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Crush injuries of the foot are one of the most difficult and challenging tasks for a trauma surgeon to manage in terms of limb salvage and provision of a painless functional foot. Injuries to the foot, especially the hindfoot, account for almost 24.6% of all the warfare injuries in Afghanistan, of which more than 70% end in amputation for various reasons. We devised a method using the principles of Ilizarov’s distraction osteosynthesis to salvage limbs with bony defects in the hindfoot which otherwise were candidates for amputation. The procedure is done in two stages. Initially, the ring fixator is applied for the soft tissue reconstruction and infection control, and the next stage consists of percutaneous “inverted L”-shaped osteotomy in the posterior half of the lower tibia. The study included 32 patients with hindfoot crush injuries involving talus, calcaneum, a combination of both, or even involving the adjacent tarsal bones. All these crush injuries were classified using the Gustilo and Anderson classification. The postoperative functional assessment of the feet was done using the Maryland Foot Score system with a minimum follow-up of four years. We had good results in 53%, fair in 34% and failure in 13% of our cases. The complications of this procedure were the same as with the use of the ring fixator elsewhere in the body. This method provides a technique to salvage the foot and produce a painless, stable, fused foot in one of the most difficult settings of a hindfoot crush injury.
Le traitement des écrasements du pied est une des thérapeutiques les plus difficiles pour les chirurgiens traumatiques notamment si l’on veut conserver le membre. Ces lésions, notamment celles de l’arrière pied ont représenté 24.6% des blessures de guerre en Afghanistan, 70% d’entre-elles conduisant à une amputation pour diverses raisons. Nous avons utilisé une méthode selon les principes de l’ostéosynthèse en distraction d’Ilizarov chez des patients qui étaient candidats à l’amputation. Le traitement a été réalisé en deux temps. Initialement le fixateur circulaire est utilisé pour la reconstruction des tissus mous et pour permettre le contrôle des problèmes infectieux, secondairement est réalisée une ostéotomie inversée en L au niveau de la partie postérieure basse du tibia. Ce travail a permis d’analyser 32 patients présentant de telles lésions. Ces lésions ont été classées selon Gustilo et Anderson. Le devenir fonctionnel des pieds opérés a été évalué selon le score de Maryland (MFS) sur un suivi minimum de 4 ans. Nous avons obtenu 53% de bons résultats, 34% de résultats moyens et 13% d’échecs. Cette technique permet d’améliorer la conservation du membre ainsi que la stabilité et l’indolence du pied.
Crush injuries around the hindfoot are very complex to manage, because of the anatomy, the specialised heel cover and importance for weight bearing. Unfortunately there are no standard protocols or guidelines for management of these injuries. As we mentioned earlier, most of these injuries are due to warfare trauma, especially anti-personnel mine blasts. These patients are usually very young active individuals. The most common line of management for these patients is below knee amputation, around 70% . There are few options for treating compound comminuted fractures of the hindfoot with added superficial infection, so we designed an indigenous salvage procedure using the Ilizarov ring fixator for those who had primarily adequate soft tissue covering of the sole or after initial debridement and plastic cover with fasciocutaneous or myocutaneous flaps or split skin grafting.
The aim was to give the patients a pain-free, infection-free and stable foot at the cost of mobility, so that they could resume their activities of daily living without the sense of being disabled. The only prerequisite for this salvage procedure is adequate neuro-vascular status of the foot.
Our study presents 32 such cases, which were salvaged with the ring fixator and their functional outcome.
From 1984, 32 patients were treated for crush injuries of hindfoot using this approach. The mean age was 23.5(19–28) years. All were male apart from one female. The most common mode of injury was directly or indirectly stepping on a landmine, in 27 cases; four sustained injury on the battle field due to heavy machine guns; and one suffered the injury due to a road traffic accident. All these crush injuries were classified using the Gustilo and Anderson [4, 5] classification for open injuries. All were grade IIIb/c injuries (Figs. 1 and and2).2). The procedure is divided into two stages. In the first stage we apply the fixator so that it serves as an external splint and allows soft tissue to heal, immobilizes the limb, and allows redebridements and any plastic procedures if required. Nine cases who had soft tissue loss around the foot were successfully treated using fasciocutaneous or myocutaneous flaps, and split skin grafts either from the same or the opposite limb.
The apparatus consists of two full rings for proximal hold applied to the mid tibia, using 2 crossed wires on each ring. Next a half ring is fixed using one or two Kirschner wires to the metatarsals. The purpose of this half ring is to prevent equinus deformity and for compression of the midfoot to the hindfoot at a later stage if necessary. It is connected to the tibial rings via connectors. Once the soft tissue had healed, we performed a percutaneous corticotomy of “inverted L shape” of the posterior half of tibia in coronal plane by using our Gigli saw technique. It was fixed with another half ring with the help of two K-wires and connected to the main rings with the help of connectors (Fig. 3). It should be mentioned that when the malleoli are intact and the talus is removed malleolectomy should be done to align the bone for better cosmesis. Any articular areas or joints (tibiotalar, subtalar or transverse talar joints) if partially intact are curetted out via a separate incision to achieve fusion.
