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THE EXPERIENCE WITH PRESERVING THE LOWER LIMB IN A VICTIM WITH A SERIOUS MINE-BLAST WOUND
Khominets V.V., Brizhan L.K., Shchukin A.V., Mikhaylov S.V., Arbuzov Yu.V., Shakun D.A., Khominets I.V.
Kirov Military
Medical Academy, Saint Petersburg, Russia,
Burdenko Main
Military Clinical Hospital, Moscow, Russia
The problem of treatment of
patients with severe injury to the extremities, including gun-shot wounds, is
still important [1, 2, 3]. The specific scientific literature demonstrates the
discussion of criteria for making a decision in favor of amputation or
preservation of the extremity in patients with doubtful prognosis for viability
of the extremity [4, 5, 6].
According to our opinion,
three key positions can be separated for solving this problem. Firstly, the
extremity preservation after severe injury requires for urgent and sometimes
traumatic, long term and extensive surgical interventions, which negatively
influence on the general condition of the patient. Another important aspect is
high risk of severe local and, most importantly, general infectious
complications. Finally, the third disputable question is prediction of
functional capabilities of the preserved extremity in comparison with
possibilities of the modern prostheses. Moreover, amputation usually allows
reducing the time of inhospital treatment, decreasing the probability of
life-threatening complications, and reducing the costs for treatment. From
other side, amputation causes the disability and severe mental disorders [7].
It is calculated that quite low cost for primary costs significantly increases
several years after amputation due to inevitable wearing out of components of
the exoprosthesis, necessity for their change, as well as due to expenses
relating to medicosocial rehabilitation. The costs significantly exceed the
economic losses in reconstructive treatment in case of making decision on
extremity preservation [8]. The above-mentioned aspects make the process of
making a decision on extremity preservation as subjective one and dependable on
multiple non-measurable factors [9].
Some scales are offered for objectification
of severity of extremity injury. They simplify making a decision on primary
amputation or preservation of a segment of the extremity. For example, the
popular scales are Mangled Extremity Severity Score (MESS), Limb Salvage Index (LSI), Predictive Salvage Index
(PSI), Nerve injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, Age of
Patient Score (NISSSA), and Hannover fracture scale (HFS-97). At the same time,
Bosse M.J. et al. carried out the analysis of efficiency of estimation of
condition of injured extremities in 556 patients. They used five above-mentioned
scales. The analysis did not find any clear relationship between values of the
scores and selection of management techniques [10]. Also there are not any
estimation systems for prediction of recovery of function of the preserved
extremity.
Therefore, the
decision on extremity preservation after severe trauma requires for the individual
approach for each patient, with use of scores for estimation of injury
severity. Also one should consider the possibilities of a medical facility and
surgeon’s experience.
Objective – to demonstrate the
opportunity of limb salvage treatment in patients with severe combat blast
injury and uncertain prognosis
of limb viability.
The study
corresponds to Helsinki Declare – Ethical Principles for Medical Research with
Human Subjects, and the Rules for Clinical Practice in the Russian Federation
confirmed by the Order of Russian Health Ministry on June, 19, 2003, No.266.
The patient gave the informed consent for publishing the clinical case.
MATERIALS AND METHODS
The patient A., male, age of 56, received a severe concomitant mine-blast injury to the head, the neck, the chest, and upper and lower extremities. There were a closed traumatic brain injury, brain concussion, bilateral acoustic barotraumas, primary gun-shot defects of distal epiphysis of the tibia, fibular and talar bones, gun-shot fractures of tarsus and metatarsus, a crushing injury to soft tissues in region of left ankle joint with strong contamination, a wound of posterior tibial artery, injuries to tibial and fibular nerves, multiple shrapnel wounds of soft tissues of the neck, the chest and upper extremities, acute blood loss of severe degree (up to 1.5 l), shock of degree 2 (Fig. 1).
Figure
1. Appearance of the wound
on admittance to the hospital: a) primary gunshot soft tissue defects on the
dorsolateral surface of the left foot; b) rupture of the posterior tibial
artery.
The generalcondition of the patient according to Military Field Surgery Score-State on
Admission was 27 points (severe). Military Field Surgery Score-Gun-Shot Wounds
was 10 (severe). AIS was 5. Gustilo-Andersen’s classification of opened
fractures was 3C.
