International Orthopaedics

, Volume 43, Issue 12, pp 2653–2659 | Cite as

Decision-making algorithm for sequential treatment of diaphyseal bone gaps in war-wounded patients in the Middle East

  • Rasheed M. FakhriEmail author
  • Patrick Herard
  • Mohammed I. Liswi
  • Anne L. Boulart
  • Ali M. K. Al Ani
Original Paper



Tibial bone gaps after war injuries are common and can be managed by different types of surgery, including compression, bone graft, tibialisation of fibula, bone transport, and free flaps. Here, we present an algorithm developed at a humanitarian surgical hospital to manage tibial bone gaps. We also identify some key factors affecting patient outcomes and describe some clinical considerations for choosing treatment strategy.


We performed retrospective data analysis on war-wounded adult patients with tibial injuries treated at our project according to the described algorithm. Patient outcomes were followed for at least four  years. Outcomes assessed were length of stay, complication rate, re-admission (late complications), and final discharge.


Among the 200 included patients, 103 (51.5%) had bone gaps. Univariate analysis showed that the presence of a bone gap, but not its size, was associated with significantly increased risk of early complications, while type of surgery was significantly correlated with re-admission. Presence of a bone gap and type of surgery were each significantly associated with length of stay. Bone gap size showed no correlation with outcomes, an unexpected finding.


Soft tissue damage with compromised vascularity may explain the lack of association between bone gap size and outcomes. Specialised centres using standardised approaches to complex surgical reconstruction can play an important role in expanding the evidence base needed to improve case management.


Less invasive procedures may lead to better patient outcomes, although unfortunately may not always be possible given the nature of the injury and/or injury site.


Tibial bone gap Bone grafts Tibialisation of fibula Bone transport Reconstruction Humanitarian surgery 



We thank Patricia Kahn, medical editor at MSF-USA, for her kind editorial support of this manuscript.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© SICOT aisbl 2019

Authors and Affiliations

  1. 1.Medicines Sans FrontièresAmmanJordan
  2. 2.Medicines Sans FrontièresParisFrance
  3. 3.Hôpital Saint-LouisParisFrance

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