Introduction:
The 274^TH Forward Surgical Team (ABN) was deployed to Iraq in support of Operation Iraqi Freedom from 14 October 2005 through 3 October 2006. During that period the FST was deployed to Tall Afar in support of 3^rd Armored Cavalry security and counterinsurgency operations and also as an augmentation element for the 47^th Combat Support Hospital in Mosul Iraq. FST providers had extensive opportunity to utilize a broad spectrum of SILVERLON dressing products. The purpose of this report is to summarize the various clinical applications and experience with these products. This series of case reports is not a product endorsement by the author, or an endorsement or representation of the opinions or policies of the United States Army or the Army Medical Department.

Silverlon Dressing Product Experience:
The 274^TH FST (ABN) was provided with a generous sample quantity of Silverlon dressing products for field trial during its deployment to Iraq from October 2005 to October 2006. The paucity of conventional FST deployment missions within the theater initially, proved for limited application and opportunity to test the products. Therefore, the majority of the products were used at the 47^th Combat Support Hospital (CSH).

Initially, the Silverlon products were used almost exclusively by the FST Surgeons. The largest initial utilization was for the drains and packing material and initial utilization by some CSH surgeons was met with skepticism. When it became clear that the outcomes of operative cases in which the Silverlon dressings were used, results appeared more favorable, most of the surgeons also began to use the Silverlon dressings.

Surgeons who utilized the appropriate Silverlon dressings, witnessed fewer complications, fewer returns for infections, and higher rates of graft success that those of surgeons not using the products.

By the end of the first 6 months, the majority of CSH surgeons were using the products, experimenting with creative and unique applications and the 47^th CSH began ordering additional products. Six months into the deployment, all of the PROFIS surgeons rotated back to the United States and new surgeons arrived. Initially, the new providers expressed the same hesitations and reluctance to try products with which they were unfamiliar, but superior outcomes once again won the confidence of these new providers.

Overall results demonstrated no complications related to the products. There were no incidences of skin pigmentation, no returns to the operating room for recurrent infection or abscess in cases where Silverlon products were used. Wound care on the wards was immensely simplified and the demands on nursing staff for traditional Silvadene and dry gauze dressing changes were significantly reduced. Skin graft success in cases dressed with Silverlon produced consistently higher percentages of first time graft success than in cases where Silverlon was not used.

Silverlon Cases
The following are but a few of the applications and cases that reflect innovative and routine applications and the success of the Silverlon products. These are all cases performed by the author of this document. The situation, resources and operational tempo of the combat medical treatment facility were not conducive to meticulous record or data collection. Frequently, patients had to be evacuated to other facilities, which made long term follow-up frequently impossible. Hence, no claims are made here of scientific or statistical analytical significance.

Although long term follow-up was not possible in many of the cases due to the nature of surgical outcome assessment in a combat environment, these results of these cases were deemed to be empirically favorable and typical of the outcomes experienced by other surgeons.

Case One
This 24 year old active duty US Soldier sustained a gunshot wound to his left arm without fracture or neurovascular injury near Mosul Iraq. He sustained 70 percent transection of his biceps at the exit wound.

The wound was debrided, irrigated and the skin edges were re-approximated with a vessel loop "Jacob's ladder" over a Silverlon packing strip as a drain.

48 hours later, he was returned to the operating room for repeat irrigation and repair of the biceps muscle transaction. Skin edges were again re-approximated with vessel loops, the wound dressed with a Silverlon 2X4 inch dressing, and splinted in flexion.

Completed biceps muscle transection repair.

He was subsequently evacuated to Landstuhl Medical Center where he underwent repeat irrigation and uncomplicated delayed skin closure. He recovered full function and motion in 12 weeks without complication or limitation. His full story was also published in the May 2005 issue of "SOLDIER" magazine.

Case Two
This is a similar case of a 29 year old Iraqi Soldier who sustained a nearly complete triceps laceration from IED shrapnel in Tall Afar Iraq. His wound was acutely irrigated; debrided and the wound was partially closed with a vessel loop "Jacob's Ladder" over a Silverlon packing strip as a drain.

Uncomplicated Triceps repair and delayed wound closure

He underwent uncomplicated repair of the triceps muscle transection and delayed primary closure at 48 hours over a vessel loop drain and was evacuated to Landstuhl Germany and eventually back to CONUS. He experienced eventual complete recovery by 12 weeks without limitation.

Case Three
This 22 year old male active duty enlisted Soldier underwent incision and drainage of a postero-medial thigh abscess of uncertain etiology by a General Surgeon at the 47^th CSH in Mosul Iraq. The wound was irrigated and packed with Iodoform gauze and the patient was discharged. He returned in 48 hours and had the packing removed and the provider closed the wound with staples. The patient subsequently presented to the clinic in 10 days as instructed, for removal of the staples at which time the wound dehisced and a copious amount of purulent discharge was expressed.

