Differential approach for the management of femoral post-traumatic combat-related osteomyelitis in the war in Ukraine: a clinical case series

INTRODUCTION: The ballistic-associated and related to combat trauma osteomyelitis was and remained a clinical challenge for orthopedic war surgeons because of the variability of the infection course and frequent open fractures, including the Russia-Ukraine war. The aim of the study was to demonstrate approaches for management of femoral osteomyelitis associated with ballistic injury in combat settings, as well as to share clinical experience from military orthopedic surgeons obtained in the war in Ukraine. PATIENTS AND METHODS: 19 male individuals were diagnosed with multifragmentary fractures of the femur complicated by osteomyelitis due to ballistic injury on the battlefield in Ukraine. The Cierny-Mader osteomyelitis classification was applied for the evaluation of the patients' injuries. The orthopedic tactic for the femoral osteomyelitis included 4 stages to achieve the best treatment results. There were applied various approaches for the external bone fixation, such as temporary modular external fixation systems or Illizarov device, as well as monofocal, bifocal, and multifocal compression-distraction osteosynthesis. RESULTS: A significant bone defect > 7 cm associated with diffuse osteomyelitis was diagnosed in 5 (26%) patients. The bone resection was performed for these 5 patients, followed by multifocal osteosynthesis and distal osteotomy. 4 (21.1%) patients were diagnosed with cortical osteomyelitis intraoperatively, requiring removal of the sequestered bone tissue, followed by implantation of the antibiotic-loaded bone cement. As soon as the regression of the infectious process was confirmed, these 4 (21.1%) patients underwent bone alloplastic operation. 6 (31.5%) patients had a moderate bone defect up to 5 cm. These 6 (31.5%) patients underwent removal of the sequestered bone tissue along with bone resection and implantation of the antibiotic-loaded bone cement. CONCLUSIONS: In addition to adequate surgical debridement of the osteomyelitis, it is also important to administer an appropriate antibiotic therapy for the management of post-traumatic and ballistic-related osteomyelitis in patients with open fractures of the femur. Application of various modifications of compression-distraction osteosynthesis is one of the most appropriate methods in the complex surgical treatment of bone tissue defects resulting from segmental resection of osteomyelitis foci in the femur.