07-Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war

Journal Pre-proof<img src="/media/202408//1724838777.6407921.png" /><table><tr><td></td></tr></table>Management of severe defects of humerus in combat patients injured in Russo-Ukrainian warIgor Lurin , Oleksandr Burianov , Yurii Yarmolyuk , Yurii Klapchuk , Serhii Derkach , Maksym Gorobeiko , Andrii DinetsPII: S0020-1383(23)00997-XDOI: <a href="https://doi.org/10.1016/j.injury.2023.111280">https://doi.org/10.1016/j.injury.2023.111280</a> Reference: JINJ 111280To appear in: InjuryAccepted date: 11 December 2023Please cite this article as: Igor Lurin , Oleksandr Burianov , Yurii Yarmolyuk , Yurii Klapchuk , Serhii Derkach , Maksym Gorobeiko , Andrii Dinets , Management of severe defects of humerus in combat patients injured in Russo-Ukrainian war, Injury (2023), doi:<a href="https://doi.org/10.1016/j.injury.2023.111280">https://doi.org/10.1016/j.injury.2023.111280</a>This is a PDF ﬁle of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the deﬁnitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its ﬁnal form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.© 2023 Published by Elsevier Ltd.<img src="/media/202408//1724838777.82091.png" />Highlights● Russo-Ukrainian war is associated with both severe injuries and severe bone defects dueto frequent application of high-energy weapon● 3D-printing and polyetheretherketone (PEEK) implants could be used in management ofcombat patients with severe bone defects &gt; 10 cm● Closed reduction, percutaneous lag screw for distinct compression, Ilizarov externalfixation are appropriate methods to treat severe bone defects● Fibula on avascular pedicle could be used as a graft to replace severe bone defects incombat patients with injuries to the long bones<img src="/media/202408//1724838777.869605.png" />Management of severe defects of humerus in combat patients injured in Russo-Ukrainian warIgor Lurin1,2 , Oleksandr Burianov3 , Yurii Yarmolyuk4, Yurii Klapchuk5 , Serhii Derkach3, Maksym Gorobeiko1,6,7, Andrii Dinets1,6,8*1National Academy of Medical Sciences of Ukraine, Kyiv, Ukraine2 State Institution of Science “Research and Practical Center of Preventive and ClinicalMedicine”, State Administrative Department, Kyiv, Ukraine 3Bogomolets National Medical University, Kyiv, Ukraine4National Military Medical Clinical Center “Main Military Clinical Hospital”, Kyiv, Ukraine 5Military Medical Clinical Center of the Northern Region, Kharkiv, Ukraine6Department of Healthcare, School of Medicine, Kyiv Agrarian University, Kyiv, Ukraine 7Department of Surgery, Lancet XXI, Kyiv, Ukraine8Department of Surgery, Verum Expert Clinic, Kyiv Ukraine*Corresponding author: Andrii Dinets MD, PhD, Associate Professor, Department of Surgery, Verum Expert Clinic; Ukraine, 03039 Kyiv, Demiїvska 13, email: andrii.dinets@knu.uaKeywords: Russo-Ukrainian war; war in Ukraine; gunshot wound; gunshot fracture; severe bone defect; humerus defect; long bone gunshot fracture; polyetheretherketone; bone 3Dprinting;AbstractIntroductionRusso-Ukrainian war is associated with application of high-energy weapon, causing severe multifragmental injuries to the bones an associating with severe bone defects.<img src="/media/202408//1724838777.945724.png" />The aim of the study was to evaluate various methods to treat combat patients with severedefects of humerus and to demonstrate the experience of orthopedic war surgeons in managing gunshot injuries to the humerus defects in the ongoing war.Patients and methodsA 24 patients were active-duty military personnel of Armed Forces of Ukraine. These patients were diagnosed with severe humerus defects due to gunshot injury in battlefield zone in various areas of Ukraine. Data was collected within period between February, 24th 2022 till January,01st 2023. The following approaches were applied to replace bone defect: preoperative 3D printing with polyetheretherketone (PEEK) as orthobiological material; closed reduction, percutaneous lag screw and Ilizarov external fixation; vascularized fibula grafting.ResultsData analyses of the segmental defects of humerus showed 5 cm defect in 3 (13%) patients, from 5 to 10 cm in 4 (17%) patients, over 10 cm in 17 (71%) patients. Analyses were performed in these 17 (71%) patients, showing 5 patients treated with 3D-printed PEEK implants, 6 patients with vascular-pedicle graft of fibula, 6 patients with closed reduction, percutaneous lag screw, Ilizarov