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

Abstract

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-026-01270-6.

Introduction

Ballistic injuries are associated with severe trauma, disability, and fractures to the long bones associated with osteomyelitis [1, 2]. The Russia-Ukraine war consists of two periods as a hybrid one during 2014–2022, followed by a full-scale invasion in February 2022, accompanied by the large-scale use of multiple launch rocket systems, artillery ammunition with volumetric action, various high-speed and hypersonic missiles, FPV drones constituting low- and high-velocity projectiles [3–5]. These weapons cause a high mortality or sanitary losses among those who survived, showing injuries to the maxilla-facial are, abdomen, genitourinary tract, damage to the major vessels, as well as significant defects to the long bones [6–13]. The severity of the combat trauma has been demonstrated in basic and clinical studies [14, 15]. 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 [1, 2, 16, 17]. Also, the patients with combat-related osteomyelitis usually demonstrate challenges for the war surgeons, because of a frequent unusual course of the trauma requiring a careful patient-centered approach, which helps to improve management guidelines and achieve the best treatment outcomes [6–13]. For example, Ukrainian surgeons presented a possibility of application of minimally invasive technologies, hemodialysis, etc., at various Roles of deployed field hospitals, which is in contrast to NATO’s guidelines or current protocols within the Military Medical Doctrine of Ukraine [18, 19]. To improve the management of patients with bone fractures and osteomyelitis is also an important task for military medicine, because of the frequent presentation of patients with segmental bone defects > 5 cm. Although the utility was demonstrated for open reduction and internal fixation (ORIF), intramedullary nailing (IMN) as well as for 3D-printing with various graft materials, the approaches for the effective treatment of post-traumatic combat-related osteomyelitis should be elucidated [11, 20]. The combat injuries to the femur are associated with post-traumatic combat-related osteomyelitis, and the latter have not been presented before from the war in Ukraine, suggesting a possible differential approach to the management of such patients.

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

A 19 male patients were identified for the study. These patients were servicemen of the Armed Forces of Ukraine who were injured in the Russia-Ukraine war from September 2022 to June 2023 in various regions of Ukraine. These individuals were diagnosed with multifragmentary fractures of the femur complicated by osteomyelitis due to ballistic injury on the battlefield. The Cierny-Mader osteomyelitis classification was applied for the evaluation of the patients’ injuries [21]. Patients were treated at the Role 3 and 4 hospitals in Kyiv and Kharkiv cities. The echeloned deployed hospitals’ Role system was adopted within the Military Medical Doctrine of Ukraine and presented in detail in our previous studies [22]. All patients with femoral post-traumatic combat-related osteomyelitis were eligible for the study, including those who had damage to vessels and nerves. All 19 patients were neither diagnosed with damage to the major vessels nor to the nerves. Upon admission, all patients underwent clinical chemistry investigations, measurements of C-reactive protein, procalcitonin, chest X-ray, and X-ray-guided fistulography, whole body multispiral computed tomography (CT) scan with angiography of magistral vessels, as well as Doppler ultrasonography. Wound culture was performed to achieve optimal antimicrobial stewardship. The considerable evidence suggests applying a specific orthopedic tactic for the post-traumatic and ballistic-associated osteomyelitis, as well as other gunshot-related bone defects, as we presented previously [11]. The orthopedic tactic for the femoral osteomyelitis included 4 stages to achieve the best treatment results.

Stages of management

The Stage I (sanitation stage) included damage control surgery (DCS) and damage control resuscitation (DSR), primary surgical debridement with sequestrectomy and pulsed lavage systems application, and fasciotomy. At Stage 1, an ultrasonic cavitation and vacuum-assisted closure (VAC) therapy were applied according to the method presented before by using VAC-machine KCI (Heaco, China) and Sonoca 185 (Söring, Germany) [4, 11, 12, 23].

At Stage ІІ an intramedullary osteosynthesis and application of antibacterial coated intramedullary nails were applied.

