War Injuries of the Extremities: Twelve-Year Follow-Up Data

Military Medicine,  Jan 2006  by Busic, Zeljko,  Lovrc, Zvonimir,  Amc, Enio,  Busic, Vlatka,  Et al

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secondary operations were performed, i.e., delayed skin-defect closure with split-skin grafts in three cases and bone grafting in four cases. Combined parenteral antibiotic therapy was applied (metronidazole, 1,500 mg; aminoglycoside, 240 mg; penicillin G procaine, 20,000,000 IU).

In two cases in which external fixation of the femur was converted to internal fixation (Kuntscher fixation in one case and plate fixation in one case), osteomyelitis occurred and necessitated removal of internal fixation and application of secondary external fixation. In 2 (7%) of 27 cases, external fixators had to be changed because of pin-tract infection. In two (33%) of six cases with internal fixation, the plates were changed because of osteomyelitis.

The results were evaluated concerning (a) fractured bone nonunion, (b) osteomyelitis, (c) late amputation, (d) nerve palsy, and (e) function. Function was evaluated through the reduction of range of motion of proximal and distal joints of the fractured bone, as follows: O, no reduction; 1, mild reduction (10-33% of normal); 2, serious reduction (34-66% of normal); 3, severe reduction (67-100% of normal). The Index of Independence in Activities of Daily Living was used to evaluate the ability to perform essential life functions.16

Results

Twelve years after injury and primary management, 35 (85%) of 41 wounded patients with isolated war injuries of the extremities were evaluated; 8 (16%) of 49 patients underwent primary limb amputations and 6 (12%) were not available for follow-up monitoring and were thus excluded from the statistical analyses. Among 35 evaluated patients, primary external fixation was applied for 27 (77%), whereas internal fixation was used for 8 (23%).

No delayed union or nonunion was recognized. For five patients (14%), osteomyelitis (methicillin-resistant Staphylococcus aureus) was the reason for additional treatment (two femurs, one tibia, and two patellas). In one case of a femoral fracture treated with external fixation, only repeated debridement and external fixation throughout 8 months led to bone union. No recurrence of osteomyelitis has occurred in the past 5 years. The leg is abbreviated 6 cm; the patient did not agree to proposed operative limb lengthening.

In a case of a femoral fracture primarily treated with internal plate fixation, refracture occurred because of osteomyelitis. It was treated with bone grafting and internal fixation twice. There has been no recurrence in the past 5 years. In a case of conversion of external fixation to internal fixation for a tibial fracture and osteomyelitis, extraction of Kuntscher intramedullary fixation, with delayed bone grafting and only cast immobilization, produced good results, with no recurrence of osteomyelitis in the past 5 years.

No late amputation was needed. In two cases with fractured patellas and internal fixation with wire cerclage, the osteosynthetic material had to be removed because of infection, with consecutive patellectomy and open wound treatment (lavage and sterile dressings on a regular basis). In both cases, mild functional reduction of the knee remained.