Wound with Silverlon drain and Jacob's ladder

The wound was meticulously debrided in the OR and the wound was dressed with Silverlon packing material as a drain with a vessel loop "Jacob's ladder" tension closure.

The patient was returned to the OR in 48 hours and underwent repeat irrigation and uncomplicated wound closure after intra-operative Gram stain revealed no organisms. Cultures and sensitivities were not available in theater without a 3 week turn-around of specimens sent to Germany. His wound healed completely without further complication. He returned to full duty without limitations following 2 weeks of convalescence in Qatar.

Clean wound at the time of delayed primary closure, after Jacob's ladder removal.

Case Four
This 29 year-old Iraqi Army recruit sustained shrapnel injuries and burns in a suicide bomber attack on a recruiting station in Al Kisik Iraq. He sustained penetrating injuries with second and third degree burns. He underwent repeat irrigation and debridement of the lower extremity with Silverlon packing of the deep wounds and Silverlon burn dressings every 48 hours until the wounds could be managed by closure and in the out patient environment.

Blast inflicted shrapnel wounds and burns to the right lower extremity.

Fragments of shrapnel, clothing, human teeth, bone, skin and hair from the suicide bomber were repeatedly removed from the wounds during the three successive operative explorations with irrigation and debridement. All of his wounds were permitted to close by secondary intention.

Tissue and "foreign bodies" debrided during the serial procedures. The picture on the right includes a piece of the suicide bomber's mandible with an intact molar.

The outpatient course was managed with moist Silverlon burn dressing strips over-wrapped with I.C. sports wrap to maintain the moisture in the dressings. These were changed in the clinic every 3 days. The patient recovered fully in 8 weeks with out complication.

Case Five
A 32 year old Iraqi Army Soldier sustained penetrating blast injuries from an Improvised Explosive Device in near Tall Afar. He sustained grade 3 highly comminuted open fibula and tibial fractures with clinical evidence of compartment syndromes of the lateral and posterior compartments necessitating fasciotomies through the traumatic penetrating wounds. His fractures were reduced, stabilized, irrigated and debrided after resuscitation. He was subsequently returned twice to the operating for repeat irrigation and debridement with delayed primary closure at the time of the third procedure.

Traumatic wound after fasciotomies and initial debridement; subsequent primary wound closure following third irrigation and debridement at 48 hour intervals.

Healing wound dressed with large Silverlon Island dressing changed daily with pin care.

His post-operative course was uneventful and he was subsequently evacuated to an Iraqi medical facility in Dohuk 10 days after his injury, and was subsequently lost to follow-up.

Case Six
This 22 year old right hand dominant active-duty American Soldier sustained bilateral crush injuries to both hands in a roll-over HUMVEE accident in Mosul. Hen he grabbed the top of the armored plates on his turret instead of the safety handles inside of the turret, sustaining a complete amputation of his right hand proximal to the mid-palmar crease, as well as a near amputation of his left thumb through the thenar region.

Due to extensive crushing, neurovascular avulsions, contamination of the amputated hand compounded by a paucity of appropriate microscopic equipment, no attempt was made to replant the amputated part. The right hand was debrided and dressed with Silverlon and splinted; the left thumb injury was structurally reconstructed and provisionally stabilized with k-wire fixation. He was evacuated out of theater within 36 hours of injury.

Amputated portion of the right hand.

Mid-palmar amputation site of right hand.

The right hand following debridement and irrigation. The wound margins have been re-approximated with Jacob’s ladder vessel loops and dressed with 2 X 2 inch Silverlon fabric dressings, followed by compressive dressings and a splint.

Near amputation of the left thumb through the thenar region of the hand.

The left hand injuries were repaired after debridement and the wounds left open and dressed with Silverlon after fixation of the thumb metacarpal with k-wires. This Soldier was sent to the Amputee Center at Walter Reed Army Medical center where he has continued to recover from the devastating injuries. According to reports from his family he has recovered full function of his left hand and thumb and is working with several potential prosthetic options for his right hand as he struggles through post-traumatic stress issues.

Case Seven
This 35 year old Iraqi Policeman sustained penetrating and blast trauma to his chest, pelvis, abdomen, scrotum and shrapnel wounds to all four extremities during a suicide vest bomber attack on his checkpoint in Mosul Iraq. He had stopped two insurgents in a vehicle at his checkpoint. Both were posing as police officers and when he confronted them for proper identification, the drive got out of the car and ran away. The passenger got out of the car and exposed his suicide vest. This Iraqi policeman immediately positioned himself between the suicide bomber and his fellow police officers before the bomber detonated the vest. His courageous actions saved the lives of all of his comrades. His injuries were further complicated by second degree burns to 55 percent of his body, including his face and predominantly anterior body surfaces. Unfortunately, his heroism nearly cost him his life. After 12 different surgical procedures and nearly 4 weeks in intensive care, he ultimately recovered; after losing his left eye, right testicle, a finger and portions of both ears and his nose.