external fixation. Osteomyelitis was diagnosed in one case (20%) after the use of PEEK implants, requiring to remove both PEEK implant and metal implants followed by application of the antibiotic joint spacers and Ex-Fix fragments of the humerus. In our opinion, the osteomyelitis happened due to inadequate debridement of the wound and non-compliance with the conversion criteria (replacement of the fixation method). The mean length of hospital stay was 5.5 months for patients treated with 3D-printed PEEK implants.ConclusionsClosed reduction,percutaneous lag screw and Ilizarov external fixation as well as vascularized fibula grafting are associated with good outcomes in management of the patients with severehumerus defect due to gunshot injury. 3D printing and PEEK implants could also be considered for the reconstructions of the humerus multifragmental fractures with a bone defect over 10 cm associated with gunshot injury due to high-energy weapon in the war settings.<img src="/media/202408//1724838778.042499.png" />IntroductionThe full-scale war of Russia against Ukraine is associated with application of high-energy weapon, causing severe injuries to the military personnel and civilians in Ukraine, ecocide, humanitarian disaster and nuclear escalation (1-7). According to our observations and investigations, Russians frequently apply such high-energy weapons as artillery shells, cruise missiles, drones, as well as prohibited by international humanitarian law expansive bullets (2, 8- 10). Because of such a weapon, the gunshot injuries frequently affect the limbs, causing severe combined trauma of soft tissues and segmental defect to the bones or critically sized bone defects, which is a clinical challenge in most of the cases (11). It is worth to mention, that during hybrid period of Russo-Ukrainian war (2014-2022) the injuries to the upper extremity were also frequent, showing humerus fractures in up to 9.5% of cases, as well as limb amputations at the level of the shoulder in up to 0.5% of the combat patients (5, 6, 12).Frequently, it is a clinical challenge to choose the best tactics for management of patients with gunshot fractures to the humerus due to the high risk of complications. It is also worth mentioning, that purulent complications occur in 21.4-25.6% and gunshot-related osteomyelitis in 12-14% (13, 14). Such complications are usually associated with longer hospital staying and unsatisfactory anatomical and functional treatment results. Important task in management of gunshot fractures is to perform correct reposition of bone fragments as well as to achive its stable fixation, resulting in faster rehabilitation process (13-15). To improve preoperative planning, a three-dimensional (3D) printing (i.e. additive manufacturing) is actively used in routine orthopedics practice. 3D printing was introduced in orthopedics in early 1990s, when a 3D- printed individual template with guidelines for inserting screws was applied for knee joint replacement (16, 17). Preoperative 3D printing can be also applied for military orthopedics and traumatology, allowing to improve following aspects: rational preoperative planning and intraoperative orientation, production of individual metal fasteners and (3D printing with titanium), design of individual implants and grids (containers) for plastic materials, plastic and biodegradable materials; creation of tools for carrying out complex stages of the operation.The discovery of new and implementation of known 3D-printing methods might improve management of the severe gunshot injury, including large defects of the long bones. Taking into account the severity of gunshot injuries in Russo-Ukrainian war, there is a need to improve treatment strategy, especially in management large bone defects. Previously published series demonstrated utility of various approaches for management of gunshot injuries such as application of orthobiological materials or closed reduction, percutaneous lag screw for distinct compression and Ilizarov external fixation (i.e. bilocal osteosynthesis) as well as 3D printing (18-20). It is also worth to mention that gunshot injury is well described in various warfares<img src="/media/202408//1724838778.123727.png" />and armed conflicts, including studies from Russo-Ukranian war during its hybrid period of 2014-2020 and later. However, the current state of the orthopedics trauma management as well as possible role 3D printing