{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,13]],"date-time":"2026-10-13T00:46:44Z","timestamp":1791852404135,"version":"4.3.4"},"reference-count":31,"publisher":"Georg Thieme Verlag KG","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Z Orthop Unfall"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>As a life-saving procedure, limb amputation is frequently indicated in severe war injuries, especially in suboptimal medical supply. We report of a 56-year-old Ukrainian male who was wounded on the battlefield by an air attack during Russian early invasion in Zaporizhzhia. The blast injury caused a critical soft-tissue defect of the lower leg combined with comminuted fractures of the tibia and fibula. Although indicated, the patient refused the amputation of the lower leg. Initially closed reduction and stabilization by an external fixator, local debridement as well as soft-tissue coverage by a porcine skin were performed at a local field hospital. Due to destroyed infrastructure and missing escape corridors, further evacuation was difficult. Thus, it took 15 days to transfer the patient by ground transportation to our institution. Based on the massive tissue loss, superinfection necrosis and questionable blood supply, the indication for amputation was confirmed, but the patient insisted on limb preservation. To save the lower leg, a brought spectrum of regenerative strategies was applied, accompanied by standard trauma treatment regimens (debridement, vacuum sealing, antibiotics, intramedullary nailing, suralis flap).<\/jats:p>\n                  <jats:p>These included the local application of growth factors, the use of innovative tissue collectors, the implementation of biomaterial\/tissue combinations and the application of a vasodilator. Six months after treatment, the patient was free of pain and infection. However, further follow-up was complicated by delayed bone healing and required revision surgery. Although the limb was saved, it ultimately took 1 year until full rehabilitation was achieved. This case illustrates the special demands in war lower leg injuries but also demonstrates that a combination of standardized and innovative treatment protocols can save a limb, even when amputation might be indicated as a first-line therapy.<\/jats:p>","DOI":"10.1055\/a-2972-3247","type":"journal-article","created":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T23:54:27Z","timestamp":1791849267000},"source":"Crossref","is-referenced-by-count":0,"title":["Saving the Limb\u2014Tissue Collectors, Growth Factors, and Antibiotics in a War Injury"],"prefix":"10.1055","author":[{"given":"Eleftherios","family":"Papaeleftheriou","sequence":"additional","affiliation":[{"name":"St. Marien Hospital M\u00fclheim a.d. Ruhr, Germany","place":["M\u00fclheim a.d.Ruhr"],"department":["Department of Orthopaedics, Trauma and Reconstructive Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrea","family":"Sowislok","sequence":"additional","affiliation":[{"name":"University of Duisburg-Essen, NRW, Germany","place":["Essen"],"department":["Chair of Orthopaedics, Trauma and Reconstructive Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Wegner","sequence":"additional","affiliation":[{"name":"University of Duisburg-Essen, NRW, Germany","place":["Wolfsburg"],"department":["Department of Trauma, Orthopaedics and Hand Surgery, Klinikum Wolfsburg"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcel","family":"Haversath","sequence":"additional","affiliation":[{"name":"University of Duisburg-Essen, NRW, Germany","place":["Essen"],"department":["Chair of Orthopaedics, Trauma and Reconstructive Surgery"]},{"name":"University of Duisburg-Essen, NRW, Germany","place":["Nettetal"],"department":["Centre Arthroscopy and Arthroplasty, St\u00e4dtisches Krankenhaus Nettetal GmbH"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9516-1058","authenticated-orcid":false,"given":"Marcus","family":"J\u00e4ger","sequence":"additional","affiliation":[{"name":"St. Marien Hospital M\u00fclheim