Extensive penetrating, blast and burn injuries inflicted by a suicide vest bomber's attack.

Iraqi Policeman victim of a suicide vest bomber.

Bilateral hand blast and burn injuries; the left middle finger required amputation.

Silverlon glove and burn dressings worked superbly without any complications or graft failures on the upper extremities with 100% graft success. Unfortunately, the General Surgeons did not use the Silverlon on his other skin grafts. He subsequently lost 70% of those skin grafts to infection and sepsis, requiring subsequent repeat grafting

Immediate post-debridement appearance and dressings prior to the application of Silverlon gloves.

Appearance of hands 48 hours after initial debridement. Note the dramatic reduction in edema following the Silverlon applications.

The left wrist laceration was covered with split thickness skin graft which integrated fully and healed under Silverlon dressings.

Long term follow-up was not possible for this patient after he was transferred to the Iraqi National Medical Center in Baghdad for long term care.

Case Eight
This 69 year old male Iraqi civilian sustained this 50 caliber gunshot wound when he ignored warning signs at a security check point and drove out of control into the side of a Stryker fighting vehicle. He underwent immediate irrigation and debridement and amputation of his non-viable thumb and index finger. He was dressed in modified Silverlon gloves and healed completely within 3 weeks. He was seen in a remote clinic 12 weeks after injury and had excellent function. Unfortunately, I did not have my camera at that time to take final outcome pictures. Additionally, the Occupational Therapist, fabricated an Auqua-plast hand-based thumb post prosthesis that afford him a functional post against which to oppose against. This provided him suitable function for picking up objects with his injured non-dominant hand.

50 caliber gunshot wound to a left hand before and after.

Case Nine
This 47 year old Iraqi Army Major sustained multiple gunshot wounds in an ambush on his vehicle by insurgents in Tikrit. He initially underwent multiple lifesaving surgeries at the 47^th Combat Support Hospital in Tikrit, with debridement of his complex right hand injury. He was subsequently transferred after stabilization north to the 47^th CSH element in Mosul for attempted reconstruction of his hand.

Right dominant hand injury at initial presentation in Tikrit. His entire thumb metacarpal was gone but he had intact sensation and palmar vascularity. The metacarpal was reconstructed with iliac crest graft harvested through the same incision as the abdominal flap for soft tissue coverage of thenar defect

Right thumb appearance at the time of abdominal flap takedown and flap closure at two weeks.

Major Talal 9 weeks after his injury is pain free and has 15 degrees of IPJ motion (MPJ and CMC were fused to graft) and improving with motivational assistance provided by his Occupational Therapist Captain Sarah Mitsch.

The abdominal flap was taken down, contoured and inset at two weeks. The flap "tube" and the flap itself were dressed with moist Silverlon fabric dressings and changed once daily. Silverlon dressings were continued until all of the sutures were removed (by approximately 2 weeks after flap take down). The metacarpal graft pin was removed at 6 weeks.

Case Ten
This 24 year old Iraqi Army Soldier sustained bilateral lower extremity penetrating trauma from a vehicle born improvised explosive device (VBIED) near Sinjar Iraq. He sustained a grade 3 open right tibial fracture with penetrating trauma and complex fractures to both feet. He had a left foot injury that was originally felt to require amputation; however the author of this paper argued for preservation of the extremity due to intact sensation and the presence of the complex fracture of the contra-lateral extremity.

Primary reduction and stabilization of the comminuted right tibial fracture was achieved with external fixation and vessel loop closure over a Silverlon drain

Subsequent delayed primary wound closure over Iliac crest bone graft and dressing with Silverlon island dressings.

Right foot penetrating trauma after irrigation, debridement and insertion of Silverlon drains.

The patient underwent serial irrigation and debridement every 48 hours with progressive wound reduction and eventual closure of all of his wounds, using the vessel loop tension closure "Jacob’s ladder" technique. Silverlon drains were used in the early phases of wound management. Subsequently, the right Tibia was grafted with Iliac crest bone graft and the residual left lateral heel wound was closed with full thickness defatted skin graft which healed completely under Silverlon island dressings after initial Wound-VAC over inlayed Silverlon fabric placed under the vacuum sponge.

Right foot after delayed primary closure of all wounds

Complex left foot wound with loss of the 5th metacarpal and portions of the cuboid and lateral calcaneous.

Silverlon fabric dressing material was laid into the wound and covered with a Wound-VAC sponge.

