Sequential Osteosynthesis in the Context of Modern Armed Conflicts

BACKGROUND: Limb injuries remain the most prevalent combat injuries in modern armed conflicts, accounting for 55% to 75% of all cases. The transosseous compression-distraction osteosynthesis technique developed by Ilizarov has long been used in Russia to treat this patient population. However, given the current rate of mass casualty admissions to central military medical facilities, there is a growing need to improve treatment quality while shortening treatment time. Sequential internal osteosynthesis is one way for improving care. Antibiotic-coated implants reduce the risk of infectious complications during sequential osteosynthesis. AIM: This study aimed to assess the efficacy of sequential osteosynthesis in the treatment of gunshot fractures of long bones of the limbs in the current armed conflict setting, based on our clinical experience and global scientific data. METHODS: The study is based on an analysis of treatment outcomes in 320 patients with upper and lower limb injuries who received specialized medical care at the Department of Traumatology and Orthopedics of the N.N. Burdenko Main Military Clinical Hospital, Ministry of Defense of the Russian Federation. Patients were divided into three groups based on the osteosynthesis technique used. All patients were male, aged 18 to 59 years, with a mean age of 32.2 ± 9.02 years. Stepwise X-ray examinations were performed in all patients following osteosynthesis. Functional outcomes of humeral fracture treatment were assessed using the DASH score, whereas functional outcomes of femoral and tibial fracture treatment were evaluated using the Neer– Grantham–Shelton scale. RESULTS: The study included 90 patients (28.125%) with humeral fractures and 230 patients (71.875%) with lower limb injuries associated with femoral or tibial fractures. Shrapnel wounds and/or blast injuries predominated in 288 cases (90%). An intergroup comparison showed that antibiotic-coated implants significantly (p < 0.0167) accelerated the transition from external to internal fixation and reduced the risk of infectious complications. CONCLUSION: Sequential osteosynthesis has proven to be an effective two-stage treatment for long bone fractures in wounded individuals. In the context of modern armed conflict, it is considered the primary approach to managing isolated and multiple uncomplicated gunshot fractures, provided that established guidelines are strictly followed. Furthermore, given the recent advances in traumatology and orthopedics, antibiotic-coated implants can be used to reduce the risk of infectious complications. © 2025 Elsevier B.V., All rights reserved.