Secondary Limbs Reconstruction in Military Injuries from the Libyan Front
I would like to thank the organized committee of the congress, first, for the honorary invitation, to give this lecture here to Barcelona.
The war injuries are not common. The management includes the Emergency Care, the Primary treatment, the Reconstruction, the Rehabilitation, and, it is very important, the Psychiatric Support. The emergency care required the blood loss control, the surgical debridement, and the infection control. The Tourniquet use is one of most promising lifesaving military achievements, which can lead to the dramatic decrease in mortality rates of injured service members.
The War injuries survival rate depends from the historic period. In the World War II was 70.7%. Forty – Fifty years later in the IRAQ and AFGANISTAN war improved to 87.7% up to 92%, as M. BOSSE reported in 2012.
The war limbs injuries are high energy trauma. They have extensive soft tissue loss, osseous destruction, vascular and neural damage and serious infection. All these lead to high amputation rate.
The aim of treatment includes the preventing, the wound infection and gangrene, the reducing the amputation rate, and the increasing the functional outcome.
The role of the orthopaedic surgeon is to manage the infection, the bone fracture and bone loss, the nerve laceration and loss, the complex injuries, and the post – traumatic arthritis.
The role of MICROSURGERY is very important for the treatment of those complex injuries.
Between 2011 and 2013, in the Athens Medical Group, the major private group in Greece, with 6 hospitals in Athens and Salonika, more than 3500 injured people from the Libian front, were treated with several problems. From these, more than 600 patients with injuries in the limbs were treated by our department, the Hand, Upper Extremity and Microsurgery Unit, of the Athens Medical Center. From them, 581 were male, with average age 28 Y.O. (range 4-70), and 24 were female with average age 30 Y.O. (range 5-65).
There were two group pf patients. In the first group the emergency care was performed in LIBYA, and the primary treatment and reconstruction surgery in GREECE. In the second group emergency care was performed in LIBYA, the primary treatment in TUNISIA, EGYPT and TURKEY and the secondary reconstruction in GREECE. The emergency care and the primary treatment in the most of the cases were evaluated from acceptable to excellent!!! Only in a few cases had fair or poor outcome.
The main problem of the treatment was that the majority of the patients was lost for Follow-Up!!! Only in a few cases is known the final result!
The cases that we operated in our department were as showed on the slide: Nerve injuries 92, Hand injuries 86, Elbow injuries 38, Fractures 85, Bone loss 34, Plexus injuries 11, Infection 96, Foreign bodies 78 and others 85.
The treatment algorithm was the evaluation of the main problem, first. The infection management, and if possible the one stage procedure was followed. Finally the early rehabilitation was very important for the best outcome.
The infection was one of the major problem that we had. It is known that the surgical wound management must be in a 6-8 hours period after injury and the delayed wound treatment increased dramatically the possibility of infection.
From the multiple trauma war victims which were transferred to Athens Medical Center from Libya, for further care, many of the wounds were found to be infected. The cultures obtained revealed multi-resistant bacteria including Klebsiella pneumoniae, Acinetobacter baumanni and Enterobacter cloacae. 25% of the victims were found to have multi-resistant bacterial wound infections. (see attached cultures). All the patients were previously hospitalized in Libya. The patients were placed on broad spectrum antibiotics including tygecycline, meropenem, colistin and trimethoprim / sulfamethaxazole. Despite multi-drug resistance the patients did clinically well with mechanical, surgical debridement of the wounds. The patients were placed on contact isolation within the hospital and no cross-infection was observed in patients of Greek origin.
The nerves injuries was the main problem in our target group. So, we had all the possibilities with nerve injuries, as neuropraxia, axonotmesis, partial or complete nerve laceration, and nerve loss.
We performed exploration in all casa with nerve paralysis after a gun shot injury. 50% of them, presented Nerve injury, due to the significant scar tissue formation around the nerve. To the majority of the others cases neurolysis was performed.
The treatment options were Neurolysis, Direct Repair (that it was rare), Nerve Grafts, Neuroma treatment, and Tendon transfers.