with PEEK implants remain less studied in the period of the full-scale russian invasion since February, 24th 2022 (5, 20-27). In this study we hypothesize that 3D printing with PEEK implants could be applied for the management of severe diaphyseal humerus gunshot fractures related to application of high-energy weapon.The aim of the study was to evaluate various methods to treat combat patients with severe defects of humerus and to demonstrate the experience of orthopedic war surgeons in managing gunshot injuries to the humerus defects in the ongoing war..Patients and methodsA 24 patients were identified for the study. These patients were active-duty military personnel of Armed Forces of Ukraine, injured in battlefield zone in the various areas of Ukraine. Non-classified data was collected within period between February, 24th 2022 till January, 01st 2023. The inclusion criterion for the study was diagnosis of the humeral diaphyseal gunshot fracture. Exclusion criteria for the study were osteomyelitis following gunshot wounds, severe microbal wound contamination (colony-forming units (CFU) &gt; 106/ml), complete rupture of radial and ulnar nerves. The mechanism of injury was due to various high-energy wapon such as multiple launch rocket system (e.g. Grad, Uragan, Smerch etc.), artillery, mortars shelling, cruise-missiles attacks, unmanned aerial vehicle (i.e. combat drone).The 2018 revision of the AO/OTA Fracture and Dislocation Classification was applied to determine the complexity of the fracture. Upon admission to the military hospital (Level IV), all patients were examined by routine clinical chemistry and urinary tests. Patients were also examined by X-ray imaging in two projections, by computed tomography (CT) scan for the injured limbs, Doppler imaging of vessels in order to determine the features of the major and collateral blood supply of the injured upper limb. CT angiography was performed to identify devascularized bone fragments.. At admission, patients were evaluated for comorbidity, structural changes in the wounds and bones, and the degree of inflammatory changes in the area of removed pins. All patients were also evaluated for possible damage of the major vessels, including possible ischemia and phlebothrombosis at the level of injured limb segment. A microbiological examination of the wounds was performed by determination of microbial contamination by calculatuion of CFU for all patients. The management of the patients was performed at three Stages I, II, III to solve specific task in the wound treatment. In this paper we have focused on Stage II. The brief description of each stage is provided below.<img src="/media/202408//1724838778.20052.png" />At Stage I all patinets were treated with application of damage control surgery, second look surgery, reconstructive surgery, primary surgical debridement, fasciotomy, extra-focal osteosynthesis, application of antibacterial joint spacers. Stage I also included ultrasonic cavitation and vacuum-assisted closure (VAC) therapy according to previously described protocols using VAC-machine KCI (HEACO, China) and Sonoca 185 (Söring, Germany) (4, 5, 28, 29).The Stage IIA included the replacement of the orthopedic fixation devices (conversion). To perform a conversion from external fixation, we used a 3D imaging at preoperative stage in order to accurately determine the position of the humerus fragments, the size and shape of the fragments, to create virtual restoration of the humerus bone. 3D imaging also helped to select or develop the necessary details for fixation and to determine the need to use a graft instead of part of the bone to restore its shape, as well as to visualize the location of vessels for minimization of the risk of its intraoperative damage. The first stage of creating a physical 3D model was processing of the two-dimensional CT images. The analysis of the two-dimensional CT images was the first stage of creating physical 3D model. This process included analyses of each CT slice by orthopedic surgeons in order to remove all artifacts. The software Mimics Medical 24.0 was used to trasform CT images from DICOM into STL format for further 3D printing. The software Graphics Medical 14.1 was applied for 3D model rotation in all dimensions and to connect it with other parts, for instance with a blocked intramedullary rod or Philos-type plates for injuries at the level of the proximal third of the humerus.At Stage