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.
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Figure 1a Appearance of the wound on admittance to the hospital: primary gunshot soft tissue defects on the dorsolateral surface of the left foot |
Figure 1b Appearance of the wound on admittance to the hospital: rupture of the posterior tibial artery. |
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The general condition 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 1
Results of estimation of limb injury of the patient A. with MESS (Mangled Extremity Severity Score) – 8 points
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À. Soft tissue/skeletal injuries |
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Low energy (blow, simple fracture, low-velocity gun-shot wounds) |
1 |
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Middle energy (opened or multiple fractures, displacements) |
2 |
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High energy (high-velocity gun-shot wounds, compression) |
3 |
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Very high energy (above mentioned + abundant contamination, soft tissue laceration) |
4 |
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Â. Limb ischemia |
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Weak or absent pulse, with normal perfusion |
1* |
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No pulse, paresthesia, low capillary imbibition |
2* |
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Cold palsied non-sensitive limb |
3* |
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Ñ. Shock |
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Systolic pressure > 90 mm Hg |
0 |
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Transitory hypotension |
1 |
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Permanent hypotension |
2 |
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D. Age |
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< 30 |
0 |
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30-50 |
1 |
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> 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”
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Figure 2a Appearance of the limb of the patient A.: on admittance to the hospital, the non-vital bone fragments of the trochlea of the talus and soft tissue defects were seen |
Figure 2b Appearance of the limb of the patient A.: 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” |
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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
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Figure 3a X-ray of the left ankle joint of the patient A. in frontal lateral view: the talus bone is gone after astragalecromy, ongoing bone fusion after tibia-calcaneal arthrodesis, external fixation with Ilizarov’s frame |
Figure 3b X-ray of the left ankle joint of the patient A. in lateral view: the talus bone is gone after astragalecromy, ongoing bone fusion after tibia-calcaneal arthrodesis, external fixation with Ilizarov’s frame |
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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)
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Figure 4a Dynamics of the wound healing: purulent inflammation and necrosis (3 weeks) |
Figure 4b Dynamics of the wound healing: the wounds are cleaned and granulating (6 weeks) |
Figure 4c Dynamics of the wound healing: wound epithelialization (2.5 months) |
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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
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Figure 6a X-rays of the shin of the patient A.: after the right tibia osteotomy |
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| Figure 6b X-rays of the shin of the patient A.: 4.5 cm tibia lengthening; regenerating bone tissue in the upper third of the tibia | Figure 6c X-rays of the shin of the patient A.: angiography of the left shin vessels |
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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.