At Stage ІІІ stabile bone fixation systems were installed. These included Illizarov external fixation devices and their modifications, as well as corrections of the previously installed temporary bone external fixation devices. The modular external fixation system serves as a temporary device installed at the Role 2 of medical facilities prior to evacuation of the patients to Role 3 or 4.

At Stage ІV a substitution and plastics of the bone defects were performed using the following approaches: autoplasty, alloplasty by cortico-medullary granules, alloplasty by synthetic bone graft substitutes (e.g. Neobone, TriOSS, Neocement), transosseous bilocal compression-distraction osteosynthesis for > 5 cm bone defects.

Conversion from internal to external fixators

The conversions from internal to external fixation were considered in case of infection of the intramedullary nails and development of osteomyelitis of the femoral fragments. Confirmatory criteria were applied for internal fixation-related infection. The presence of at least one of the following signs confirmed the infection of the internal fixator:

1. Presence of a fistula or wound communicating with the implant or bone.

2. Purulent discharge from the wound or around the structure.

3. Positive microbiological culture: the same pathogen in ≥ 2 separate tissue or fluid samples.

4. Pathohistological confirmation of infection: presence of neutrophils in periprosthetic tissues.

5. Detection of microorganisms on histopathology or special microbiological staining.

Antibiotic susceptibility approach

The wound culture was performed before and during the surgery, as well as every 3–4 days in the post-operative period. Assessment of the wound culture included the kind of pathogen, quantitative contamination, and sensitivity to antibiotics. This approach allowed for a dynamic assessment of the microbial landscape and timely adjustment of antibacterial therapy.

Before the results of the wound culturing and considering common infectious agents previously identified in the combat patients (i.e., a mix of Gram-positive and Gram-negative bacteria, anaerobes), an intravenous empiric antibiotic therapy was performed using the following schemes: cephalosporins of the III–IV generation (ceftriaxone, ceftazidime, cefepime) and metronidazole (to cover possible anaerobes), fluoroquinolones (ciprofloxacin, levofloxacin). Carbapenems (meropenem, imipenem) were administered in case of a severe course of the infection or suspicion of multidrug-resistant bacteria.

Further antibacterial therapy was adjusted according to the results of the antibiogram. The most typical treatment options were applied: methicillin-sensitive Staphylococcus aureus - cefazolin, oxacillin, amoxicillin/clavulanate; MRSA - vancomycin, linezolid, daptomycin; Gram-negative bacteria (Pseudomonas aeruginosa, Enterobacter spp.) - ceftazidime, cefepime, fluoroquinolones, carbapenems. In case of polymicrobial associations, the following antimicrobial therapy was administered: combination therapy according to the sensitivity profile; anaerobic microflora - metronidazole as part of combination regimens. Correction of antibiotic therapy was carried out each time the spectrum of pathogens changed or according to the results of repeated wound culture studies. Usually, the parenteral administration of antibiotic therapy was continued for 14–21 days. The total duration of antibiotic treatment was 6–8 weeks, which depended on the osteomyelitis process, the radicality of surgical resection, as well as the results of serial wound culture studies.

Follow-up assessments

The patients were under follow-up for 3, 6, and 8 months to evaluate osteomyelitis relapse, bone graft resorption status, condition of bone consolidation. At follow-up, the patients were assessed for radiological signs of bone regeneration formation, the degree of bone mineralization and corticalization, the possible relapse of the osteomyelitis, as well as the functional status of the limb. Verticalization of patients was carried out in stages with a gradual increase in axial load on the limb depending on the status of the bone regeneration. In the post-operative period, all patients were admitted to rehabilitation Role 5 military medical centers.

Results

The mean age of the wounded was 34 ± 8,7 years (range 22–50 years). The mean time from the moment of injury to the development of complications in the form of post-traumatic osteomyelitis was 90 ± 5 days (range 80–100 days). All patients had combat-related Gustilo Type III femur fractures. The injury patterns and clinical outcomes are summarized in Table 1.