IIB, areconstructive and restorative surgical interventions were performed. This stage included the replacement of the bone defects. Polyetheretherketone (PEEK) was used as orthobiological material to replace the bone defect. PEEK matrix was used for 3D printing. Also, replacement of the bone defects was achieved by closed reduction, percutaneous lag screw for distinct compression and Ilizarov external fixation. The fibula on a vascular pedicle was used as a graft to replace bone defects.At Stage III, all patients were treated at rehabilitation centers in Ukraine and abroad. The data from the physical rehabilitation management is not available for the study.The follow up of the patients was performed in 3, 6, 12 months. At followup, there were considered such parameters as the period from injury to reconstructive surgery, the duration of surgical intervention, the range of motion (ROM) in the shoulder and elbow joints, the neurological status and neurological improvements, the presence of the complications (osteomyelitis, the formation of paraosseous ossifications, instability of the orthopedic implants, failures of bone consolidation and the formation of false joint (i.e. pseudoarthrosis), autograft<img src="/media/202408//1724838778.2230232.png" />lysis. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to measure upper-limb disability and symptoms in 12 months after the injury.The study was approved by the Ethical Committee at Bogomolets National Medical University (Kyiv, Ukraine). Considering that war is ongoing, detailed clinical information about patients is classified by the Government until the end of the war. Therefore, it is possible for authors to show only that information that is presented in this paper. The statistical analyses were not applicable because of small sample size of the cohort, indicating this study as “descriptive study” .ResultsAll patients received severe gunshot injury due to artillery strikes. All patients were males with mean age of 33.8 years. The mean time between injury and admission to the hospital at Level IV was 1.6 days.According to AO/OTA Fracture and Dislocation Classification (rev.2018), a simple type A fractures were observed in 4 (17%) patients, fragmentary type B fractures in 8 (33%) patients, multifragmentary and segmental type C fractures in 12 (50%) patients. A multifragmental severe fractures of the humerus are illustrated in the Figure 1 and 2.Analyses of microbial contamination of the wounds at admission showed the mean CFU of 105/ml (range 104-106/ml). Such microbial contamination was reduced to mean CFU of 102/ml (range 101-103/ml) in 21 (88%) patients on 21-24 day from the baseline.Of 24 patients, the segmental defects of the humerus up to 5 cm were diagnosed in 3 (13%) patients, from 5 to 10 cm in 4 (17%) patients, defects of 10 cm and more in 17 (71%) patients. Out of these 17 (71%) patients, 5 patients were treated with 3D-printed PEEK implants (Figure 3, 4, 5), 6 patients with closed reduction, percutaneous lag screw and Ilizarov external fixation, as well as 6 patients with vascular-pedicle graft of fibula (Figure 6).The follow up for 5 patients treated with 3D-printed PEEK implants was 14.8 months. In these patients, the mean time from the injury to the reconstructive surgery was 5.3 months, and the mean duration of the operation was 80.4 min. The mean DASH score at baseline was 75.3 and 49.6 at follow up of 12 months, indicating self-reported improvements. X-ray analyses did not reveal paraosseous ossifications. CT scans in 12 months after the injury showed formation of the bone bridges between the auto-alloplastic material in the PEEK lattice and the main fragments of the humerus. Osteomyelitis was diagnosed in one case (20%) after the use of PEEK implants, requiring to remove both PEEK implant and metal implants followed by application of the antibiotic joint spacers and Ex-Fix fragments of the humerus. In our opinion, the<img src="/media/202408//1724838778.330282.png" />osteomyelitis happened due to inadequate debridement of the wound and non-compliance with the conversion criteria (replacement of the fixation method). The mean length of hospital stay was 5.5 months for the patients treated with 3D-printed PEEK implant.The 6 patients treated with closed reduction, percutaneous lag screw and Ilizarov external fixation were followed up for 13.4 months. In these patients, the meantime from the injury to the reconstructive