1. Challenges in reconstructive surgery - the bony reconstruction
CDR Dr. Falk von Lübken
november 28th 2017

2. Disclosures Bony Reconstruction Presenter has no interest to disclose.
AMUS and PESG staff have no interest to disclose.
This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, planning committee members and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

3. Learning objectives Bony Reconstruction
At the conclusion of this activity, the participant will be able to
see the differences between a typical war injury to extremities and an injury under civilian conditions.
decide which stabilizing treatment to the bone will be the most promising in those war injuries of the extremities and which techniques have a high risk to fail.
make decisions about the overall antiseptic treatment in contaminated open war injuries of the extremities.

4. What is this all about...? Bony Reconstruction
In this presentation different strategies of how to treat different war injuries to the extremities will be presented and discussed.
This presentation is based on four ukraine soldiers wounded in action in the Ukraine conflict with Russia.
The German Armed Forces supported the medical forces in the Ukraine by taking over the treatment of some more complex cases by treating them in the German Armed Forces Hospitals in Germany.

5. Case I – the easy one? Bony Reconstruction History
This 44 year old soldier was wounded in november 2016
Explosion injury by fragmentation granade
Injury to the right distal femur, left lower leg, fragments at different parts of his body
Arrived in Germany in june 2017

6. Bony Reconstruction
Case I – the easy one?

7. Case I – the easy one? Bony Reconstruction Diagnostics
x-ray, ultrasound, CT, MRI, leucocytes scintigraphy
Fracture of the left tibia an left fibula
Fracture of the right medial femur condylus
Foreign bodies at his left shoulder an right chest
No acute infection to the the bones around the fractures
microbiological swabs
MRSA positive in nasal swab

8. Bony Reconstruction
Case I – the easy one?

9. Case I – the easy one? Bony Reconstruction Therapy
Anti-Septic Therapy with special washing lotions in order to eradicate the MRSA
Debridement of the left distal femur, implantation of PMMA chains
Removal of foreign bodies left shoulder and right chest

10. Case I – The easy one? Bony Reconstruction Therapy
ORIF of left distal fibula
Aggressive debridement of the left tibia, reconstruction of its original length and bony reconstruction using a ankle stable plate and filling the defect zone with Bioglass, a tricortical bone graft and spongiosa of the left iliac crest

11. Case I – The easy one? Bony Reconstruction Therapy
Debridement, osteotomy of the right medial femur condylus, stabilizing by an ankle stable T-plate and bony reconstruction with a tricortikal bone graft from the right iliac crest

12. Case I – the easy one? Bony Reconstruction Lessons learned
Eradicate MRSA if possible.
Remove foreign bodies that could be a source of infection.
Not every old open fracture show evidence of microbiological colonization.
As long as the soft tissue around the bone is intact, there will be a chance for the bone to heal.
You do not always need PMMA with antibiotics or local antibiotics in septic bone surgery

13. Case II – the quick one? Bony Reconstruction History
This 31 year old soldier was wounded in the beginning of june 2017
Explosion injury of his right upper arm – treated with external fixateur
GSW on his left shoulder
The injury of his right brachial artery was treated with a vein graft in Ukraine
Arrived in Germany in the end of june 2017

14. Bony Reconstruction
Case II – the quick one?

15. Case II – the quick one? Bony Reconstruction Diagnostics
x-ray, ultrasound, CT, leucocytes scintigraphy, NaFl-PET
Open multi part fracture the right humerus with vital and non vital fragments
No deep infection of his left shoulder

16. Bony Reconstruction
Case II – the quick one?

17. Case II – the quick one? Bony Reconstruction Diagnostics
microbiological swabs
Acinetobacter baumannii (4 MRGN) in several swabs
Neurological findings
Rupture of the median nerve
ENT findings
typanum perforation

18. Case II – the quick one? Bony Reconstruction Therapy
Anti-Septic Therapy with special washing lotions in order to eradicate the 4 MRGN
Debridement of the right upper arm, removing the non vital bone and placing a PMMA-spacer with Gentamicin and a VAC Instill using Taurolidine
Debridement of the left shoulder with wound closing

19. Case II – the quick one? Bony Reconstruction Therapy
Repeated debridements of the right upper arm, changing the PMMA spacer with Gentamicin and placing a VAC Instill using Taurolidine.
Neurolyses of the right median nerve
ORIF of the right humerus using an ankle stable plate, a tricortical bone graft from the right iliac crest, combined with a nerval reconstruction of the medial nerve by a sural nerve interponate and a muscle flap.

