SECONDARY LIMBS RECONSTRUCTION IN MILITARY INJURIES FROM THE LIBYAN FRONT

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.

In  conclusion

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!

 

SECONDARY  LIMBS  RECONSTRUCTION  IN  MILITARY  INJURIES  FROM  THE  LIBYAN  FRONT

Ομιλητής στο βήμα του Πανευρωπαικού Συνεδρίου της Μικροχειρουργικής, το 2014

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