# Extremity and Mandibular Reconstruction After Gunshot Trauma—Orthoplastic Strategies from Five Years of Humanitarian Missions in a Resource-Limited Setting

## TL;DR

This paper describes successful orthoplastic surgery techniques used in a war-torn region with limited resources to treat gunshot injuries.

## Contribution

The study demonstrates the feasibility of microsurgical reconstruction in conflict zones with scarce infrastructure.

## Key findings

- Free and pedicled flaps were used effectively for extremity and mandibular reconstruction in 98 patients.
- Microsurgical complications occurred in 18.4% of cases, primarily in fibula transfers.
- Early clinical outcomes were good or acceptable in over half of the patients.

## Abstract

Background: Surgical care in conflict regions like Tigray, Ethiopia, faces severe challenges due to limited resources, infrastructural deficiencies, and high trauma burden. From 2019 to 2023, a multidisciplinary team conducted five humanitarian missions focusing on orthoplastic reconstruction of extremity and mandibular injuries from high-energy gunshot trauma. Methods: A retrospective analysis was performed on 98 patients who underwent free or pedicled flap reconstruction. Data included demographics, flap type, technique, complications, follow-up, and early clinical outcomes score as well as mobility scores. Flaps were harvested using loupes anastomosis performed using microscopes, depending on availability. Results: Among 98 patients (25.5% female, 74.5% male), 69 free flaps and 38 pedicled flaps were performed. Free fibula flaps (n = 54) included 33 mandibular and 21 extremity reconstructions. Additional flaps included ALT, gracilis, and LD flaps. Pedicled flaps included 18 fibula and 20 ALT/LD flaps. Mean age was 35.5 years; mean operative time was 429.5 min, with mandibular fibula transfers being longest. Microsurgical techniques were used in 34% of cases. Median follow-up was 10 months. Microsurgical complications occurred in 18.4%, mainly in fibula transfers (25.9%). Non-microsurgical issues included wound infections (n = 15), graft loss (n = 3), and bleeding (n = 5). Flap loss occurred in 16.3% overall. Early clinical outcome results were good (30.6%), acceptable (28.6%), and moderate (24.5%). Conclusions: Orthoplastic reconstruction using both free and pedicled flaps is feasible in low-resource, conflict settings. Despite infrastructural challenges, functional outcomes were achievable, supporting the value of adaptable microsurgical strategies in humanitarian surgery.