Table 1.

The analyses of the trauma patterns and treatment approach for the patients

Patient ID	Age, years	Mechanism of injury	Bone defect length, cm	Cierny-Mader type	Time from injury to reconstructive surgery, months	Installation of the antibiotic-loaded bone cement, type
1.	45	Blast	8	IV	2	Intramedullary coated nail
2.	38	Blast	10	IV	3	Was not applied
3.	25	Blast	12	IV	1.5	Was not applied
4.	52	Blast	9	IV	3	Was not applied
5.	48	Gunshot	7	IV	2.5	Was not applied
6.	37	Blast	8	IV	3	Was not applied
7.	44	Blast	11	IV	1.5	Was not applied
8.	48	Gunshot	9	IV	3	Was not applied
9.	40	Blast	11	IV	2.5	Was not applied
10.	52	Blast	9	IV	3	Was not applied
11.	37	Blast	9	IV	1.5	Was not applied
12.	43	Blast	10	IV	4	Block-shaped spacer
13.	46	Blast	8	IV	2.5	Was not applied
14.	53	Blast	10	IV	3	Block-shaped spacer
15.	43	Blast	9	IV	3	Intramedullary coated nail and Block-shaped spacer
16.	38	Gunshot	7	IV	2.5	Was not applied

The wound culture revealed 10 various Gram-positive and Gram-negative bacteria in the wounds, with predominance of Klebsiella pneumoniae (32% out of all bacteria), which is a common contaminant in the wounds of combat patients (Fig. 1). The wound healing and bacterial status were taken into consideration for further antibiotic therapy.

Fig. 1.

Analysis of the wound culture showing dominance of the Klebsiella pneumoniae in the wound as a typical bacterial contamination agent of the ballistic trauma

An example of the modular external fixation system is demonstrated in Fig. 2.

Fig. 2.

An example of the modular external fixation system serves as a temporary fixator of the severe multifragmentary fracture the upper 1/3 of the of the femoral bone: A. X-ray view of the fracture. B. Photograph of the patients with installed modular external fixation system

By applying Cierny-Mader osteomyelitis classification, the Type I (medullary osteomyelitis) was diagnosed in 3 (15.7%) patients, Type II (superficial osteomyelitis) in none of the patients, Type IІІ (localized osteomyelitis) in 6 (31.5%) patients, Type ІV (diffuse osteomyelitis) in 10 (52.6%) patients (Fig. 3).

Fig. 3.

Illustration of the post-traumatic ballistic-related osteomyelitis with localization in the of the upper 1/3 of the femoral bone (Stage IV Diffuse by Cierny-Mader classification). A and B – X-ray films showing signs of the osteomyelitis (marked with arrow); C – surgically removed femoral bone fragment with signs of osteomyelitis

An upper extremity amputation was performed in 3 (15.7%) patients at the level of the upper 1/3 of the femur due to generalization of the inflammation and septic changes.

There were applied various approaches for the external bone fixation by the Illizarov device, as well as monofocal, bifocal, and multifocal compression-distraction osteosynthesis.

Out of 19 patients, 5 (26%) had a significant bone defect > 7 cm with subsequent diffuse osteomyelitis. The bone resection was performed for these 5 patients (Fig. 3), followed by multifocal osteosynthesis and distal osteotomy (Figs. 4 and 5).

Fig. 4.

Illustration of the x-ray view of the multifragmentary fracture of the 1/3 diaphysis of the right femur and features of the external fixation device. (A) Preoperative X-ray film showing fracture and signs of the osteomyelitis (marked with arrow). (B) Post-operative X-ray film at Stage I of the treatment showing area of the segmental resection of the femur affected with osteomyelitis (marked with arrow)

Fig. 5.