surgery was 5.8 months, and the mean duration of the operation was 78.1 min. The mean DASH score at the baseline was 73.1 and at 33.4 at followup of 12 months, indicating self-reported improvements. In one patient, the formation of the paraosseous ossifications and the development of the paraspinal osteomyelitis were observed, which required removal and placement of the rods. The mean length of hospital stay was 3.5 months for the patients from this group.The 6 patients with vascular-pedicle graft of fibula were followed up 14.1 months. In these patients, the mean time from the injury to the reconstructive surgery was 5.5 months, and the mean duration of the operation was 112 min. The mean DASH score at base line was 74.3 and 32.7 at the follow up of 12 months, indicating self-reported improvements. A paraosseous ossifications were diagnosed in two patients. The mean length of hospital stay was 6.5 months for the patients from this group.Overall, the postoperative complications were diagnosed in 4 (17%) patients. Analyses of the complications of the 17 patients with segmental defects of humerus &gt; 10 cm revealed seroma in 2 patients, which was managed by the wound drainage and VAC therapy.In 2 patients out of 6 who were treated with closed reduction, percutaneous lag screw and Ilizarov external fixation, there were problems with the rods, which required appropriate care of the external fixation device, and other 4 patients were treated with bilocal osteosynthesis without postoperative complications.In 2 patients treated with vascular-pedicle graft of fibula was diagnosed a serous- hemorrhagic exudation, which was managed by application of VAC-therapy. No complications were observed in the other 4 patients treated with vascular-pedicle graft of fibula.DiscussionA gunshot wounds to the upper extremity are frequently reported in combat- related papers, and all these cases are usually presented severe, including cases from the ongoing Russo-Ukrainian war (31, 32). In this study we have shown that it is possible to apply such modern technologies such as 3D printing with PEEK implants in management of a combat patients in the Level III and IV field hospitals. To our best knowledge, this is the first report demonstrating specific features of the combat-related injury to the upper extremities as well as<img src="/media/202408//1724838778.426046.png" />showing experience of managing gunshot-related fravtures of long bone (i.e. humerus) by using 3D-modeling with PEEK. 3D-printed PEEK implants are frequently applied in maxillo-fascial surgery and in civil orthopedics surgery, but infrequently in war-related injuries (39). Our results confirmed modern technologies such as 3D printing with PEEK implants as a possible approach to treat combat patients with severe defects of long bones. Our results are in line with the study of Hamsho et al., showing utility of PEEK implants for reconstruction of maxillary defect due to gunshot injury from a sniper gunshot in warfare settings (39). The application of abovementioned technologies is problematic due to interrupted medical supplies, and overall problem of healthcare planning in Ukraine (33). However, our results are in line with other researchers suggesting to use PEEK or PEEK-based implants for the bone defect management (34-36). Our choice to use PEEK over the other implants was made because of its better osseointegration and antimicrobial properties as proved by publicshed series as well as suggested in the review papers (34-38). It is worth to mention that 3D printing and PEEK implants were mainly reported for the reconstruction of the maxillofacial deformities in relation to the gunshot injury or brain tumors, but the technology was not showed before for reconstruction of the long bones such as humerus in combat patients (11, 39, 40). Although we have a relatively high frequency of complications (1 patients out of 5), our study shows that 3D printing and PEEK implants might be used for the management of long bone defects after the gunshot injury by high-energy weapon, which is consistent with Hamsho et al. and Chaiyasate et al. showing PEEK utility for the patients with PEEK implant reconstruction of maxillofacial area and cranioplasty, respectively (39, 41).As demonstrated by Chen et al, one should consider possible limitations for wide use of the PEEK implants for the bone defect repairing due to PEEK’s inherent biological inertia, which