Massive bone loss and severe soft tissue damage of the distal humerus following ballistic trauma represent a major challenge in limb reconstructive surgery.3,12 The complexity of these injuries lies in the combination of extensive bone destruction, a high likelihood of contamination, skin-coverage defects, and associated ligament damage, which often limits reconstruction options.1,6 Conventional strategies such as internal fixation, total elbow arthroplasty, or arthrodesis are often unsuitable for young, active patients because of the high risk of mechanical failure or insufficient bone stock,13 infection,11 or functional limitation.5 In such cases, biological reconstruction remains the preferred option when preservation of limb length and joint mobility is desired. Osteoarticular allografts restore bone stock and joint anatomy, but their success depends on optimal ligament reconstruction in cases involving articular damage. Combining the allograft with a pedicled latissimus dorsi flap provides reliable coverage for extensive soft tissue defects, which are consistently present in war-related injuries. This report presents the first description of a single-stage reconstruction of ballistic distal humeral bone loss using a massive allograft, ligament reconstruction, and a pedicled latissimus dorsi flap, along with early outcomes in 2 patients.
Description of the technique
Débridement, necrosectomy, and bacteriological sampling
The first step in the context of war-related trauma is extensive débridement of all nonviable bone and soft tissues, along with bacteriological sampling, followed by a 3-week antibiotic-free interval2 (Fig. 1).
Figure 1.
Pre-operative imaging and skin condition of patients 1 and 2. (A) Poor skin condition around the elbow of patient 2, requiring anticipation of soft tissue coverage following the reconstructive procedure. (B) Pre-operative anteroposterior radiograph of the elbow of patient 2 showing an associated fracture of both forearm bones. (C) Patient 2 after ulna fixation and first-stage induced membrane (Masquelet) technique for the radial diaphysis, prior to planned second-stage cancellous bone grafting. (D) Pre-operative anteroposterior radiograph of the elbow of patient 1.
Patient positioning and preparation
Under general anesthesia, the patient was placed in the lateral decubitus position, with the arm resting on a sterile support. A midline posterior incision, extended proximally, allowed full exposure of the distal humerus, olecranon, and radial head.
Preparation of the allograft
A fresh-frozen, nonirradiated distal humerus allograft from the national bone bank was thawed in sterile saline (37°C, 30 minutes). Its size was adjusted according to pre-operative computed tomography measurements of the contralateral limb. A step-cut osteotomy was performed to ensure a precise and stable fit with the proximal humerus. An allogenic Achilles tendon was prepared for triceps reconstruction and for reinforcement of the medial and lateral ligamentous structures (Figs. 2 and 3).
Figure 2.
Patient 1 treated with a distal humeral allograft for sequelae of ballistic trauma. (A) Massive complete humeral allograft prepared after a “step-cut” (merlon-crenel) osteotomy, adjusted to restore humeral length based on contralateral computed tomography measurements. (B) Press-fit insertion of the allograft onto the patient's humerus, secured with 2 compression screws. (C) Stabilization of the construct with 2 3.5-mm plates, medial and posterolateral. (D) Skin defect remaining after débridement and completion of the procedure, requiring coverage with a latissimus dorsi flap. (E) Elbow after coverage with a pedicled latissimus dorsi flap.
Figure 3.
Patient 2 treated with a distal humeral allograft for sequelae of ballistic trauma. (A) Fixation of the allograft after a “step-cut” (merlon-crenel) osteotomy using 2 mediolateral compression screws. (B) Stabilization with 2 3.5-mm plates, medial and posterolateral, with placement of 2 anchors for reinsertion of the collateral ligaments. (C) Achilles tendon allograft used for reconstruction of the triceps tendon (1) and the collateral ligament structures (2) and (3). (D) Elbow after reduction and reconstruction of the ligamentous and tendinous structures, showing a major soft tissue defect requiring coverage. (E) Coverage achieved with a pedicled latissimus dorsi flap.
