Impact of intertibiofibular graft on the ankle joint: Medium-term radiologic and clinical assessment.

HYPOTHESIS: Intertibiofibular graft (ITFG) bridges tibial non-union, but blocks bimalleolar mortise opening, leading to loss of ankle dorsiflexion. The aim of the present study was to assess dorsiflexion loss and to determine whether it was associated with secondary osteoarthritis. Material and method A 2-center retrospective study included cases of tibial non-union, without initial involvement of the ankle, treated by ITFG with more than 2 years' consolidation. Clinical, functional and radiographic parameters were analyzed. Dorsiflexion stiffness was defined as<10° flexion. Symptomatic osteoarthritis was defined by radiologic joint impingement and/or osteophytosis associated with pain>4/10 on visual analog scale (VAS) restricting walking distance to less than 1 kilometer. RESULTS: Thirty-one cases were analyzed at a mean 7±2.8 years' follow-up. Mean pain on VAS was 3±2.6. Mean AOFAS score was 62.3±20.5 and mean SEFAS was 28.3±10.5. Mean dorsiflexion was significantly lower on the ITFG side, at 6.6±7.9° versus 15.1±4.8° on the healthy side. There was dorsiflexion stiffness in 26 cases. No correlation emerged between dorsiflexion stiffness and onset of osteoarthritis. CONCLUSION: Dorsiflexion was the most severely impacted motion. The rate of osteoarthritis was too low for any implication of dorsiflexion loss to be demonstrated, especially in traumatic contexts. LEVEL OF EVIDENCE: IV; retrospective study.

Bone reconstruction by the induced membrane technique. What differences between conventional and ballistic trauma?

BACKGROUND: The induced membrane technique (IMT) has been widely evaluated for reconstruction of post-traumatic bone defects. However, no specific evaluation was conducted in ballistic injuries. The objective of the present study was to compare IMT in conventional trauma (CT) versus ballistic trauma (BT) managed in a military trauma center. METHODS: A retrospective study was conducted between 2009 and 2018 in patients treated by IMT for post-traumatic bone defects, whatever the defect location. Endpoints comprised bone union, residual infection, additional bone grafting and lower-limb amputation. RESULTS: Thirty-six patients were included: 24 in the CT and 12 in the BT group. Demographics and injury pattern were similar in both groups, with open fracture and infected lesions predominating. The only significant difference was that tibial bone defects were larger in the BT group. Operative parameters and results were also similar. At a mean 24 months' follow-up, bone union rate was 83% in both groups, without significant differences in residual infection, complementary grafting or late amputation. CONCLUSION: IMT is appropriate to bone reconstruction in the aftermath of ballistic trauma, with similar results to those obtained in conventional trauma. LEVEL OF EVIDENCE: IV, retrospective study.

Masquelet technique for open tibia fractures in a military setting.

PURPOSE: The induced membrane technique (IMT) is a two-stage procedure dedicated to reconstruction of bone defects of the limbs. The objective of this report was to evaluate employment of the IMT for the treatment of open tibia fractures managed in a military trauma center treating both wartime and peacetime injuries. METHODS: A retrospective study was performed among the patients treated via IMT for tibial bone defects related to open fractures between 2009 and 2018. The outcomes recorded included bone union, residual infection, amputation and lower limb function. RESULTS: During this period, 15 patients with a mean age of 39 years were included for the treatment of Gustilo II (2 cases) or Gustilo IIIB (13 cases) injuries. A mean number of 2.9 debridements were required before stage 1. Flap coverage was associated in 14 cases. The mean interval between stages was 22 weeks. Five patients were re-operated on after stage 1 due to persistent infection. The mean follow-up was 33 months. Bone union was achieved in 13 of the 15 cases (87%) at a mean time of 10.1 months. However, seven additional bone healing procedures were required, including six inter-tibiofibular grafting. Only one late septic recurrence was found. Most patients returned to work in sedentary jobs. CONCLUSIONS: This series is the first to report IMT use in a military setting. The prior eradication of infection constitutes a major challenge in tibial bone defects, especially in high-energy, multi-tissue injuries. An inter-tibiofibular bone reconstruction approach is required when external fixation is chosen.