a.d. Ruhr, Germany","place":["M\u00fclheim a.d.Ruhr"],"department":["Department of Orthopaedics, Trauma and Reconstructive Surgery"]},{"name":"University of Duisburg-Essen, NRW, Germany","place":["Essen"],"department":["Chair of Orthopaedics, Trauma and Reconstructive Surgery"]},{"name":"Philippus Stift, Germany","place":["Essen"],"department":["Department of Orthopaedics, Trauma and Reconstructive Surgery"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"194","published-online":{"date-parts":[[2026,10,12]]},"reference":[{"key":"ref1","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1038\/s41536-018-0053-4","article-title":"Regenerative medicine and war: a front-line focus for UK defence","volume":"3","author":"A M Spear","year":"2018","journal-title":"npj Regener Med"},{"key":"ref2","doi-asserted-by":"crossref","first-page":"S1","DOI":"10.1097\/TA.0000000000001981","article-title":"The new reckoning: the combat casualty care research program responds to real and present challenges in military operational projections","volume":"85","author":"M R Davis","year":"2018","journal-title":"J Trauma Acute Care Surg"},{"key":"ref3","first-page":"66","article-title":"Risk factors for musculoskeletal injuries in the military: a qualitative systematic review of the literature from the past two decades and a new prioritizing injury model","volume":"8","author":"S Sammito","year":"2021","journal-title":"Mil Med Res"},{"key":"ref5","doi-asserted-by":"crossref","first-page":"304","DOI":"10.1055\/a-1073-8473","article-title":"Bone substitutes in orthopaedic surgery: current status and future perspectives","volume":"159","author":"A Busch","year":"2021","journal-title":"Z Orthop Unfall"},{"key":"ref6","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1186\/s13287-019-1461-0","article-title":"Surgical vacuum filter-derived stromal cells are superior in proliferation to human bone marrow aspirate","volume":"10","author":"K Henze","year":"2019","journal-title":"Stem Cell Res Ther"},{"key":"ref7","first-page":"808","article-title":"Bioactivation of scaffolds in osteonecrosis","volume":"51","author":"M Jager","year":"2022","journal-title":"Orthopadie"},{"key":"ref8","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1093\/milmed\/usab065","article-title":"IDCRP combat-related extremity wound infection research","volume":"187","author":"J L Petfield","year":"2022","journal-title":"Mil Med"},{"key":"ref9","doi-asserted-by":"crossref","first-page":"290","DOI":"10.1007\/s12178-015-9286-7","article-title":"Challenges in definitive fracture management of blast injuries","volume":"8","author":"W Gordon","year":"2015","journal-title":"Curr Rev Musculoskelet Med"},{"key":"ref10","first-page":"6150","article-title":"Long-term clinical results after Iloprost treatment for bone marrow Edema and avascular necrosis","volume":"8","author":"T Classen","year":"2016","journal-title":"Orthop 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platelet-rich plasma and mesenchymal stem cell milieu: a review of therapeutic effects on bone healing","volume":"38","author":"B E Liebig","year":"2020","journal-title":"J Orthop Res"},{"key":"ref16","doi-asserted-by":"crossref","first-page":"1263","DOI":"10.1016\/j.injury.2013.06.008","article-title":"Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single Centre 204 case series","volume":"44","author":"L M Qvick","year":"2013","journal-title":"Injury"},{"key":"ref17","doi-asserted-by":"crossref","first-page":"S116","DOI":"10.1016\/j.injury.2014.10.034","article-title":"Incidence of donor site morbidity following harvesting from iliac crest or RIA graft","volume":"45","author":"G M Calori","year":"2014","journal-title":"Injury"},{"key":"ref18","doi-asserted-by":"crossref","first-page":"S3","DOI":"10.1016\/j.injury.2011.06.015","article-title":"Complications following autologous bone graft harvesting from the iliac crest and 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Experience of the French military health service (FMHS)","volume":"65","author":"A Baus","year":"2020","journal-title":"Ann