Preparation of the recipient site
After thorough débridement of necrotic tissues and debris, the healthy bone ends were exposed. The ulnar, radial, and median nerves were identified and protected. The humeral stump was recut following the same osteotomy pattern as the allograft.
Fixation
The allograft was inserted using a primary press-fit technique. Compression was achieved with 2 3.5-mm screws, supplemented by dual locking plates spanning at least 10 cortices on each side of the graft–host junction.
Ligament and extensor mechanism reconstruction
A fresh-frozen allograft (Achilles) was used for all ligament reconstructions. The anatomical footprints of the collateral ligaments were identified on the osteoarticular allograft at the medial and lateral epicondyles. Suture anchors were placed at the corresponding humeral isometric points. The lateral collateral ligament complex was reconstructed first, fixed proximally at the lateral epicondyle and distally at the supinator crest using anchors. Fixation was performed with the elbow at 30° of flexion in neutral rotation, applying slight valgus stress to restore posterolateral stability. The medial collateral ligament was then reconstructed and fixed to the medial epicondyle and the sublime tubercle of the ulna. Tensioning was adjusted at 60° of elbow flexion under varus–valgus stability testing. Triceps reconstruction involved distal fixation to the olecranon through transosseous tunnels with nonabsorbable Krackow sutures at approximately 60° of flexion.
Soft tissue coverage
A pedicled latissimus dorsi flap was harvested through a postero-axillary incision, preserving the thoracodorsal pedicle. The flap was tunneled subcutaneously to the elbow, wrapped around the graft–host junction, and sutured to the reconstructed triceps to restore the extensor mechanism and provide immediate vascularized soft tissue coverage.
Post-operative course
Patient 1 required a hinged external fixator for 6 weeks due to immediate post-operative instability. Patient 2 was immobilized at 90° of flexion for 7 days, followed by protected mobilization with an articulated brace. Active motion began at 6 weeks, and muscle strengthening started at 10 weeks once early callus formation was observed.
Results
Both patients were reviewed at a mean follow-up of 14 months (12 and 16 months). In both cases, complete osseous union at the graft–host junction was achieved between 8 and 10 months, with no evidence of lysis or nonunion. Patient 1 experienced immediate post-operative lateral instability due to transosseous anchor avulsion of the lateral collateral ligament reconstruction, requiring a hinged external fixator for 6 weeks. Patient 2 developed an early post-operative infection, effectively managed with 2 surgical débridements and prolonged antibiotic therapy, without graft loss. No neurological complications or flap necrosis were observed. The final range of motion ranged from 50° to 130° of flexion, with both patients reporting satisfactory functional recovery (Table I and Fig. 4).
Table I.
Summary of patient characteristics, surgical details, and outcomes at last follow-up (14 months).
| Patient | Age/sex | Mechanism of injury | Delay before reconstruction | Size of implanted allograft (cm) | Complication | Time to union (mo) | Final range of motion (°) | Functional outcome |
|---|---|---|---|---|---|---|---|---|
| 1 | 26/M | High-velocity gunshot wound (military) | 3 weeks | 10 | Instability stabilized with an articulated external fixator | 8 | 55-118 | Returned to light professional activity QuickDASH = 53 |
| 2 | 32/M | High-velocity gunshot wound (military) | 6 weeks | 12 | Early post-operative infection (2 surgical washouts) | 10 | 65-121 | Satisfactory daily function QuickDASH = 55 |
QuickDASH, Disabilities of the Arm, Shoulder and Hand.
Figure 4.
Final range of motion of both patients at more than one year of follow-up after management of post-operative complications (infection, instability). (A) Patient 1 with elbow extension to 65°. (B) Patient 1 with elbow flexion to 121°. (C) Patient 2 with elbow extension to 55°. (D) Patient 2 with elbow flexion to 118°. (E) One-year post-operative computed tomography reconstruction of patient 1 demonstrating solid union at the graft–host junction with near-complete graft integration. (F) One-year post-operative radiographs of patient 2 after removal of humeral hardware, demonstrating graft–host union with partial graft integration.
