Efficiency of damage control orthopaedics strategy in the management of military ballistic limb trauma

Abstract

Background: In conflict areas, orthopaedic surgeon adopted this concept of damage control orthopaedic (DCO) to face limb fracture due to ballistic trauma because of the gravity of the hurts, the limitation of equipment, and precarious conditions of asepsis. They use external fixation as an initial treatment at the nearest health centre. And they delay the definitive treatment to be realized in better conditions. Our study aims to assess the outcome of damage control orthopaedic (DCO) strategy in military ballistic limb trauma according to the experience of the Military Hospital of Tunisia. Materials and methods: This study is a retrospective study on patients who were hospitalized for a limb ballistic fracture. It includes military patients treated urgently with primary external fixation at the nearest health centre. We adapted Gustilo classification to describe the wound opening, Winquist and Hansen classification to define the fracture comminution and Grading system for bone loss to evaluate the bone loss. Then all victims were evacuated secondary, to the Military hospital to receive the definitive treatments. The conversion to internal osteosynthesis had taken place according to some criteria. They were the absence of local sepsis, a haemoglobin level (> 10 g/dl), a serum protein level (> 50 g/l) and a negative or falling CRP kinetics. We studied the delay of conversion from external fixation to an internal osteosynthesis, bone healing time and complications. Result: Our study included 32 patients, all men, mean age was 31 years. The average follows up was 33,2 months. 88% of trauma concerned lower limb. The average delay for conversion from external fixation to internal osteosynthesis was 7,8 days. The bone union was achieved in 26 cases, with an average delay of 4.23 months. Observed general complications were anaemia, pulmonary embolism and rhabdomyolysis. Local complications were essentially sepsis on osteosynthesis material and pseudarthrosis. These complications were significantly associated with a type III of Gustilo skin opening, a type III and IV of the Winquist fracture comminutions, a type II and III of the Grading system for bone loss, and the delay for conversion from external fixation to internal osteosynthesis. Conclusion: DCO is a global strategy which involves all measures participating in the acceleration of the wound healing and fighting against the infection. These measures shorten the delay of conversion from external fixation into an internal osteosynthesis, which constitutes a key parameter in the management of limb fracture due to ballistic trauma.

Efficacy of damage control orthopedics strategy in the management of lower limb trauma

“…In addition, more type III fracture cases were found in the DC group and fracture type was also identified as a marginally significant influencer for treatment selection. This is in line with the above-mentioned study [ 17 ] and a previous retrospective study performed on military ballistic limb trauma in Tunisia, where they found that a type III of Gustilo skin opening was significantly associated with local complications [ 18 ]. Given that some inflammatory indices were shown to reach the maximum values at the time of admission before surgery, DC treatment prior to ICU admission may have a positive impact on infections.…”

“…In a prospective, randomized, multicenter study, sustained inflammatory response was only observed after primary intramedullary femoral instrumentation, but not after initial external fixation or after secondary conversion to an intramedullary implant [ 8 ]. In a retrospective study carried out on patients with gunshot limb trauma treated by DC surgery, DC was shown to be able to accelerate wound healing and protect against infection, which could shorten the delay of conversion from external fixation into an internal osteosynthesis [ 23 ]. In term of DC treatment for multiple trauma, it is suggested that DC can effectively reduce the mortality and complication rate, as well as shorten the ICU duration [ 24 ].…”