Treatment of type IIIa open fractures with Ilizarov fixation and delayed primary closure in high-velocity gunshot wounds

Military Medicine, Jan 2002 by Atesalp, Ali Sabri

A total of 142 patients with 163 Gustilo-Anderson type IIIa limb fractures resulting from high-velocity gunshot wounds were treated with primary delayed closure and Ilizarov fixation in our department between 1988 and 1998. Average follow-up was 72.4 months. The average union period in fractures without bone loss was 16.8 weeks. It took 2 months for each 1 cm of bone defect to heal in fractures with bone loss. All fractures healed with good anatomic alignment and functional outcomes. Complications included pin-track infection in 72 fractures (50.790), post-traumatic osteomyelitis in 5 tibial fractures without bone loss (3.190), delayed union in 25 fractures (15.396), nonunion in 10 (4 with bone loss) fractures (6.1%), and refracture in 4 fractures (2.4%). Our results indicate that type IIIa limb fractures caused by high-velocity gunshot wounds can be treated with Ilizarov fixation and primary delayed closure with a low overall complication rate and a remarkably low infection rate.

Introduction

Modern sophisticated high-velocity weapons are being produced and used to improve the defensive and deterrent powers of national armies.1,2 Unfortunately, terrorist organizations, which intend to inflict deadly force on noncombatant civilians to promote their agendas, have increasingly obtained such weapons through various means. Security guards, military personnel, and civilians have all too frequently suffered the consequences of such weapon procurement by terrorists. Surgeons who must care for their victims face many challenges in attempting to repair the damage caused by high-velocity bullets.

The treatment of Gustilo-Anderson type III open fractures caused by this type of firearm is one of the most challenging problems faced by military orthopedic surgeons (Fig. 1).3,4 There are interdependent goals in the successful care of these fractures, including prevention of infection, obtaining bone healing, and restoration of function.5,6

The Gulhane Military Medical Academy in Ankara, Turkey, is the premier medical institution for the Turkish Armed Forces. The academy's Department of Orthopedics and Traumatology has provided reconstructive surgical care and rehabilitation for approximately 2,000 individuals with terrorist-related injuries involving open fractures during the last 12 years.

The treatment of each open fracture is planned according to the fracture type and the extent of soft-tissue damage. Plastic surgeons are included in the treatment team when needed. The fracture is stabilized with an unreamed nail, a reamed nail, a cast, or an external fixator depending on the circumstances of the case.

In this article, we present our experience and treatment resuits for primary delayed closure and Ilizarov fixation in type IlIa limb injuries.

Patients and Methods

Between 1988 and 1998, 142 patients with 163 Gustilo-- Anderson type IIIa limb fractures resulting from high-velocity gunshot (infantry rifle, machine gun) wounds presented to the Gulhane Military Medical Academy Department of Orthopedics and Traumatology.

Patients were first assessed at forward field hospitals and then transferred to our facility for delayed primary closure and Ilizarov fixation of their injuries. The patient population consisted of 4 females and 138 males with a mean age of 23.4 years [range, 14-62 years). Meticulous wound debridement was applied to all patients in the first 6 to 8 hours after injury as part of the care received at the field hospital. A total of 105 fractures were stabilized with unilateral-uniplanar or bilateral-uniplanar external fixators, and 58 fractures were immobilized with plaster casts. After initial debridement, all patients received an intravenous first-generation cephalosporin and an aminoglycoside antibiotic for 72 hours.

Patients were transported to our facility by air evacuation within the first 24 to 72 hours after the initial debridement. Forty of 142 patients had multiple injuries, including 22 with fractures in the opposite extremity. Details of the injuries and their frequencies are listed in Table I. The distribution of comminuted fractures according to their localization and bone loss is shown in Table II.

All patients were taken to surgery within 72 hours after arriving at out facility. At the initial operation, previously applied external fixators were removed and aggressive wound irrigation was performed with saline solution. Thorough debridement and excision of all necrotic and suspect bone fragments followed this procedure. The Ilizarov apparatus was preassembled according to the fracture location and desired technique. Kirschner wires and half-pins were used to attach the apparatus to the extremity (hybrid application). Open fractures were closed (delayed primary closure) in an orientation that ensured that there would be no tension on the suture line.

The Ilizarov apparatus was applied to 91 comminuted fractures without bone loss by providing suitable alignment and the reduction of fracture fragments in accordance with standard monofocal techniques. Forty patients had bone loss. The sizes and locations of these bone losses are listed in Table III. The treatment methods used for the fractures with bone loss are listed in Table IV.