Neglected war injuries: Reconstruction versus amputation

War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation.

From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction.

This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases.

Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.