Distraction is started after one week at the rate of 1 mm/24 hours divided into four 0.25-mm increments (Fig. 4). Once the talocalcaneal gap and any bony gap in the consolidating transverse tarsal joints is replaced with the new bone, the fixator left in situ until evidence of remaining of callus and fusion around the ankle area is seen radiographically (Fig. 5). The apparatus is then removed and the limb is put into a below-knee cast for three months. Patients were observed postoperatively and were evaluated with serial radiographs and clinical examinations (Fig. 6). At the final follow-up examination, the Maryland Foot Score (MFS)  system was used to assess the functional outcome.
Twenty-six patients were available for follow-up at a mean interval of seven years (range 4 to 16 years). All these patients were injured due to landmine blast except for two who were injured by a machine gun. All were compound grade III injuries. The bony defects varied from crushing of calcaneum (six patients) to comminuted fractures of calcaneum and talus (ten patients) and comminution of calcaneum, talus along with navicular, cuboid and cuneiforms (eight patients). The remaining four patients had a combination of the above fractures associated with fractures of both leg bones of the same limb, along with subluxation or dislocation of the surrounding joints.
Average time for the fixator in situ was 125 days (100–206 days), and 3 months in below-knee cast.
At a mean follow-up of 7 years, the mean MFS of our patients was 63 (43 to 84) against maximum of 100 (Tables 1 and and2).2). Fifty-three percent of our patients had good results according to MFS score, they used to get slight pain without affecting their activities of daily living (ADL) after walking for about four kilometres; 34% had fair results, meaning mild pain resulting in minimal modifications of their daily activities and modification of their shoes; and the rest had poor results. Most of our patients had a stable limb and could walk without any aid with a slight limp and minor shoe modifications. Stair climbing was not affected in 65% of our patients, but most of them had difficulty in walking over uneven surfaces. Cosmetically, most of them had a plantigrade but scarred foot (Fig. 6).
The complications we faced during our treatment course were infection in 11 patients. Two underwent below-knee amputation and the rest responded to intravenous antibiotics, change of pins and further debridements. Two of these cases returned with chronic discharging sinus not responding to antibiotics after 13 and 17 months of injury respectively and both of them refused to undergo amputation. Below-knee amputation was done in one more patient due to postoperative gangrene. Three of our patients had chronic ischemic and neurological changes in midfoot and forefoot. At the end of treatment all the fractures had united and there were no nonunions.
Landmine injuries are special because of the ravaging wounds that they frequently inflict not only through the blast effect but also by propelling dirt, bacteria, clothing, and casing fragments into soft tissue and bone, often causing secondary infection [1, 11, 15]. Because of the rarity of these injuries the treatment options available are not well defined.
Literature available for treating complex fractures around the foot due to mine blasts and war injuries is sparse and suggestions for treatment are: amputation [8, 18], secondary internal fixation , arthrodesis [2, 6, 7], and minimal osteosynthesis using Kirschner wires . However, the usual outcome of all these treatment modalities is unsatisfactory and most end in below- or even above- knee amputations. To the best of our knowledge no one has described the method which we have developed to salvage these limbs.
Salvaging these types of limbs or opting for primary amputation will always be debated among traumatologists. The arguments in favour of amputation are early rehabilitation and short hospital stay, but in our experience most of our patients refuse to consent to amputation. The availability of good prostheses is also a limiting factor. The method described by us salvages the foot giving our patients a painless, sensate, plantigrade foot with good functional results and low failure rates. Salvaging the limb is also more cost effective in the long run, as has been proven by various studies [10, 14].
According to Hansen , amputation frequently is the best solution for a comminuted pilon fracture associated with a comminuted talus or calcaneus fracture, though it might even be possible to save the limb.
Khan et al.  studied 28 feet with landmine injuries and could salvage only four feet with injuries to forefoot; the rest of them underwent below-knee amputation.
Beals  states that limb salvage should be attempted in complex foot and ankle trauma and all options should be discussed with the patients; the use of a ring fixator is a good option.
With advances made in trauma management we feel that we still need to improve and find better ways to salvage rather than amputate the limbs as this not only gives the patient the feeling of not being disabled but also is more economical in the long term .
There is a growing support in the literature for limb salvage using external ring fixator in complex foot and ankle fractures. Clinical studies that determine definitively the optimal treatment for particular injuries are absent.
So we present our method as an option available for combating these complex injuries, with a double advantage: first, the Ilizarov fixator is used as an external splint for immobilisation and soft tissue healing, and second, the same frame is converted into a definitive treatment method which is patient friendly. Mobilisation of the patient is also accelerated and it has fewer complications than other devices.
The main drawback of our procedure is the so-called “inverted L”-shaped osteotomy, which is a complex operative procedure with high risk of neurovascular insult, especially in those who have undergone plastic procedures.
As the world becomes more and more victim of the so- called terrorism by individuals, parties and governments and the use of weapons increases we should try to find ways of salvaging these limbs and not amputating them.
Mussa Wardak, Email: moc.liamffider@kadrawmmrd.
Emal Wardak, Email: moc.liamg@igplame.