The use of nerve autografts (Sural nerve), was used in the majority of the cases. Neurotubes were used only in a few cases of digital nerves with small gap. In the cases with nerve loss below the Knee, the use of the contralateral Sural nerve as graft was a typical procedure, in order to protect the limited sensibility of the ipsilateral Sural nerve.
This is case of a 28 Y.O. male, with Sciatic nerve palsy. The exploration shows a partial tear of the nerve and neuroma –in –continuity. Under microscope magnification we performed interior neurolysis and scar tissue removal and the gap was bridged with grafts from the sural nerve. Another similar case of injured sciatic nerve, which treated by the same way. In this case we can see a complete sciatic nerve laceration, with a big gap. Nerve grafting was also used for the treatment. Here, we present a case of a fixation of the radial nerve, in a young man, 19 years old, during a humerus external fixation. After the nerve debridement, there was a gap of 5 cm, which bridged by nerve grafts. A ulnar nerve laceration, before and after the treatment, and a median nerve.
The injuries of the hand were very often, and digital nerve repair was performed in many cases. We can see that all these injuries does not allow the end to end repair as there is a significant nerve loss. A peroneal nerve is showed, here, with intraneural trauma from a foreign body. All these injuries were significant painful without a serious open wound trauma.
In cases with intensive scar tissue formation around the nerve, the vein graft wrapping technique was used to improve the nerve gliding, as you can see on the pictures. This is a case with the use of neurotubes for digital nerve reconstruction. In this case which was operated elsewhere with neurotubes for high median and ulnar nerve laceration, the result was poor two years post-operatively. The neurotubes use for major nerve reconstruction are not effective.
We had Brachial plexus injuries, in 11 cases. We performed neurolysis in 3 cases, repair with grafts in 4, nerve transfer in 3 and tendon transfer in 1. In this case the plexus was intact, but with significant scar tissue formation around the roots, and we perform neyrolysis. Another case with rupture of the C7 root, which treated with nerve grafts. 19 years old man, with total plexus injury. We performed nerve transfer: Accecory to suprascapular, and intercostals to musclucutaneous nerve. The result is unknown.
Tendon Transfers were performed in cases with extensive nerve loss near to neuro-muscular junction, or in cases with poor results after the primary treatment. Such case was this man with Posterior Tibialis transfer for Peroneal nerve palsy, Or this Latissimus Dorsi transfer, for a Brachial plexus palsy. Fachial latta graft was used to improve the tendon fixation.
The neuroma treatment was an another significant group of our practice for these injured patients. The neuromas were neuroma – in – continuity or amputation stump neuroma. In the left side you can see a stump neuroma of a sural nerve. The neuromas in continuity were treated by excision, internal neurolysis, nerve grafts, or by Vein graft Wrapping. Left, is a ulnar nerve with neuroma-in-continuity.
The amputation stump neuromas were treated by resection, ligation, coagulation, and muscle or bone implantation.
The Hand Complex Injuries were the second cause of our patents. The management included the debridement, the skin cover and the bone, tendon and nerve reconstruction. You can see a case here with an young man with a very complex hand injury. After the debridement we performed a groin flap to cover the skin defect. Unfortunately there is no follow-up of this patient. Another case with a very serious hand complex injury, with finger and trans- metacarpal extensive loss. After the debridement we performed a groin flap, as the palm injury did not allowed a pedicle from the antibrachial flap (chinece for example). This is the primary result, and we are prepared to do bone reconstruction in near future.
This a case of a young 15 years old man with a serious burn of his hand which has as result significant contracture of the fingers, especially of the thumb, with minimal motion. We performed a posterior interoseous flap, after the 1st web release to increase the thumb function. The result looks acceptable.
This is another case of a 45 years old man with a complex injury of his right index finger. After the primary treatment elsewhere the functional outcome was poor. We performed R-amputation, as we think that it was the best choice for this patient.
