Fatimah Ghalib Mahdi Al-Najjar

Department of Surgery, College of Medicine, University of Wasit Al-Kut, Wasit Governorate, Iraq

Abstract

Background: The long history of war in Iraq has created a high level of high-blast upper limb trauma that
necessitates a complicated reconstruction process. The tissue defects resulting with improvised explosive
devices and other munitions require solid wound coverage to maintain limb viability and functionality.
Free tissue transfer is not always possible in resource-limited health care settings like Baghdad Medical
City, thus pedicled local flaps is the main mode of reconstruction in healthcare.
Objectives: To compare the clinical outcomes, functional recovery, and resource efficiency of local flaps
reconstruction of upper limb soft tissue defects caused by blast injuries, and treated over seven years at a
national tertiary referral centre in Iraq.
Methods: A retrospective cohort study was carried out in Ghazi Al-Hariri Hospital of Surgical Specialties
(GAHHSS), Baghdad Medical City in January 2017 to December 2023. One hundred and twenty-two
(112) patients who met pre-specified criteria of inclusion were enrolled. Standardised data extraction
involved demographics, injury severity (Gustilo-Anderson classification), flap, and postoperative
outcomes. At three and six months, functional recovery was measured by means of the Arabic version of
Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The flap choice was controlled by the
a priori institutional algorithm, based on the anatomical zone and the size of defects. IBM SPSS v28.0
was used to conduct the statistical analysis; Chi-square and Fisher exact tests were used to compare
categorical variables, and multivariate logistic regression was used to determine independent predictors
of flap failure (significance level p < 0.05).
Results: In 112 patients (mean age 27.6 9.3, 92.0% males), improvised explosive devices were the cause
of 69.6 percent of injuries. The commonly injured area was the dorsum of the hand (33.0%), then forearm
(28.0%), and wrist (24.1). Eight different local flap methods were used; the most commonly used ones
were the dorsal metacarpal artery flap (25.9%), and the radial forearm adipofascial flap (19.6%). The total
survival rate of people at the flaps was 91.1%. Infected wound cases were 8.0 per cent and re-operation
9.8. The average DASH score increased significantly between three months and six months (28.4: 11.2
and 19.1: 9.8) (p = 0.001). Two out of three patients (67.9) went back to pre-injury activities in six months.
Local flaps took significantly less operative time (102 vs. 385 minutes), shorter intensive care unit (0.4
vs. 3.2 days) and cost per case (420 vs. 2850) than free tissue transfer.
Conclusions: Local pedicled flaps, when chosen and utilized in a guided anatomical procedure, result in
the same results that are presented in high-income systems and give incontrovertible logistical and
economic benefits in resource-constrained systems. The wider implementation of this algorithm in local
trauma departments and the inclusion of this algorithm into the national surgery education programs are
highly advised.

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