skills.

Soft tissue coverage procedures were imperative to the management of complex lower extremity trauma that occurred during recent conflicts.

The purpose of this study was to evaluate advanced soft tissue coverage procedures performed on the lower extremity over the previous decade on military and civilian trauma patients at a Department of Defence Level 1 trauma centre to provide data that can be used to guide future training efforts.


The electronic surgical record system was searched for cases that utilised advanced soft tissue coverage (rotational and free flaps) to the lower extremity.

The date of treatment, indication, procedure performed, and military/civilian patient designation were recorded.

The data was categorised between military and civilian cases, rotational versus free flap, and indication and then charted over time.

It was assessed as moving averages over a 12-month period. Statistically distinct periods were then identified.


From January 2006 to March 2015, 132 advanced soft tissue coverage procedures were performed on the lower extremity (100 military, 32 civilian).

Military soft tissue coverage data demonstrated peaks in 2007 and late 2011 to late 2012, averaging 6.5 (3.5-9.6) and 4.5 (3.2-5.8) per quarter, respectively.

There were two low periods, from 2008 to mid-2010 and from mid-2012 to the end of the study, averaging 1.1 (0.6-1.6) and 1.8 (1.1-2.6) cases per quarter, respectively.

Civilian procedures averaged 0.9 per quarter (0.5-1.2) throughout the study, but notably were equal to the number of military procedures by the last quarter of 2013 at 2.0 (1.2-2.8 civilian, 0.8-3.1 military).


This data supports prior identified trends in military cases correlating increased number of procedures with increased combat activity related to the conflicts in Iraq and Afghanistan in 2007 and 2011, respectively.

The data showed relative stability in the numbers of civilian procedures with a slight uptrend beginning in mid-2012.

A comparison after mid-2012 shows military procedures declining and civilian procedures increasing to eventually become equivalent at the end of the data collection.

These trends follow previously reported data on tibia fracture fixation procedures and lower extremity amputations for the same time periods.

These data demonstrate the importance of the civilian trauma mission for maintaining surgical skills relevant to limb salvage, such as rotational and free flaps, during a low-volume combat casualty flow era.


Wood, T.T., Roberts, H.J. & Stinner, D.J. (2020) Being Prepared for the Next Conflict Part II: Case Analysis of a Military Level 1 Trauma Center. Military Medicine. pii: usaa054. doi: 10.1093/milmed/usaa054. [Epub ahead of print].


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