Risk factors and failures in the management of limb injuries in combat casualties.

INTRODUCTION: Treatment of war wounds is based on a sequential surgical strategy, which frequently faces therapeutic failures, which then burden the final functional result. The aim of this study was to identify risk factors of failure of the different treatments to prevent the therapeutic failure. METHODS: A monocentric case-control study was done on French war-wounded soldiers treated for an open fracture caused by an invasive war weapon. The primary end point was the treatment failure three months after the injury. The risk factors of failure studied were the traumatic mechanism, the general and local lesional assessment, and the surgery performed. RESULTS: Between January 1, 2004 and December 31, 2016, 57 soldiers were included, with an average follow-up of 3.42 years. On 81 limb segments studied, the most injured segment was the leg (37.0%). A vital or urgent surgery requirement (OR = 1.56; p = 0.02) and bone loss substance (OR = 5.45; CI95% = 1.54-20.09) were risk factors of failure for limb salvage treatment. Improvised explosive device traumatic mechanism (OR = 1.56; p = 0.02) and the persistence of surgical site contamination after two debridement procedures (OR = 1.20; p = 0.04) were risk factors of failure for amputation procedures. CONCLUSIONS: Two main risk factors of treatment failure are highlighted: those in relation to traumatic mechanisms and general lesional assessment and those in relation to surgical site conditions. There is no over risk of failure in relation to surgical procedure and treatment.

Strategic proposal for a national trauma system in France.

In this road map for trauma in France, we focus on the main challenges for system implementation, surgical and radiology training and upon innovative training techniques. Regarding system organisation: procedures for triage, designation and certification of trauma centres are mandatory to implement trauma networks on a national scale. Data collection with registries must be created, with a core dataset defined and applied through all registries. Regarding surgical and radiology training, diagnostic-imaging processes should be standardised and the role of the interventional radiologist within the trauma team and the trauma network should be clearly defined. Education in surgery for trauma is crucial and recent changes in medical training in France will promote trauma surgery as a specific sub-specialty. Innovative training techniques should be implemented and be based on common objectives, scenarios and evaluation, so as to improve individual and team performances. The group formulated 14 proposals that should help to structure and improve major trauma management in France over the next 10 years.

Input of a Multi-Disciplinary Meeting in the Treatment of Osteoarticular Infections in French War Casualties.

INTRODUCTION: Extremity war-wounds present an elevated risk of infection and compromise reconstructive procedures. In a French military hospital, a multi-disciplinary meeting (MDM) was created to standardize the care given to soldiers with osteoarticular infection. The aim of this study was to evaluate the usefulness of MDM decisions. METHODS: An observational case study was performed including the French wounded at war treated for an osteoarticular infection between 2004 and 2016. They were separated into two groups according to their time of management: before (group A) or after (group B) the MDM creation in September 2010. Various operative and bacteriological parameters were analyzed retrospectively. A questionnaire was created to evaluate healthcare professionals' satisfaction toward the usefulness of the MDM on their practice. RESULTS: During the study period, 38 patients were included: 19 in group A and 19 in group B. Initial tests found an infection with one pathogen in 15 patients, an infection with 2 pathogens in 11 patients, and an infection with 3 or more pathogens in 12 patients. Enterobacter cloacae was the most common pathogen. Pseudomonas aeruginosa and Escherichia coli were also frequent. The mean number of samples taken to conduct the bacteriological tests per operating session was significantly higher for group B than for group A. Twelve of the 14 questioned healthcare professionals believed the MDM was very useful in their patient management. CONCLUSION: The MDM seems to have had a beneficial impact on orthopedic surgeon practices. A significant increase of the number of samples taken was the most obvious sign that the French recommended practices for osteoarticular infections were followed since the creation of MDM.

Sequential management of tibial fractures using a temporary unicortical external fixator.