The condition of
the extremity according to MESS was 8 points. The table 1 shows the results of
estimation of the extremity by the patient A. (the values are indicated by black
type). Therefore, at the moment of the injury, the indications for extremity
amputation for primary indications changed according to this score.
Table. Results of estimation of limb injury of the patient A. with MESS (Mangled Extremity Severity Score) – 8 points
|
Soft tissue/skeletal injuries |
|
|
Low energy (blow, simple fracture, low-velocity gun-shot wounds) |
1 |
|
Middle energy (opened or multiple fractures, displacements) |
2 |
|
High energy (high-velocity gun-shot wounds, compression) |
3 |
|
Very high energy (above mentioned + abundant contamination, soft tissue laceration) |
4 |
|
Limb ischemia |
|
|
Weak or absent pulse, with normal perfusion |
1* |
|
No pulse, paresthesia, low capillary imbibition |
2* |
|
Cold palsied non-sensitive limb |
3* |
|
Shock |
|
|
Systolic pressure > 90 mm Hg |
0 |
|
Transitory hypotension |
1 |
|
Permanent hypotension |
2 |
|
Age |
|
|
< 30 |
0 |
|
30-50 |
1 |
|
> 50 |
2 |
Note: * – points are doubled in ischemia more than 6 hours; 6 points and less – a possibility for limb preservation; 7 points and more – indications for amputation.
At the site of
the accident, the medical care was realized: primary surgical preparation of
wounds, subcutaneous fasciotomy, transport immobilization with the military
field rod kit, infusion therapy. During aviation sanitary transferring,
anti-shock, infusion, transfusion, anticoagulant and antibacterial therapy was
continued. Within the first day after the injury, the patient was transferred
to the stage of specialized care in Burdenko Main Military Clinical Hospital.
Despite of the
fact that the assessment of the extremity with MESS supposed a necessity for
amputation, some additional factors allowed making a decision on an attempt of
the extremity salvage: 1) a possibility for recovery of the injured posterior
tibial artery (PTA); 2) absence of long term critical ischemia of the
extremity; 3) absence of a serious defect of the bone and soft tissues; 4)
relatively good basic health; 5) patient’s emphatic refusal from
amputation.
For realization
of the selected management, the following surgical procedures were carried out:
after admission – recurrent surgical preparation of the wounds of the left leg
and the foot with removal of foreign bodies of the right leg and both upper
extremities, a vascular suture with application of end-to-end anastomosis for
PTA, recurrent fasciotomy for all fascial compartments of the leg, and fixation
of the left leg and the foot with the military field surgery rod kit in
suspended position. Due to thrombosis in the region of vascular suture, the PTA
prosthetics with the reverse autovenous graft of the great saphenous vein was
performed. Within the following month, the patient received 22 operations,
including recurrent surgical preparations of gun-shot wounds of the left leg
and the left foot (each 48-72 hours), VAC-dressing (each 5-7 days) (Fig.
2).
Figure 2. Appearance of the limb of the patient A.: a) on
admittance to the hospital, the non-vital bone fragments of the trochlea of the
talus and soft tissue defects were seen; b) step-by-step treatment of the
wounds using VAC and external fixation of the shin and of the foot with KSVP in
the “suspending mode”
After 35 days from the moment of the injury, the military field surgery rod kit was dismounted from the left leg and the left foot. Also astragalectomy, tibial-calcaneal arthrodesis with Ilizarov’s apparatus, and free skin plasty with the split flap from posterior-lateral surface of the left leg were conducted (Fig. 3).
Figure 3. X-ray of the left ankle joint of the patient A. in
frontal (a) and lateral (b) views: the talus bone is gone after astragalecromy,
ongoing bone fusion after tibia-calcaneal arthrodesis, external fixation with Ilizarov’s
frame
After 37 days
from the injury, the patient was transferred to the clinic of military
traumatology and orthopedics at Military Medical Academy. At this stage, the
main attempts were oriented to correction of infectious complications and to
wound healing. For this purpose, some various techniques of chemical and
physical sanitation of wounds were used. Hyperbaric oxygenation was used.
Negative pressure therapy for soft tissues of the left lower extremity was
continued. Antibacterial therapy with tobramycin was performed with
consideration of sensitivity of Pseudomonas Aureginosa from the wounds.
