Neglected war injuries: Reconstruction versus amputation

INTRODUCTION

War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation.

PATIENTS AND METHODS

From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction.

RESULTS

This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases.

CONCLUSIONS

Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.

Honey dressing: a missed way for orthopaedic wound care

Purpose

Orthopaedic-related wounds are critical situations calling for care to avoid deep infections and its consequences. The purpose of this study was to evaluate the efficacy of using honey for care of orthopaedic-related wounds with limited resources.

Patients and methods

This prospective study included 50 cases with an average age of 38.18 (range 17–63) years with 38 males and 12 females. The most frequent wound location was the leg (41 patients; 82%), then the foot (six patients; 12%), and the ankle in three patients (6%). The aetiologies were open fractures (34 cases; 68%), infected tibial non-unions (nine cases; 18%), and post-operative infections (seven cases; 14%). Exposed tendon was present in three cases. Bone exposure was present in two cases. Deep infection was present in 29 cases (58%). Besides treating the primary cause, a ribbon of gauze soaked with honey was applied to the wounds after thorough saline washing.

Results

Wound sizes were variable. All cases showed improvement in all parameters with complete wound healing and full coverage of bone and tendons. Recurrence of deep infection occurred in three cases and treated by debridement. One case needed sequestrectomy of a small exposed tibial cortical fragment. Exposed tendon cases showed superficial necrosis which was treated by simple debridement. Initial mild itching occurred in five patients with spontaneous resolution.

Conclusion

With treating the underlying aetiology and optimising the patient’s general condition, honey was an effective, simple, and affordable method of wound care in different orthopaedic conditions even with exposed bone or tendons.

Neglected infected floating knee injury: evaluation of closed reduction techniques

PURPOSE

Floating knee injury is uncommon yet challenging problem. The situation is more complicated by presence of infection, open comminuted fractures, and late presentation. The aim of this study was to evaluate the closed reduction techniques by circular external fixation in a single stage to treat patients having infected neglected floating knee injuries.

METHODS

This retrospective study included 19 patients with a mean age of 34.4 years. The average duration from trauma to surgery was 51.1 days. All patients had at least one infected open fracture. According to Fraser's classification, ten injuries were type I, one case was type IIa, four were type IIb, and four were type IIc. Patients were treated by closed reduction techniques using the Ilizarov principles. Orthoplastic procedures were done in four cases in the same surgical setting.

RESULTS

Closed reduction and union were achieved in all cases with control of infection in 17 cases. The follow-up period averaged 41 months. The mean knee flexion was 97.4°. The complications included 5° extension lag (two cases), malunion (three cases), refracture (two cases), and DVT (four cases). The bone results were excellent (12 cases), good (5 cases), and poor (2 cases). The functional results were excellent (two cases), good (seven cases), acceptable (seven cases), and poor (three cases).

CONCLUSIONS

Closed reduction techniques using a circular frame provided a valid treatment option for infected neglected floating knee injuries in one stage without bone grafting. However, the high rate of complications and the diminished knee range of motion should be considered.

Paediatric infected femoral nonunion; mid-term results of a rare problem with a single-stage treatment and up to eleven and half years follow-up

PURPOSE

Nonunion of femur fractures is a devastating disabling complication which is rare in children. The purpose of this study was to report the outcomes of treating infected femur nonunions in children by the Ilizarov fixator in one stage.

PATIENTS AND METHODS

The study included 13 patients with unilateral infected nonunion of the femur with an average age of 9.1 years. The nonunion duration averaged 10.69 months. Ten cases were draining nonunions, and three patients had quiescent sinuses. Associated problems include shortening in all cases (mean 3.5 cm), joint stiffness (9 cases), and angular deformity (7 cases). The quiescent cases were treated by bloodless monofocal compression-distraction. Four draining cases were treated by debridement and compression with relengthening through nonunion site. The remaining six cases were treated by bifocal technique.

RESULTS

The mean follow-up duration was 60.15 months. External fixation period averaged 5.3 months. Successful union was achieved in all patients. Recurrences of infection occurred in two cases including one with refracture and another one with late pathological fracture. Other complications included pin tract infections, one delayed union, two residual angular deformities, and 6 cm residual shortening in one patient. ASAMI bone results were excellent (8 patients), good (3 patients), fair (one patient), and poor (one patient). The functional results were excellent (9 cases), good (3cases), and fair (one case).

CONCLUSIONS

The Ilizarov method provided a viable treatment option for treating paediatric infected femur nonunions in single stage of management with infection control in most cases and satisfactory outcomes.

Treatment of open intraarticular distal femur fractures by Ilizarov fixator; an approach to improve the outcome with mid-term results

PURPOSE

Open comminuted intraarticular distal femur fracture represents a formidable challenge for the orthopaedic surgeon for the inherent fracture complexity, soft tissue damage, and contamination. The purpose of this study was to evaluate the mid-term outcome results and safety of using the Ilizarov fixator to treat these fractures.

PATIENTS AND METHODS

The study included 22 fractures treated by debridement with reduction and stabilization by Ilizarov external fixator. The mean age was 35 years. Gustilo grade of open fracture was III-A (19 cases), III-B (2 cases), and III-C (1 case). Six fractures were AO-OTA type 33C2, and 16 cases were type 33C3. Eight patients had associated injuries. Bone and functional results were evaluated by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria, and Neer knee score. The statistical analysis was done using the IBM SPSS Statistics for Windows.

RESULTS

Seven cases had autogenous bone grafting. The frame crossed the knee in 8 patients. The fixator was removed after a mean of 7 months with union in all cases, and without any malalignment >5°. Deep infection occurred in two cases. Quadriceps-plasty was needed for 3 cases. After a mean of 44 months, the last follow-up results showed full knee extension and a mean flexion of 107.59°. The ASAMI functional and bone results were good to excellent in all cases. Neer knee score averaged 86.59.

CONCLUSIONS

Ilizarov fixator was an effective treatment modality of open comminuted distal femur fractures with high union rate, adequate alignment and satisfactory functional outcomes.

Preliminary Outcomes of Calcaneal Lengthening in Adolescent Flatfoot in Müller-Weiss Disease

BACKGROUND

Müller-Weiss disease (MWD) remains a controversial painful foot condition without consensus on its pathogenesis or a gold standard treatment modality. The aim of the study was to evaluate the outcomes of calcaneal lengthening in adolescent patients with symptomatic MWD with flatfoot.

METHODS

The study included 13 feet of 7 patients including 5 females and 2 males who were treated from March 2012 until June 2015 by calcaneal lengthening. The mean age was 15.6 years. The mean duration of symptoms was 13.5 months. The body mass index (BMI) averaged 28.9 kg/m² at presentation. The patients were followed up for a mean of 37.8 months.

RESULTS

The osteotomy healed in all cases after a mean of 7.2 weeks. The second foot was operated on after an average of 11.5 months. The mean talometatarsal-1 angle improved from 39.8 degrees preoperatively to 5.9 degrees. The mean preoperative calcaneal pitch angle of 7.5 degrees increased to an average of 17.8 degrees postoperatively. The mean American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was improved from 61.9 preoperatively to 94.2 postoperatively. Four patients had occasional exertional pain. Four feet had mild residual forefoot abduction. Arthrodesis was not needed in any case by the last follow-up.

CONCLUSION

Early diagnosis of MWD with flatfoot was important and allowed for nonfusion treatment options. Calcaneal lengthening osteotomy in selected MWD cases achieved satisfactory outcomes with pain control, deformity correction, and improvement of the functional results.

LEVEL OF EVIDENCE

Level IV, retrospective case series.