X-ray film of the post-traumatic osteomyelitis. (A) Gunshot multifragmentary fracture of the 1/3 diaphysis of the left femur complicated by gunshot osteomyelitis. (B) First stage of treatment: visualized resected segments of the right femur with application of the multifocal compression-distraction osteosynthesis construction

Out of 19 patients, 4 (21.1%) 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 (Fig. 6).

Fig. 6.

Illustration of unconsolidated gunshot multifragmentary fracture of the 1/3 diaphysis of the left femur complicated by post-traumatic osteomyelitis and treated with blocked intramedullary osteosynthesis (A) Intraoperative photograph of the femur fracture complicated with osteomyelitis. The bone defect is marked with arrow and yellowish fragment of rod is seen in the bone canal. The patient underwent removal of the metal construction, the femur was resected for 6 cm, the bone canal was irrigated followed by implantation of the antibiotic-loaded bone cement (vancomicyn 4 g), (B) X-ray film showing resected bone segments, external fixation devices. (C) X-ray film showing bilocal compression-distraction osteosynthesis. (D) X-ray of the patents 8 months after the injury showing consolidation of the two zone of the resected bone in upper 1/3 of the femur as well as strengthened bone regenerate in lower 1/3 of the left femur

Out of 19 patients, 6 (31.5%) 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 (Fig. 7).

Fig. 7.

Illustration of the multilocal compression-distraction osteosynthesis. A and C. X-ray film showing metal construction of the multilocal compression-distraction osteosynthesis with distal and proximal osteotomy of left femoral diaphysis. B and D. X-ray film 8 months after the injury showing metal constructions as well as replaced bone defect with unsolidified proximal and distal regenerate, consolidation of the comparison zone. E. Photograph of the verticalized patient 8 months after the injury and after the removal of external fixation devices

Out of 19 patients, 3 (15.7%) patients underwent conversion from internal to external fixator due to infection (patients ID 1, 8, 15 – Table 1, Table S1).

The mean time from injury to reconstructive surgery was 91 ± 5 days (range 90 to 120 days). The mean number of wound debridements was 8 ± 2 to achieve the infection eradication. The mean time of the eradication of infection and fracture healing was 9 ± 1.5 months. The overall duration of the treatment at the orthopedics ward was 8–9 months. The follow-up was available for 16 patients, excluding patients who underwent limb amputation (Supplementary Table S1).

Discussion

This study presents the current approach for management of the common and severe ballistic injury to the femur associated with osteomyelitis. It is also a presentation of the experience from Ukrainian orthopedic war surgeons, which might be useful for specialists in the field of military medicine. To our best knowledge, this is the first orthopedic study from the Russia-Ukraine war showing a differential approach in the management of the femoral ballistic-related fractures and osteomyelitis.

The bone fractures and limb amputations are frequently seen in armed conflicts and wars, as we have presented previously. In line with previously published series from combat studies, application of the known techniques and their adaptation to deployed settings is doable even in such resource-limited conditions as we have in Ukraine [4, 7, 11, 24–27]. Similar to Ertaş ES, this report also highlighted osteomyelitis secondary to ballistic injury with severe bone defects [27].

Similar to others, we also reported considerable evidence of frequent bacterial contamination of the bones and osteomyelitis formation in the combat-related patients [1, 2, 28, 29]. The microbial contamination was and remained a significant negative factor for the purulent complications, including osteomyelitis. Similar to others, we reported polymicrobial agents in our patients.

In line with previously published reports, we have also detected Klebsiella Pneumoniae as a dominant wound microbe [16, 17]. Rodero Roldán et al. and Taher et al. also reported Gram-negative bacilli and Staphylococcus aureus in combat patients, emphasizing frequent polymicrobial wounds [28, 30]. In contrast, Yun et al. demonstrated majority of patients infected mainly with Acinetobacter spp. in injured in OIF/OEF casualties [31]. Also, Taher et al. reported mainly multidrug-resistant Pseudomonas aeruginosa in the wounded in Mosul and Gaza [28]. Still, all studies confirmed frequent Gram-negative and antibiotic-resistant microbes with a risk of multidrug resistance, which is in line with our findings [30, 32].