Ilizarov’s device was reinstalled. Systemic medication and rehabilitation were
carried out.
The figure 4
shows the time course of the wound process. After 3 weeks from the wound,
purulent necrotic wounds of the left foot were noted. The wounds were cleared
and granulated in 6 weeks. Epithelization was noted after 2.5 months from the
moment of the injury. The general condition stabilized. The infectious process
was arrested.
Figure 4. Dynamics of the wound healing: a) purulent inflammation
and necrosis (3 weeks); b) the wounds are cleaned and granulating (6 weeks); c) wound epithelialization (2.5
months)
After six months from the injury, tibial-calcaneal arthrodesis (Fig. 5) was performed. The patient complained of shortening of the left lower extremity.
Figure 5. X-ray of the left ankle joint of the patient A.
Completed bone fusion after tibiotalar arthrodesis
After 8 months, after stabilization of general condition, healing of wounds, rehabilitation, and after CT-angiography for correction of length of the left lower extremity, the osteotomy was carried out at the level of the proximal tibial metaepiphysis, and lengthening of the left leg with the nail was carried out (the patent RF 2372875, registered on November, 27, 2009). Distal blocking of the nail was carried out after correction of the length of the left leg. The distraction apparatus was dismounted (Fig. 6). The patient started to walk with full load to the leg with use of the cane.
Figure 6. X-rays of the shin of the patient A.: a) after the
right tibia osteotomy; b) 4.5 cm tibia lengthening; regenerating bone tissue in
the upper third of the tibia; c) angiography of the left shin vessels
The figure 7 shows the X-ray images of the patient A. They show the regenerate of the proximal metaepiphysis of the left tibial bone, and forming ankylosis of the middle foot joints.
Figure 7. X-rays of the left shin of the patient A.: a) remodeled
bone tissue of the proximal tibial metaepiphysis; b) X-ray of the left foot,
ongoing ankylosis of the midfoot joints
One year after
the injury, the regenerate of the proximal tibial metaepiphysis readjusted. The
patient could move with the cane and could wear usual shoes. However, exacerbation
of chronic gun-shot osteomyelitis of foot bones appeared. A fistulous passage
appeared at the level of the proximal epiphysis of the tibial bone.
For correction
of the purulent inflammatory process, the first stage included the removal of
the nail, drilling and washing of the spinal channel with pulse pressure jet
and antiseptic solution (Lavasept, 0.1 %). The second stage included the necrosequestrectomy
for the foot, and fixation with Ilizarov’s device. After correction of acute
purulent necrotic signs, and appearance of granulation, the wounds were closed
with the split-skin graft.
The figure 8
shows the appearance of the foot with fistulas along dorsal external surface,
and X-ray images of the foot after fixation with Ilizarov’s device.
Figure 8. The left foot of the patient
A. after Ilizarov’s device fixation: a) appearance of the left foot and the
leg; there are some fistulas on dorsal external surface of the foot; b) X-ray
image of the left foot
Persistent remission of the gun-shot osteomyelitis was achieved. The total period of treatment was 18 months.
RESULTS
At the present time, there is a consistent tibial ankylosis, ankylosis of middle foot joints, and 1.5 cm shortening of the left lower extremity. The blood flow in the left lower extremity compensated. The pain is absent. The patient uses common foot-wear (Fig. 9).
Figure 9. The treatment result of
the patient A.: a) X-ray images of the leg of the patient A. after 2 years; b)
appearance of the left foot and the leg; c) functional result
CONCLUSION
Making a
decision on a possibility for limb salvage in case of severe combat trauma is a
complex problem, which requires for individual approach. In the presented
clinical case, the general condition of the patient and severity of the limb
injury supposed the appropriateness of amputation after assessment with the
common scales. However, some factors allowed considering a possibility for limb
preservation. These factors include early and qualified medical care at the
main stage, timely evacuation with aviation transport for the stage of
specialized care; the use of modern methods of diagnostics and treatment,
uniform military medical doctrine, succession of specialists of various
military medical facilities, and individual approach.
All these
factors, as well as high motivation of the patient, allowed returning the
patient with severe combat trauma to his usual professional activity with
preservation of high quality of life. According to our opinion, the
traumatologist-orthopedist should carefully use the scales for assessment of
limb injury severity during estimation of indications for amputation.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.
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