For the covering of the skin defects we performed pedicle flaps or free vascularized flaps. Pedicle flaps were our first option, due to limited surgical time and to the great mass of patients! So, in our patients we used, the Groin flap, Posterior Interosseous flap, free Gracilis flap, Soleus flap, and in a few cases the Cross finger or the Kite flap. On the left picture you can see a Kite flap for covering of a skin defect of the thumb.
The open tibia fractures were common in our patients. We usually performed muscle flap transfer, as they offers a better vascularization tissue, ideal for bone cover and union. In this case we used a soleous flap for an open tibia fracture.
The bone reconstruction was limited in compare with the other tissue injuries, as the general orthopaedic surgeons treated the majority of the cases. We treated bone injuries cases which included simple fractures in a few cases, and non union or bone loss in the majority of the cases. Most of these patients were infected (more than 40%)
We used internal or external fixation for bone stabilization, and for the cases that they was needed bone graft, we used iliac bone graft, free vascularized fibula graft, or metatarsal graft. Bone allograft rarely used, as we believe is not effective for these infected complex injuries. On the other hand, the use of autografts, especially the Iliac bone graft, was extremely more effective, cause the high energy trauma had a high incidence of non union. This is the case of a 40 years old man, with injury of his hand and bone loss of his 2nd and 3rd metacarpal. We performed metatarsal transfer to reconstruct the defect of the 2nd metacarpal, and iliac bone graft for the rest of defects. As we had follow- up for these patient there was union in all the sites. Another case with bone loss of the 3rd metacarpal. We used iliac bone graft. At the latest follow-up there is union of the graft. The hand function is acceptable and tenolysis may improve the finger motion.
The Free Vascularized Fibula graft was used in several cases with serious infection and great bone loss. This is the case of an 46 years old man with a communicate high energy fracture of his (L) tibia which infected. After a lot of previous operations we decided to treat him with the use of a free fibular graft. The result 10 months post operatively looks to be excellent. Another case of an 44 years old man with an infected non union of his femur. We performed again fibular transfer. In this case the graft was pedicle, from the ipsillateral limb. The result 4 months post-operatively looks to have union of the fracture. This is another interesting case of an 28 years old man with a femoral head fracture with cut off. The MRI showed necrosis of the femoral heaf. We performed revision of osteosynthesis, and we try to increase the bone healing with the use of a free fibular graft. The report than we have from Lybia says that there is union of the fracture.
This is an interesting case with hand function loss due to volkman contracture. We performed free functional gracilis transfer for finger flexion. Unfortunately the case was lost for follow-up.
The debate if we must remove the Foreign Bodies was present. Our experience from these patients the war foreign bodies does: Serious infection around the foreign body, pain and discomfort. The patient’s request and the possibility for future MRI are reasons for bodies removal, so we did a lot of them. This is a case with a painful minimal wound trauma of his left tibia. The exploration shows this injury of the peroneal nerve. He changed a lot of hospitals, as nobody believed him that he have serious pain on his leg.
We try to do primary rehabilitation for the patients in the cases that it was possible. The typical protocole was the primary mobilization, the muscle strengthening, and the re- education.
There were a lot of bad prognostic factors for the treatment of those injured people. The
smoking and drugs use, the patient’s cooperation, the communication and a few Ethical Issues were negative factors for the best way of treatment.
ORTHOPAEDIC Surgeon is not familiar with war injuries.
The majority of the cases are complex injuries with extensive tissue loss.
Goal of treatment is to eradicate the infection which is usually is very serious.
Delayed wound closure increase the prevention of infection.
Primary reconstruction have better outcome rate.
The treatment plan must be focusing to the repair the majority of the injured tissues, because the secondary reconstruction procedures are not always possible!
Exploration of injured nerves must always be performed.
Vascularized tissue transfer are more effective, due to high incidence of infection.
Finally, the Follow-up is uncertain, as the majority of the patients were lost!!!
Although there is not debate about WAR OR PEACE, War is present! The physician must be prepared to treat all these injured people by the best way!
Ομιλητής στο βήμα του Πανευρωπαικού Συνεδρίου της Μικροχειρουργικής, το 2014