INTRODUCTION: The development of damage control orthopedics (DCO) procedures has led to the development of temporary unicortical external fixators (TUEFs) intended to limit deep infectious complications and facilitate early conversion to internal fixation. METHODS: A retrospective study was conducted in two French military trauma centers, including on patients being treated for tibial fractures with a TUEF (UNYCO® - Orthofix®) followed by an early conversion to intramedullary nailing. RESULTS: Eleven patients with an average age of 41 were included between September 2015 and June 2017. A total of 12 TUEFs were implanted for one closed fracture and 11 open fractures, including one type I, eight types II, and two Gustilo types IIIB. The indication of DCO was related to hemodynamic instability in three cases, to the severity of soft tissue lesions in eight cases, and to the context of treatment in one case. The conversion to IM nailing was made after an average of 7.6 days. No significant loss of reduction was observed until internal osteosynthesis, which was performed with "fixator in place" in ten cases. The coverage of Gustilo type III injuries was performed by free flap transfers at the same time as IM nailing. All the patients were reviewed with an average follow-up of 16.5 months. Bone union was achieved in all cases. Two IM nailing dynamizations were carried out, but no bone grafting was required. Two cases of pandiaphysitis were observed and treated without functional complications. DISCUSSION: Despite a limited number of patients, this study demonstrates the reliability of the TUEF to maintain the reduction of tibial fractures and facilitate early conversion to IM nailing. Unicortical fixation does not prevent septic complications related to the severity of soft tissue injuries.

Digital replantation in forward surgical units: a cases study.

INTRODUCTION: Noncombat-related hand injuries are common in current theatres of operations. Crushing is one of the most frequent mechanisms that may cause traumatic amputations of digits. In the military setting, management of these digital amputations is challenging regarding limitation in microsurgical means in medical treatment facilities and aeromedical evacuation delays out of the combat zone. METHODS: Two cases of digital replantation performed in French forward surgical units are described. The first case was a complete distal amputation of the medius which was successfully replanted in the operating theatre of an aircraft carrier. No complication was observed after evacuation. Functional and aesthetic results were excellent. The second case was a ring finger avulsion revascularized in a role 2 facility in Central African Republic. Unfortunately, revascularization failed due to arterial thrombosis during evacuation. RESULTS: Digital, hand or more proximal upper extremity replantation may be considered for isolated amputations due to work-related accidents within the combat zone. For a surgeon trained to microsurgery, a microsurgical set and magnification loupes enable to attempt such procedures in austere conditions. DISCUSSION: The authors propose an algorithm of management in the field according to the type and level of amputation.

Initial management of complex hand injuries in military or austere environments: how to defer and prepare for definitive repair?

INTRODUCTION: The damage control orthopedics (DCO) concept is a sequential surgical management strategy indicated when ideal primary treatment is not possible or suitable. DCO principles are routinely applied to hand traumas in wartime practice, but could also be useful in a civilian setting when immediate specialized management cannot be carried out. METHODS: The authors report three typical observations of soldiers treated for a complex hand trauma on the field by orthopedic surgeons from the French Military Health Service (FMHS). Application of the hand DCO concept is analyzed and discussed considering the literature and the FMHS experience. RESULTS: With regards to treating the hand, DCO necessitates a meticulous debridement with precise wound assessment, the frequent use of a primary definitive internal fixation by K-wires, and the possibility of a temporary coverage. These simple and fast procedures help avoid infection and prepare the hand for secondary repair. CONCLUSION: Hand DCO can be applied by any surgeon in various situations: in association with polytrauma, complex injuries requiring multiple reconstructions, or delayed transfer to a specialized center.

Infectious risk for suicide bomber attack victims: management of penetrative wounds in French Army personnel.