20. Case II – the quick one? Bony Reconstruction Therapy
Reconstruction of the perforated tympanon

21. Bony Reconstruction
Case II – the quick one?

22. Case II – the quick one? Bony Reconstruction Lessons learned
Eradication of a 4 MRGN is almost impossible if it is found around the anus
Not every multiresistant germ is very pathogen or aggressive
ORIF can be done even if the 4 MRGN is still in the wound
Do not spent too much time on eradicating 3 and 4 MRGN germs if you see no improvement

23. Case III – the short one? Bony Reconstruction History
This 24 year old soldier was wounded in november 2016
Explosion injury of his right upper leg with open femur fracture
OREF of right femur in Ukraine
Suspected for osteomyelitis
Arrived in Germany in the end of june 2017

24. Bony Reconstruction
Case III – the short one?

25. Case III – the short one? Bony Reconstruction Diagnostics
x-ray, CT, leucocytes scintigraphy, NaFl-PET
Open fracture of the right femur
Vital bone
Osteomyelitis of the right femur

26. Case III – the short one? Bony Reconstruction Diagnostics
microbiological swabs
Acinetobacter baumannii (3 MRGN) in the wound
MRSA in several swabs
Clinical findings
Reduced ROM of the right hip and knee joint

27. Bony Reconstruction
Case III – the short one?

28. Case III – the short one? Bony Reconstruction Therapy
Anti-Septic Therapy with special washing lotions in order to eradicate the 3 MRGN and MRSA
Debridement of the right upper leg with resection of the woundwalls and partly resection of the right femur, placing a PMMA Spacer with Gentamicin and a VAC Instill using Taurolidine and Polyhexanide

29. Case III – the short one? Bony Reconstruction Therapy
Repeated debridements of the right femur, changing the PMMA spacer with Gentamicin and placing a VAC Instill using Taurolidine/Polyhexanide.
ORIF of the right femur, shortening the femur of at all 7cm (2,75 inch) and reaming the femur placing a thick antegrade femur nail inside. Placing a VAC.
Later closing the wounds of the right upper leg using a muscle flap

30. Bony Reconstruction
Case III – the short one?

31. Case III – the short one? Bony Reconstruction Therapy in 2018
Removing the antegrade nail, loosing up the quadriceps muscle and performing a distal osteotomy and implanting a distal femur nail with continuous lengthening to regain the original length of the right femur

32. Case III – the short one? Bony Reconstruction Lessons learned
Shortening a bone to remove the infected and destroyed part is a very good tool in septic bone surgery even though the way to go is very long.
Even with an antimicrobiological and antiseptic therapy combined with aggressive debridements there is no guaranty of eradicating the germs out of an infected bone. In Europe the terms in therapy of osteomyelitis changed from the term „healing“ to „calming down“ the osteomyelitis

33. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?
History
This 19 year old soldier was wounded in the beginning of june 2017
Explosion injury of his right leg with a non displaced femur fracture, open knee joint injury and 3rd degree open multi fragment tibia fracture
OREF of right femur in Ukraine with fistula of the right knee
Suspected for osteomyelitis
Arrived in Germany in the end of june 2017

34. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?

35. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?
Diagnostics
x-ray, CT, leucocytes scintigraphy, NaF-PET
Non displaced fracture of the right femur
Displaced open fracture of the right tibia with multiple fragments
Vital and non vital fragments of the tibia
Osteomyelitis of the right tibia
Destroyed right patella (80%) with a small cranial rest

36. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?

37. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?
Diagnostics
microbiological swabs
Acinetobacter baumannii (4 MRGN) in the wound
MRSA in several swabs
Clinical findings
No distal neurological findings of the leg

38. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?
Therapy
Anti-Septic Therapy with special washing lotions in order to eradicate the 4 MRGN and MRSA
Debridement of the right leg with resection of the fistula and the destroyed soft tissue of the right knee and lower leg, partly resection of non vital fragments of the right tibia, placing a VAC Instill using Taurolidine
The patellar tendon was gone!

39. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?
Therapy
Repeated debridements of the right leg, placing a VAC Instill using Taurolidine.
ORIF of the right femur with two screws, ORIF of the tibia using an ankle stable plate, reconstruction of extension mechanism by reconstructing the patella and the patellar ligament using an allograft (quadriceps tendon, patella, patellar tendon, tibial tuberosity), followed by a mucle flap.

40. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?

41. Case IV – the most complex one?
Bony Reconstruction
Case IV – the most complex one?
Lessons learned
The patient needs a very thoroughly medical consent to make his right decisions. Especially when discussing a major amputation as an option.
Debride aggressive
Do not lose too much time on repeated debridements and antiseptic therapy, if you see no progress. Stabilize the bone and reconstruct the soft tissue

42. Learning objectives Bony Reconstruction
From these four cases with war injuries of the extremities we learned, that...
war injuries to the extremities are always contaminated and complex
do not repeat your debridements too often, prefer some thoroughly debridements instead
the external fixateur is old-fashioned, not very sexy and not easy to handle but still the workhorse in war surgery
the eradication of multiresistent germs is not always possible and not always nescessary before doing the final stabilization of fractured bones.

43. Learning objectives Bony Reconstruction
From these four cases with war injuries of the extremities we learned, that...
successful therapy in colonized open war wounds requires a combination of
antibiotics
antiseptics
thoroughly debridements
stabilization
wound concept

44. Learning objectives Bony Reconstruction
From these four cases with war injuries of the extremities we learned, that...
the key to success in war injuries of the extremities is the interdiciplinary approach which requires at least the following experts:
microbiologist
pharmacists/internist
radiologist/nuclear medicine specialist
trauma and orthopaedic surgeon
plastic surgeon
wound nurse
the bone is nothing without the soft tissue around it!

45. Thank you for
your attention!