Early in our experience we used the Silverlon fabric dressings under wound vacuum dressings and subsequently began using the webbed digital dressings that were split and permitted exudate drainage under suction. The CSH subsequently ordered the Silverlon Wound VAC dressings, but they arrived just prior to my departure from theater in October 2006 and I did not have opportunity to use them. The patient recovered remarkably and was well on his way to a solid tibial union at follow-up twelve weeks after his initial injury (no pictures of wounds were taken).

The patient (second from left) is 12 weeks after his initial injury is ambulating independently with partial weight bearing on crutches. He is standing to the right of his Physical Therapist, Captain Coy Judd.

Miscellaneous clinical applications
The combat environment presented numerous opportunities for out-patient and emergency room procedural applications of the Silverlon products. It also provided opportunities for innovative utilization as well.

This US Army 1LT sustained an open right great toe distal phalanx fracture and nail bed laceration which the author repaired under local anesthesia in the Troop medical clinic in Tall Afar Iraq. Note that the author is also wearing a black Silverlon T-shirt!

This US Soldier had left hand extensor tendon repairs after sustaining lacerations when he fell into concertina wire. The wounds were closed primarily after irrigation with vessel loop drains (removed at 24 hours) and were dressed with the Silverlon digital dressings.

This young Iraqi Soldier presented to the CSH ER with combination superficial shrapnel and burn injuries that responded well to improvisational hybrid therapy. In this case, Silvadene ointment was applied to first degree burn areas and Silverlon to the second degree burns and penetrating wounds. The sterile surgical gloves permitted early range of motion, ADLs and therapy and kept the Silverlon dressings moist. We were not able to locate the Silverlon gloves at that time.

This 32 year old Iraqi Solider sustained second degree burns to his right upper extremity, face, neck and right chest wall and inhalation injuries when the bus in which he and 42 other Iraqi Soldiers were riding back to their base near Que West Iraq was hit by an IED. The fuel tanks on the bus were ingnited by the blast and 18 Soldiers were killed.

Silverlon burn burn dressing applied to right upper extremity second degree fuel burns.

He underwent debridement of his burns and his right upper extremity burns were dressed with Silverlon burn dressings and over-wrapped with Kerlex moistened with sterile water and covered with IC wrap. His dressings were changed daily. His upper extremity burns healed faster and with less scarring, even though more severe, than his chest wall burns, which were treated with conventional dry dressings and Silvadene. Once stabilized, he was transferred to Baghdad where he is reported to have subsequently recovered.

There were dozens of undocumented anecdotal success stories for small wounds and injuries using the Silverlon Band-Aids. I personally used them when I fell in the dark onto sharp gravel and split my right palm open. It was a wound that should have been sutured, but I merely washed it out and applied the Silverlon Band-Aids and over-wrapped them with Coban to keep them in place. I scrubbed normally and continued to operate with double gloves. I had absolutely no pain with the Band-Aids in place and the wound healed fully in 10 days.

One of the senior general surgeons for the CSH also sustained a finger laceration and was similarly impressed with the Band-Aids when he used applied them on his finger. Because of this and his experience with the other Silverlon products, he supported and authorized the order and acquisition of additional products to replace what had been provided by the FST, to sustain the product volume at the CSH.

It was noted that the plastic band-aids tended to cause maceration and did not adhere well for very long. Therefore, it might be worthy to suggest re-fabrications them with flexible adhesive cloth or at least the same type of tape as the island dressings.

Discussion and Recommendations
During the 12 month deployment of the 274^th FST, we depleted approximately 75 percent of the inventory of the Silverlon product that were given to us. The large majority of the product was used in cases performed at the 47^th Combat Support Hospital in Mosul Iraq. The experience with the product at the 47^th CSH was impressive and the products were ordered to sustain inventories. In all cases, no adverse effects were noted and results were consistently impressive. The use of the Silverlon products immensely simplified dressing changes, decreased staff requirements, reduced soft tissue edema and patient discomfort.

The over-wrapping of the Silverlon by occlusive coverings like the IC wrap proved a useful addition in keeping the Silverlon dressings moist and active longer. In those cases where over-wrap was not used, the dressings were kept moist with mist bottles of sterile water.

It was also appreciated that the meshed finger dressing fabric when split, served as an ideal dressing over small wounds, skin grafts and under wound vacuum dressings as they provided better drainage and less adhesion to the tissue and grafts than the tighter knit burn fabric dressings. It is our recommendation that consideration be given to also manufacturing sheet dressing applications with this fabric as well, especially for skin graft coverage.

Additionally, I believe that gloves fabricated, if possible, with this or a similar fabric would provided better fit and compression for hand injury and burn applications, than the regular burn fabric. Our supply of gloves was depleted rapidly and it took quite a while to get those back in once ordered. However I think that this was more reflective of Army Medical logistics problems, than provision from the company.

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