Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war

INTRODUCTION: Russo-Ukrainian war is associated with application of high-energy weapon, causing severe multifragmental injuries to the bones an associating with severe bone defects. The aim of the study was to evaluate various methods to treat combat patients with severe defects of humerus and to demonstrate the experience of orthopedic war surgeons in managing gunshot injuries to the humerus defects in the ongoing war. PATIENTS AND METHODS: A 24 patients were active-duty military personnel of Armed Forces of Ukraine. These patients were diagnosed with severe humerus defects due to gunshot injury in battlefield zone in various areas of Ukraine. Data was collected within period between February, 24th 2022 till January, 01st 2023. The following approaches were applied to replace bone defect: preoperative 3D printing with polyetheretherketone (PEEK) as orthobiological material; closed reduction, percutaneous lag screw and Ilizarov external fixation; vascularized fibula grafting. RESULTS: Data analyses of the segmental defects of humerus showed 5 cm defect in 3 (13 %) patients, from 5 to 10 cm in 4 (17 %) patients, over 10 cm in 17 (71 %) patients. Analyses were performed in these 17 (71 %) patients, showing 5 patients treated with 3D-printed PEEK implants, 6 patients with vascular-pedicle graft of fibula, 6 patients with closed reduction, percutaneous lag screw, Ilizarov external fixation. Osteomyelitis was diagnosed in one case (20 %) after the use of PEEK implants, requiring to remove both PEEK implant and metal implants followed by application of the antibiotic joint spacers and Ex-Fix fragments of the humerus. In our opinion, the osteomyelitis happened due to inadequate debridement of the wound and non-compliance with the conversion criteria (replacement of the fixation method). The mean length of hospital stay was 5.5 months for patients treated with 3D-printed PEEK implants. CONCLUSIONS: Closed reduction, percutaneous lag screw and Ilizarov external fixation as well as vascularized fibula grafting are associated with good outcomes in management of the patients with severe humerus defect due to gunshot injury. 3D printing and PEEK implants could also be considered for the reconstructions of the humerus multifragmental fractures with a bone defect over 10 cm associated with gunshot injury due to high-energy weapon in the war settings.