Discussion
Rationale and comparison with the literature
Reconstruction of massive distal humeral bone loss following ballistic trauma represents a major challenge due to the combined destruction of bone, joint structures, and soft tissues. Conventional strategies such as internal fixation, arthrodesis, or total elbow arthroplasty are generally not applicable in the cases presented. Amputation remains a last-resort option in situations of uncontrollable infection or non-reconstructible soft tissue loss, but it is often poorly accepted by young patients.9 Osteoarticular allografts have been reported as an alternative for distal humerus reconstruction after tumor resection or closed trauma, allowing restoration of bone stock and joint anatomy while preserving limb length and retaining a degree of functional potential.4,10 However, no published work has reported cases related to war-related trauma with concomitant soft tissue loss. To our knowledge, this is the first description of a single-stage reconstruction combining a massive osteoarticular allograft with a pedicled latissimus dorsi flap for ballistic distal humeral bone loss.
Advantages and limitations
The main advantage of this approach lies in the ability to perform bone, ligamentous, and soft tissue reconstruction in a single operative stage. The pedicled latissimus dorsi flap is particularly well suited for elbow coverage, providing substantial tissue volume, high vascular reliability, and minimal donor-site morbidity. This technique also preserves humeral bone stock, articular congruence, and the potential for functional recovery. However, it is a technically demanding and lengthy procedure that requires close coordination between orthopedic and plastic surgery teams. Its main limitations include the risks of infection, instability, graft resorption, or secondary lysis, as well as late degenerative changes related to chondrocyte necrosis and the partial revascularization of the allograft. It must be emphasized that osteoarticular allografts do not fully incorporate biologically: osseous union is typically achieved at the graft–host junction, while the central portion of the graft undergoes only partial revascularization.8 Moreover, the articular cartilage remains nonviable and may progressively deteriorate over time, potentially leading to secondary degenerative changes. In our series, an early post-operative infection occurred but was successfully managed with 2 surgical débridements, without graft loss. Long-term follow-up is necessary to assess the durability of the osteogenic junction and the evolution of the elbow articular cartilage. Nevertheless, the small sample size and short follow-up period limit the generalizability of these results. An alternative in selected cases is pedicled bone grafting or arthrodesis, which, although functionally less “brilliant,” may provide a more durable biological solution with permanent joint fusion once solid bony union is achieved.7
Clinical relevance
This combined approach is particularly relevant in high-energy ballistic injuries with massive bone loss in young patients with high functional demands. In such cases, this reconstruction may be considered a temporary functional preservation strategy, aimed at maintaining joint motion and bone stock for as long as possible. However, this strategy should not be regarded as definitive. Given the biological limitations of osteoarticular allografts and the risk of long-term degenerative changes, secondary surgical procedures (such as arthrodesis or arthroplasty) may eventually be required. Importantly, the reconstruction described does not preclude or compromise potential future salvage procedures. Residual limitations in extension may occur and are likely multifactorial, related to extensive soft tissue reconstruction, post-operative fibrosis, and the prioritization of stability in this complex setting.
Conclusion
Single-stage reconstruction of massive distal humeral bone loss using a combined osteoarticular allograft, ligament reconstruction, and a pedicled latissimus dorsi flap offers a reliable option for young patients with complex ballistic injuries. In our 2 cases, this biological approach provided stable bone union, relatively satisfactory elbow motion, and durable soft-tissue coverage despite post-operative challenges. Although longer follow-up and larger cohorts are required, this technique appears to be a valuable reconstructive alternative when preservation of limb length and function is desired.
Disclaimers
Funding: No funding was disclosed by the authors
Conflicts of interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Declaration of generative AI and AI-assisted technologies in the writing process
During the preparation of this work, the authors used generative AI tools to assist with language editing and grammar correction. After using these tools, the authors carefully reviewed and edited the content as needed and take full responsibility for the content of the publication.
Footnotes
This study was reviewed and approved by the local ethics committee of HIA Laveran (Acasan).