might cause fibrotic changes around the implant with subsequent negative impact on the osseointegration (42). However, in case of war-related and severe defect of the long bone, the utility of the PEEK implants was considered over the possible risk of impaired osseointegration. Similar to Stewart et al. we also showed less frequent wound infection as the post-traumatic complications, indicating good management protocols, including damage control surgery and overall principles of Military medical doctrine of Ukraine (43).In line with other researchers, we have used 3D-printed PEEK implants for the bone reconstruction, considering similar mechanical properties of the PEEK to the human bone tissue and high transmittance (44). It is worth to mention, that PEEK is mainly applied for the mandibular reconstructions, however our results demonstrated its utility for the combat-related long bone injury. Similar to others, we also consider fibula as a good graft for the reconstruction of the long bone defects. Heitmann et al. showed an overall utility of using fibula grafting in the<img src="/media/202408//1724838778.4765382.png" />15 patients with segmental defects of the humerus, resulting in excellent results, but associated with higher frequency of postoperative complications (45). The fibula graft on a vascular pedicle is associated with a good outcomes due to better fusion of the grafted bone with the recipient one, decresed risk for false joints, fractures of the graft, as well as lower hypertrophic changes of the fibula graft during the time under the impact of physiological axial loading. Similar to Kumar et al. we also demonstrated a relatively low rate of postoperative complication in the patients, indicating fibula grafting as a good method for the bone reconstruction in selected patients (31).Ilizarov distraction osteogenesis is commonly used in both civil and war-related bone fractures (46). This method is good to apply in combination with closed reduction and percutaneous lag screw for for significant bone defects, because it is associated with sufficient bone compression. However, Iliarov method is not appropriate to fix smaller bone fragments, which is frequently seen in battlefield trauma.This study has a several limitations. There is a lack of some demographic data, that can not be shared due to the war Law restrictions in Ukraine. Also, the sample size is small and statistical analyses cannot be accurate for such study groups, making this study descriptive.In this paper we would like also share some general points about the full-scale war settings in Ukraine, which in our ipinion is important for the other military orthopedic surgeons. The gunshot wounds to the humerus are frequently diagnosed among Ukrainian military personnel from Armed Forces of Ukraine and such kind of injury is usually severe. As demonstrated in previous reports from our research group and other researchers, Russo- Ukrainian war is associated with very severe trauma due to frequent application by russians of high-energy weapons such as artillery, cruise-missiles attacks, drones not only on the war theater, but also against military medical facilities, civil population and civil infrastructure (1-5, 21, 47). Such conditions are associated with higher risk for medical evacuation, as well as for more severe injury patterns as compared to gunshot wounds in civil conditions.According to our observations (unpublished data) at National Military Medical Clinical Center “Main Military Clinical Hospital” (Level IV hospital, Kyiv, Ukraine) during February 2022 – January 2023 the upper extremity injuries were to 45% out of all extremity’s injuries. Also, up to 69% of patients were diagnosed with gunshot wounds to the limbs, out of the total number of wounded, in contrast to 65.7% of combat patients injured in the hybrid period of Russo-Ukrainian war (2014-2021).ConclusionsClosed reduction, percutaneous lag screw and Ilizarov external fixation as well as vascularized fibula grafting are associated with good outcomes in management of the patients with severe humerus defect due to gunshot injury. A 3D printing and PEEK implants could aslo<img src="/media/202408//1724838778.5018141.png" />be considered for the reconstructions of the humerus multifragmental fractures with a bone defect over 10 cm associated with gunshot injury due to high-energy weapon in the war settings.Declarations of interestNoneFundingThis study received no funding<img src="/media/202408//1724838778.5079381.png" />References1. Golovko S, Gybalo R, Lurin I, Taraban I, Kobirnichenko A, Ganiuk V, et al. 