INTRODUCTION: In suicide bomber attacks (SBAs), the explosive forces may disperse fragments from the body of the bomber to which the device is attached. This biologic material can cause physical injury to bystanders and may represent a source of severe infectious diseases. PATIENTS AND METHODS: Two French soldiers, victims of an SBA in Africa, were managed in the Percy Military Teaching Hospital. They sustained multiple injuries, including some caused by bony fragments converted into projectiles by the explosion. One patient had multiple superficial wounds managed conservatively. The other was treated surgically by serial debridement with removal of a bony piece related to the suicide bomber. The decision not to prescribe antiretroviral therapy was determined after discussion with infectious disease specialists. RESULTS: Blood tests for HIV, HCV and HBV were taken at months zero, three and six; all were negative. CONCLUSION: In the French Military Health Service, guidelines are based on evaluation of the viral status of the bomber and on the regional HIV prevalence breakpoint. There is no indication for HCV post-exposition prophylaxis (PEP). Accessible human foreign bodies related to an SBA should be removed as soon as possible, in association with antibiotic medication and a possible HIV PEP. These infectious risks have been discussed in some military and law enforcement literature. It should be a risk-based decision supported by medical intelligence.

Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali.

INTRODUCTION: On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces. METHODS: All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded. RESULTS: 268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest. CONCLUSION: this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.

Humanitarian Surgical Care Provided by a French Forward Surgical Team: Ten Years of Providing Medical Support to the Population of the Ivory Coast.

INTRODUCTION: The aims of this study were as follows: first to quantify and review the types of surgical procedures performed by military surgeons assigned to a Forward Surgical Team (FST) providing medical support to the population (MSP) in the Ivory Coast (IC), and second to analyze how this MSP was achieved. METHODS: Between 2002 and 2012, all of the local nationals operated on by the different FSTs deployed in the IC were included in the study. The surgical activity was analyzed and divided into surgical specialties, war wounds, nonwar emergency trauma, nontrauma emergencies, and elective surgery. Demographics, circumstances of health care management, wounded organs, and types of surgical procedures were described. RESULTS: Over this period, surgeons operated on 2,315 patients and performed 2,556 procedures. Elective surgery accounted for 78.7% of the surgical activity, nontrauma emergencies accounted for 12.7%, nonwar emergency trauma accounted for 8%, and war wounds accounted for 0.6%. The main surgical activities were visceral (43.8%) and orthopedic (including soft tissues) surgeries (38.5%). CONCLUSION: The FSTs contributed widely to MSP in the IC. This MSP required limited resources, standardization of the procedures and specific skills beyond the original surgical specialties of military surgeons to fulfill the needs of the local population.

Initial deployment of the 14th Parachutist Forward Surgical Team at the beginning of the operation Sangaris in Central African Republic.

As part of the operation Sangaris begun in December 2013 in the Central African Republic, the 14th Parachutist Forward Surgical Team (FST) was deployed to support French troops. The FST (role 2 in the NATO classification) is a mobile surgical-medical treatment facility. The main goal of the FST is to assure the initial damage control surgery and resuscitation for combat casualties, allowing for the early evacuation to combat support hospitals (roles 3 or 4), where further treatments are completed. During the first trimester of the operation Sangaris, 42 patients were treated at FST, of whom 29 underwent surgery. Almost 50% of patients operated on were French servicemen. All admissions were emergency admissions. Orthopedic surgery represented two-thirds of surgical interventions executed as a result of the high proportion of limb injuries. Fifty percent of injuries were specifically linked to combat. Surgery in an FST is primarily dedicated to the treatment of combat casualties with hemorrhagic injuries, but additionally plays a part in supporting general medical care of French troops. Medical aid to the general civilian population is justifiable because of the presence of medical treatment facilities, even in the initial implementation of a military operation.

Modern teaching of military surgery: why and how to prepare the orthopaedic surgeons before deployment? The French experience.

PURPOSE: Improved survival of combat casualties in modern conflicts is especially due to early access to damage control resuscitation and surgery in forward surgical facilities. In the French Army, these small mobile units are staffed with one general surgeon and one orthopaedic surgeon who must be able to perform any kind of trauma or non trauma emergency surgery. METHODS: This concept of forward surgery requires a solid foundation in general surgery which is no longer provided by the current surgical programs due to an early specialization of the residents. Obviously a specific training is needed in war trauma due to the special pathology and practice, but also in humanitarian care which is often provided in military field facilities. RESULTS: To meet that demand the French Military Health Service Academy created an Advanced Course for Deployment Surgery (ACDS), also called CACHIRMEX (Cours Avancé de CHIRurgie en Mission EXtérieure). Since 2007 this course is mandatory for young military surgeons before their first deployment. Orthopaedic trainees are particularly interested in learning war damage control orthopaedic tactics, general surgery life-saving procedures and humanitarian orthopaedic surgery principles in austere environments. CONCLUSION: Additional pre-deployment training was recently developed to improve the preparation of mobile surgical teams, as well as a continuing medical education for any active-duty or reserve surgeon to be deployed.

