Alexander Lerner

Retrospective analysis of case series of patients with vascular war injury treated in a district hospital

INTRODUCTION As the Syrian civil war continues, medical care of the injured remains a priority for health facilities receiving casualties. Ziv Medical Centre, the closest hospital in Israel to the Syrian border, has received 500 casualties since February 2013. Seventeen of these patients had vascular injuries. This research reports the care of these seventeen patients and explores the challenges of treatment in patients with little antecedent clinical history and improvised initial care that may be complicated by delay to definitive care, sepsis and limb ischaemia. METHOD Electronic and paper patient records were examined. Descriptive case series data are presented. RESULTS Fifteen of the 17 patients were male. The mean age was 20 years (range 8-30 years). Causes of injury included gunshot wounds (4 patients), shrapnel (multi-fragment) injury (12 patients), and 1 patient was run over and dragged behind a car. The time from injury to transfer to definitive care ranged from 5h to 7 days (mean 43 h). All but one patient had associated non-vascular multiple-trauma. Thirteen patients presented with limb ischaemia. Four patients had arterio-venous fistula (AVF) or pseudoaneurysm. There were 5 upper and 10 lower limb major vascular injuries. Three patients had neck vessel injuries. All patients were investigated with CT angiography and underwent surgical or endovascular intervention. In 12 patients, 4 vessels were debrided and re-anastomosed and 13 vessels bypassed. Endovascular repair was performed in 4 patients. After initial revascularisation, 4 patients went on to amputation. There were no deaths. CONCLUSIONS The injuries treated are heterogeneous, and reflect the range of high energy vascular trauma expected in conflict. The broad range of vascular solutions required to optimise outcomes, in particular, limb salvage, in turn, reflect the challenges of dealing with such injuries, especially within the context of sepsis, ischaemia and delay. As war continues, there is a pressing need to address the needs of patients with high energy injuries in austere environments where there is a dearth of health resources and where definitive care may be days away.

Complex Lower Limb Deformity in Paediatric Patient After Blast Injury with Extensive Tissue Damage and Loss: A Case Report

Because of their complexity, war injuries inflicted by blast mechanism often require tailoring of treatment to attain a more individualized solution. We report a case of paediatric patient who suffered from severe complication after a blast injury to the lower limb with extensive tissue damage and loss.

Computed navigated total knee arthroplasty compared to computed tomography scans

BACKGROUND Successful total knee arthroplasty (TKA) includes accurate alignment. Controversy remains as to whether computer-navigated TKA improves the overall result and clinical outcome. Our aim is to compare the limb alignment and prosthesis positioning according to the pre- and postoperative computed tomography (CT) scans with the data collected from the navigation system. METHODS We compared the pre- and postoperative limb alignments and prosthesis alignment provided by the Orthopilot navigation system, Aesculap®, with CT scans measured by the Traumacad® software of 70 TKAs. RESULTS A positive correlation with statistical significance (P=0.00001, r=0.874) between the navigation system data and the CT images was found. Mean femoral cut was five degrees (valgus), and mean tibial cut was one degree (varus). Our study revealed that the navigation system assisted the surgeon to implant the prosthesis at a good acceptable alignment. CONCLUSION We found that the navigation system is accurate and correlates to the pre- and postoperative CT scans. Furthermore, the navigation system can assist the surgeon to achieve good limb alignment and cutting planes of the prosthesis.

Amputations in Disasters

Mass casualties related to either natural or man-made disasters are a reality of our lives, affecting large populations happening in both developed and developing countries. The earthquake that hit Haiti on January 12, 2010, caused around 237,000 deaths and nearly 300,000 wounded and left about 1 million homeless—revealing just how unprepared most countries are to deal with mass casualties and disaster-related injuries. A large percentage of the injuries typically seen in these situations are to the limbs [1, 2]. An overwhelming number of casualties; delayed presentation; crush injuries and crush syndrome; lack of adequate medical facilities and sometimes expertise, regional and cultural; and other factors influence the decision to amputate, to save lives, or to preserve function.

Primary Skeletal Stabilization and Role of External Fixations

Injuries related to natural disasters and wars are typically high-energy trauma or crush injuries. The majority of these are injuries to the musculoskeletal system [1, 2] and more specifically the extremities. Adequate limb stabilization is of major importance. It protects the injured from devastating complications, such as hemorrhage and fat embolisms [3]. High-energy fractures are often open fractures and secondary injuries due to the movement of bone fragments. These processes can lead to an increase in the contamination of bone and soft tissues, resulting in infection, nonunion, and wound healing complications [4]. The rapid and effective stabilization of high-energy trauma wounds can be a life-saving tool in complex trauma patients.

Acute Temporary Malpositioning for Dealing with Extensive Tissue Loss After Severe High-Energy Trauma to Extremities

Management of high-energy, complex limb injuries is a difficult challenge for orthopedic surgeons. Fractures do not heal without adequate soft tissue coverage and vascular supply. In cases of complex limb injuries, acute shortening and angulation is a viable option for treating both bone and soft tissue defects, providing early coverage and preventing many serious complications. In this chapter, the authors introduce the shortening and angulation technique as a strategy for management of traumatic open limb fractures with soft tissue defects.

Acute shortening and angulation for limb salvage in a paediatric patient with a high-energy blast injury

We present the case of an 8-year-old girl casualty of the Syrian conflict who arrived with open fractures of the right tibia and fibula with extensive bone and soft tissue loss as well as an open fracture of the left calcaneus as the result of a high-energy blast injury. She was successfully treated with repeated debridement procedures, external fixation with acute temporary shortening and angulation of the right leg and skin grafting to both lower limbs.

Hemipelvectomy images of loss caused by war

As we treat our 230th patient from the Syrian conflict, the pathology we see is more debilitating and the humanitarian needs of the wounded have become even more obvious. This case presents some graphic images of the realities of war. Care in the most advanced units cannot restore broken limbs, let alone broken lives. We present a case of a young war-injured man, who suffered severe crush injury to the pelvis and lower limb, arriving at our medical facility after a delay of hours. The lower limb was shattered from the pelvis down (essentially a traumatic hemipelvectomy). His life had been saved in Syria by ligation of the femoral vessels in an unknown facility by an unknown medical team. On arrival in a centre in Israel for definitive care of an unsalvageable leg, formal hemipelvectomy was performed.