Considering the ballistic properties of weapon projectiles, special attention should be paid to limb injuries, to be often associated with multistructural changes due to damage to almost all anatomical structures (i.e. skin, nerves, vessels, muscles, and tendons) [33]. In this matter, massive damage to soft tissues along with gunshot fractures frequently leads to the emergence of massive segmental defects of bone tissue, which we also considered during war orthopedics protocols [11, 14, 20, 34].

A gunshot-related osteomyelitis is considered a specific entity and challenging for orthopedic war surgeons due to its association with severe bone defects, multidrug-resistant bacteria, accompanied by massive damage to bone tissue, with its subsequent osteonecrosis and the formation of bone sequestra. Taken together, these features of combat trauma require specific measures as well as a differential approach, as we have demonstrated in this paper. In our opinion, the key to successful treatment of ballistic osteomyelitis is early diagnosis, including sampling for microbiological and histopathological examination, to ensure targeted and long-term etiotropic antibacterial therapy. In this study, we introduced radical surgical debridement to ensure stabilization of bone fragments, the use of spacers with antibiotics, and intravenous antibiotic therapy.

Gunshot fractures of the femur are usually complicated by post-traumatic osteomyelitis, resulting in sequestration of bone fragments, which in turn leads to massive bone defects, which pose a problem in further fixation of these fragments, replacement of bone defects, and restoration of the supporting capacity of the damaged limb. In this matter, antibiotic cement-coated rods and spacers demonstrate their utility for combat settings, which is in line with other reports of osteomyelitis [35].

In this study, we have also demonstrated the need for conversion from an external fixator to an internal fixator. This is a typical approach in case of infection, and our data are in line with Zhao et al., who also suggested applying such an approach in case of infection in civil patients. Zhao et al. reported 13% of cases with postoperative infection due to open fractures, which is close to our frequency of 15.7% in combat patients [36].

Apart of antibiotic therapy, it is important to apply appropriate external fixation devices. The application of modular external fixation systems is a temporary, but important part of the management of patients, as shown in this study. These temporary fixation devices are applied for the ballistic injuries to the bones in order to temporarily fix the bone fragments before healing of other tissue wounds, as well as to get the time for the decision to choose the best fixation device, which might be an intramedullary nail or another fixation method. The utility of using modular external fixation is that it is easier and faster to install as compared to compression-distraction osteosynthesis to achieve good fixation of bone fragments. We also demonstrated several kinds of compression-distraction osteosynthesis (osteogenesis) techniques with rod devices in various modifications. The compression-distraction osteosynthesis is a well-known approach to treat patients with defects of the long bones in both combat and civil trauma conditions, and our study confirmed its utility for the post-traumatic and ballistic-related osteomyelitis with severe defects (> 7 cm) of the femur [37, 38]. The compression-distraction osteosynthesis might be considered as bilocal in case of two locations, or multilocal in case of several locations of bone defects, which is common in combat trauma [39]. Despite its overall usefulness, the possible disadvantages of the compression-distraction osteosynthesis are related to the massiveness of the metal construction as well as the impossibility of fixing small bone fragments.

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.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

IL – designed the study, drafted the manuscript, literature search, and analyses; OB – study conception and design, collected the data; YK – designed the study, acquisition of data, drafted manuscript, literature search, and analyses; SS – study conception and design, collected the data, preparation of figures; IR – study conception and design, collected the data; MG – drafted the manuscript, literature search, and analyses; AM – drafted the manuscript, literature search, and analyses; AD – analysis, and interpretation of data, critical revision and supervision; final approval, submission of the manuscript. All authors read and approved the final manuscript.

Funding

The study received no funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

The study was approved by the Ethical committee at Bogomolets National Medical University (Kyiv, Ukraine). The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from participants.

Competing interests

The authors declare no competing interests.