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.

Allogeneic platelet-derived growth factors local injection in treatment of tennis elbow: a prospective randomized controlled study.

PURPOSE: The purpose of this study aimed to evaluate the efficacy of local injection of allogeneic platelet-derived growth factors in treatment of patients with tennis elbow. PATIENTS AND METHODS: This study included 120 tennis elbow patients randomly divided into two groups. The patients were locally injected with allogeneic growth factors (treatment group) or with normal saline (control group). The outcomes were assessed using Patient-Related Tennis Elbow Evaluation (PRTEE) and quick Disabilities of the Arm, Shoulder and Hand (qDASH) scales. The clinical outcomes were accordingly classified as excellent, good and poor. The patient's satisfaction and adverse effects were also recorded. RESULTS: There was no statistically significant difference between the two groups regarding the age, gender, dominant arm or the pre-injection scores. At three month follow-up, the reductions in the mean PRTEE and qDASH scores were 88.7% and 70.6% in the treatment group versus 21.8% and 14.9% in the control group, respectively. At the last follow-up, the outcomes in the treatment group were excellent in 85% of patients and good in 15%, versus 8% and 32% in the control group. Overall, 95% were satisfied in the treatment group compared to 25% in control group. Forty patients in the treatment group experienced mild transient post-injection pain. CONCLUSION: This study strongly suggests that local injection of allogeneic platelet-derived growth factors could be a promising safe treatment option for tennis elbow with significant pain relief, functional improvement and patient's satisfaction. Yet, additional larger studies are needed to assess the durability of these outcomes.

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.

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.

Infected tibial nonunion in children: Is radical debridement mandatory?

Nonunion is a devastating complication of tibial fractures with a debilitating effect. Several studies reporting tibial nonunions in adults are available; however, the reports on infected nonunions in children are scarce. The purpose of this study was to evaluate the results of treating paediatric infected tibial nonunion using Ilizarov fixator without radical resection. MATERIALS AND METHODS: The study included 36 cases with infected nonunion of the tibia with 31 males and 5 females, and an average age of 11.4 years. The mean number of previous operations was 3.5. The duration before presentation averaged 10.4 months. At presentation, 24 cases were draining nonunions, while 12 patients had quiescent sinuses. Preoperative shortening was evident in 31 patients ranging from 1 to12 cm. Six cases had equinus foot deformity. Stiffness of the ankle and/or knee was present in 11 cases. Angular deformity of more than 10° was evident in 13 nonunions. The monofocal compression-distraction was used for 10 cases managed by bloodless technique, and four draining cases managed by limited debridement and compression distraction. Limited debridement and bone transport was used in the remaining cases including proximal chondrodiastasis (two cases), proximal tibial corticotomy (17 cases), and partial osteotomy (three cases). RESULTS: The mean follow-up duration was 51.9 months. The external fixation period averaged 5.3 months. Delayed union occurred in three cases treated by repeating compression-distraction. Eventually, union was achieved in all cases. Two cases suffered refracture. Four cases had residual angular deformity of about 5-7°. Infection recurred in one case. ASAMI bone results were excellent in 29 patients, good in three patients, fair in two patients, and poor in two patients. The ASAMI functional results were excellent in 27 cases, good in 5 cases, fair in two cases, and poor in two cases. CONCLUSION: The Ilizarov method provides a viable treatment method for treating paediatric infected nonunions in a single stage of management. Limited debridement was enough to control infection and achieved good results without radical resection.

Clinical outcomes with the corticotomy-first technique associated with the Ilizarov method for the management of the septic long bones non-union.

PURPOSE: Corticotomy is an integral part of the Ilizarov method on management of infected nonunited fractures that are challenging orthopaedic surgeons. However, the presence of active draining sinuses may contaminate the operative field with the potential of developing corticotomy site infection. The authors present a surgical technique aiming at minimizing or avoiding the risk of surgical site infection (SSI) in the corticotomy zone. PATIENTS AND METHODS: A total of 144 cases of draining infected nonunions were treated by Ilizarov fixator using the corticotomy-first technique. The study included humeral (18 cases), femoral (52 cases), and tibial (74 cases) nonunions. The mean age was 44.48 years with 87 males and 57 females. The mean duration of nonunion was 28.69 months. After debridement, the combined shortening and nonunion gap averaged 5.98 (range 3-10) cm. Evaluation of bone and functional results was done according to Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. RESULTS: The follow-up period averaged 51.05 (range 36-72) months. None of the cases developed corticotomy site or distraction gap infection. Union was successfully achieved in 141 cases (97.92%). Nonunion persisted in three cases (2.08%) in the distal tibia. Infection was eventually controlled in 138 cases (95.83%). Bone grafting was not needed in any case. CONCLUSIONS: The Ilizarov fixator with the corticotomy-first technique was effective in the management of draining infected non-united fractures of long bones while avoiding the SSI in the corticotomy site in all cases.