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Strafun S, Kurinnyi I, Borzykh N, Tsymbaliuk YV, Shypunov V. Tactics of Surgical Treatment of Wounded with Gunshot Injuries of the Upper Limb in Modern Conditions. Herald of Orthopaedics, Traumatology and Prosthetics. 2021(2 (109)):10-7.<img src="/media/202408//1724838778.619478.png" />Figure legendsFigure 1. Photograph of the patient with a multifragmentary fracture of the right humerus with the presence of a bone defect and displacement of fragments. A. X-ray film illustrating severe fractures. B. Preoperative photo of the patient.<img src="/media/202408//1724838778.871746.png" /><img src="/media/202408//1724838778.9324238.png" />Figure 2. X-ray films illustrating the left humerus gunshot fractures. A. The patient with a gunshot multifragmentary fracture of the diaphysis of the left humerus with the presence of a bone defect and displacement of fragments. B. The patient with a gunshot multifragmentary fracture of the middle third of the diaphysis of the left humerus with a bone defect and fragment displacement.<img src="/media/202408//1724838778.991528.png" /><img src="/media/202408//1724838779.037032.png" /><img src="/media/202408//1724838779.081908.png" />Figure 3. Illustration of 3D modeling: processing of two-dimensional CT images in a patient with a gunshot multifragmentary fracture of the diaphysis of the left humerus with fragments displacement.<img src="/media/202408//1724838779.0981078.png" />Figure 4. Illustration of 3D-modeling stages. A. Comparison of the bone fragments to form a vision of the possibility to restore the integrity of the damaged bone structure in a patient with a gunshot multifragmentary fracture of the diaphysis of the right humerus with displacement of fragments. B. Illustration of the 3D-modeling final stage with PEEK material.<img src="/media/202408//1724838779.1320052.png" /><img src="/media/202408//1724838779.152131.png" />Figure 5. Photograph of the clinical case of the patient with severe fractures to the right humerus and treated with 3D-printed PEEK implant.A. Preoperative X-ray film illustrating sevre humerus defect &gt; 10 cm with a false joint of the middle third of the humerus with the formation of a defect in the bone structure, sclerotic lesion to the proximal and distal parts.B. Preoperative 3D modeling figures of the right humerus determines the formation of a false joint and the change in the axis of the bone.C. Preoperative 3D modeling illustrating calculations of the size for furhter resection of the sclerotized parts of the proximal (69.7 mm) and distal (85.2 mm) fragments of the humerus.D. Illustration of the 3D modelling of PEEK implant before the surgery.E. The 12 months postoperative X-ray film of the right humerus in the direct projection showing the replacement of the bone defect with a cortico-spongy granulates with signs of consolidation of the right humerus, which is fixed with a blocked nail.F. Intraoperative photograph of 3D-printed PEEK scaffold with a combined auto-alloplastic material to be placed to the humeral diaphysis defect.G. The photograph of the patient 12 months after the surgery with postoperative scar on his right upper limb.<img src="/media/202408//1724838779.168936.png" /><img src="/media/202408//1724838779.175661.png" /><img src="/media/202408//1724838779.239289.png" />Figure 6. Clinical photographs of the patients illustrating treatment stages for closed reduction, percutaneous lag screw and Ilizarov external fixation (A, B, C) and fibula on the vascular pediclegraft (D, E, F). A. Intraoperative photograph of the right humerus fractures. B. The postoperative photograph of the injured right humerus after the application of the closed reduction, percutaneous lag screw and Ilizarov external fixation and its (C) Postoperative X-ray film of injured extremity. D. Preoperative marking of the area before taking the fibular graft. E. Intraoperative photo of the excision of the fibula on the vascular pedicle. F. Control X-ray of the patient after an operation for open repositioning of fragments with replacement of a bone defect of the middle third of the humerus diaphysis by using a fibula on avascular pedicle.<img src="/media/202408//1724838779.384127.png" /><img src="/media/202408//1724838779.398323.png" />