References
- 1.Bilichtin E., de Rousiers A., Durand M., de l’Escalopier N., Collombet J.-M., Rigal S., et al. Bone reconstruction by the induced membrane technique. What differences between conventional and ballistic trauma? Orthop Traumatol Surg Res. 2020;106:797–801. doi: 10.1016/j.otsr.2019.10.026. [DOI] [PubMed] [Google Scholar]
- 2.de Geofroy B., Pfister G., Andro C., Choufani C., Lemé C., Mathieu L., et al. Non-vascularized fibular autograft for two-stage scapulohumeral arthrodesis in ballistic shoulder injuries: a case series and review. Mil Med. 2025;25 doi: 10.1093/milmed/usaf362. [DOI] [PubMed] [Google Scholar]
- 3.Held M., Engelmann E., Dunn R., Ahmad S.S., Laubscher M., Keel M.J.B., et al. Gunshot induced injuries in orthopaedic trauma research. A bibliometric analysis of the most influential literature. Orthop Traumatol Surg Res. 2017;103:801–807. doi: 10.1016/j.otsr.2017.05.002. [DOI] [PubMed] [Google Scholar]
- 4.Kamalapathy P., Shah A., Raskin K., Schwab J.H., Lozano-Calderón S.A. Complications and survivorship of distal humeral allograft reconstruction after tumor resection: literature review and case series. JAAOS Glob Res Rev. 2021;5 doi: 10.5435/JAAOSGlobal-D-20-00256. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Karuppaiah K. Is there a role for elbow arthrodesis in 21st century - current concepts and overview of surgical techniques. J Clin Orthop Trauma. 2021;20 doi: 10.1016/j.jcot.2021.05.028. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kauta N., Bott A., Majirija E.T., Du Plessis J.P., Vrettos B., Maqungo S., et al. Surgical management of distal humerus gunshot fractures: descriptive case series. Eur J Orthop Surg Traumatol. 2023;33:3711–3716. doi: 10.1007/s00590-023-03611-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Koller H., Kolb K., Assuncao A., Kolb W., Holz U. The fate of elbow arthrodesis: indications, techniques, and outcome in fourteen patients. J Shoulder Elbow Surg. 2008;17:293–306. doi: 10.1016/j.jse.2007.06.008. [DOI] [PubMed] [Google Scholar]
- 8.Luk J., Stoker A.M., Teixeiro E., Kuroki K., Schreiner A.J., Stannard J.P., et al. Systematic review of osteochondral allograft transplant immunology: how we can further optimize outcomes. J Knee Surg. 2021;34:30–38. doi: 10.1055/s-0040-1721670. [DOI] [PubMed] [Google Scholar]
- 9.Maciver M., Dixon D., Powell D. Quality of life in young people with limb loss: a systematic review. Disabil Rehabil. 2024;46:4323–4334. doi: 10.1080/09638288.2023.2270908. [DOI] [PubMed] [Google Scholar]
- 10.Russo R., Guastafierro A., Della Rotonda G., Viglione S., Ciccarelli M., Fiorentino F., et al. Osteochondral allograft transplantation for complex distal humeral fractures assisted by 3D computer planning and printing technology: technical note. Eur J Orthop Surg Traumatol. 2022;32:1443–1450. doi: 10.1007/s00590-021-03118-6. [DOI] [PubMed] [Google Scholar]
- 11.Sanchez-Sotelo J. Management of the infected total elbow arthroplasty. Bone Joint J. 2024;106-B:1321–1326. doi: 10.1302/0301-620X.106B11.BJJ-2024-0549.R1. [DOI] [PubMed] [Google Scholar]
- 12.Shin E., Sabino J., Nanos G., Valerio I. Ballistic trauma: lessons learned from Iraq and Afghanistan. Semin Plast Surg. 2015;29:010–019. doi: 10.1055/s-0035-1544173. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Vauclair F., Goetti P., Nguyen N.T.V., Sanchez-Sotelo J. Distal humerus nonunion: evaluation and management. EFORT Open Rev. 2020;5:289–298. doi: 10.1302/2058-5241.5.190050. [DOI] [PMC free article] [PubMed] [Google Scholar]