Multiple blast extremity injuries: is definitive treatment achievable in a field hospital for local casualties?

PURPOSE: The objective of this report was to analyse injury patterns and definitive management of local casualties with multiple blast extremity injuries in the Kabul International Airport Combat Support Hospital. METHODS: A clinical prospective study was performed from July 2012 to January 2013. Afghan victims of a blast trauma with a minimum of two extremities injured and an Injury Severity Score (ISS) greater than 8 were included. Two groups were considered for analysis: group A including patients with amputations and group LS including patients with limb salvage procedures. RESULTS: During this period 19 patients were included with a total of 57 extremity injuries. There were six patients in group A and 13 patients in group LS, with a mean number of injuries of 3.5 and 2.8, respectively. The ISS, blood products utilization and overall time of surgery were significantly greater in group A. CONCLUSION: Reconstruction of multiple blast extremity injuries may be achieved in a field hospital despite limited resources and operational constraints. However, this activity requires the utilization of significant supplies and major investment from the caregivers deployed.

Soft tissue coverage of war extremity injuries: the use of pedicle flap transfers in a combat support hospital.

PURPOSE: Definitive management of extremity injuries including soft tissue coverage is seldom achieved in battlefield medical treatment facilities due to limited resources and operational constraints. The purpose of this study was to analyse the French Army Medical Service experience performing such reconstructive surgery in a Combat Support Hospital (CSH) in Afghanistan. METHODS: A clinical study was performed in the KaIA (Kabul International Airport) CSH from July 2012 to January 2013. RESULTS: During this period 23 Afghan patients treated for soft tissue coverage of combat-related extremity injuries were included. They totalled 28 extremity injuries including 18 blast trauma (BT) and ten non blast trauma (NBT). Overall, 35 extremity pedicled flaps were performed. There were 26 fasciocutaneous flaps, eight muscle flaps and one composite flap. Soft tissue coverage was achieved on all patients reviewed with a mean follow-up of 59 days. Five postoperative complications occurred including two deep infections, one partial flap necrosis and two flap failures, without difference according to injury mechanism. CONCLUSION: Reconstruction of traumatic soft tissue defect can be achieved in CSHs for local nationals. Pedicle flap transfers provide simple and safe coverage for war extremity injuries in this challenging environment whatever the injury mechanism.

Temporary and definitive external fixation of war injuries: use of a French dedicated fixator.

PURPOSE: External fixation is the recommended stabilization method for both open and closed fractures of long bones in forward surgical hospitals. Specific combat surgical tactics are best performed using dedicated external fixators. The Percy Fx (Biomet) fixator was developed for this reason by the French Army Medical Service, and has been used in various theatres of operations for more than ten years. METHODS: The tactics of Percy Fx (Biomet) fixator use were analysed in two different situations: for the treatment of French soldiers wounded on several battlefields and then evacuated to France and for the management of local nationals in forward medical treatment facilities in Afghanistan and Chad. RESULTS: Overall 48 externals fixators were implanted on 37 French casualties; 28 frames were temporary and converted to definitive rigid frames or internal fixation after medical evacuation. The 77 Afghan patients totalled 85 external fixators, including 13 temporary frames applied in Forward Surgical Teams (FSTs) prior to their arrival at the Kabul combat support hospital. All of the 47 Chadian patients were treated in a FST with primary definitive frames because of delayed surgical management and absence of higher level of care in Chad. CONCLUSION: Temporary frames were mostly used for French soldiers to facilitate strategic air medical evacuation following trauma damage control orthopaedic principles. Definitive rigid frames permitted achieving treatment of all types of war extremity injuries, even in poor conditions.