Chir Plast Esthet"},{"key":"ref23","doi-asserted-by":"crossref","first-page":"e1026","DOI":"10.1093\/milmed\/usaf523","article-title":"Surgical stabilization of fractures in combat trauma: external fixation during the global war on terror","volume":"191","author":"M D Cobler-Lichter","year":"2026","journal-title":"Mil Med"},{"key":"ref24","doi-asserted-by":"crossref","first-page":"323","DOI":"10.3928\/01477447-20090501-03","article-title":"Antibiotic-impregnated calcium sulfate use in combat-related open fractures","volume":"32","author":"M D Helgeson","year":"2009","journal-title":"Orthopedics"},{"key":"ref25","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1007\/s00402-019-03287-4","article-title":"General treatment principles for fracture-related infection: recommendations from an international expert group","volume":"140","author":"W J Metsemakers","year":"2020","journal-title":"Arch Orthop Trauma Surg"},{"key":"ref26","doi-asserted-by":"crossref","first-page":"149","DOI":"10.1016\/0007-1226(84)90002-X","article-title":"The free thigh flap: a new free flap concept based on the septocutaneous artery","volume":"37","author":"Y G Song","year":"1984","journal-title":"Br J Plast Surg"},{"key":"ref27","first-page":"S47","article-title":"Infectious complications and soft tissue injury contribute to late amputation after severe lower extremity trauma","volume":"71","author":"J Huh","year":"2011","journal-title":"J Trauma"},{"key":"ref28","first-page":"e847","article-title":"Recombinant human BMP-2 for the treatment of open tibial fractures","volume":"35","author":"S Wei","year":"2012","journal-title":"Orthopedics"},{"key":"ref29","doi-asserted-by":"crossref","first-page":"2267","DOI":"10.1016\/j.injury.2015.07.013","article-title":"Effects of recombinant human bone morphogenetic Protein-2 (rhBMP-2) in grade III open tibia fractures treated with unreamed nails-a clinical and health-economic analysis","volume":"46","author":"V Alt","year":"2015","journal-title":"Injury"},{"key":"ref30","doi-asserted-by":"crossref","first-page":"384","DOI":"10.1097\/BOT.0000000000001492","article-title":"A randomized controlled trial comparing rhBMP-2\/absorbable collagen sponge versus autograft for the treatment of tibia fractures with critical size defects","volume":"33","author":"Major Extremity Trauma Research C","year":"2019","journal-title":"J Orthop Trauma"},{"key":"ref31","doi-asserted-by":"crossref","first-page":"S49","DOI":"10.1016\/j.injury.2021.04.068","article-title":"Molecular enhancement of fracture healing - is there a role for bone morphogenetic Protein-2, parathyroid hormone, statins, or sclerostin-antibodies?","volume":"52","author":"L Henssler","year":"2021","journal-title":"Injury"},{"key":"ref32","doi-asserted-by":"crossref","first-page":"S57","DOI":"10.1016\/j.injury.2019.10.074","article-title":"Prevention of infection in open fractures: where are the pendulums now?","volume":"51","author":"M Rupp","year":"2020","journal-title":"Injury"},{"key":"ref34","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1097\/BOT.0b013e3181c7cb6b","article-title":"A new classification scheme for open fractures","volume":"24","author":"Orthopaedic Trauma Association: Open Fracture Study G","year":"2010","journal-title":"J Orthop Trauma"}],"container-title":["Zeitschrift f\u00fcr Orthop\u00e4die und Unfallchirurgie"],"original-title":[],"language":"de","link":[{"URL":"http:\/\/www.thieme-connect.de\/products\/ejournals\/pdf\/10.1055\/a-2972-3247.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,12]],"date-time":"2026-10-12T23:54:31Z","timestamp":1791849271000},"score":1,"resource":{"primary":{"URL":"http:\/\/www.thieme-connect.de\/DOI\/DOI?10.1055\/a-2972-3247"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,12]]},"references-count":31,"URL":"https:\/\/doi.org\/10.1055\/a-2972-3247","archive":["Portico","CLOCKSS"],"relation":{},"ISSN":["1864-6697","1864-6743"],"issn-type":[{"value":"1864-6697","type":"print"},{"value":"1864-6743","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,12]]}}}