COMPARATIVE EFFICIENCY OF VARIOUS TECHNIQUES FOR COMPLEX TREATMENT OF PATIENTS WITH GUNSHOT INJURIES TO THE EXTREMITIES

Vishnevsky Institute of Surgery, Moscow, Russia

Mechnikov North-Western State Medical University, Saint Petersburg

Saint Petersburg State University, Saint Petersburg, Russia

Novgorod State University named after Yaroslav the Wise, Veliky Novgorod, Russia

Currently, the number of patients with gunshot injuries is increasing in the civilian medical facilities. Gunshot injury is characterized with severe damages determined by drastic evolution of firearms and blasting compounds, particularly, by the sharply increased destructive force of the up-to-date modes [1-4, 5, 6, 7]. It requires the optimization of complex treatment of patients, use of differentiated surgical tactics, especially for low- and high energy gunshot fractures. Incorrect surgical treatment often results in unfavorable outcomes of gunshot injuries (high rate of bone malunion, extremity deformations, development of contractures). The posttraumatic period shows the high rate of complications including infectious complications [8, 9, 10-13]. The quantitative expression is associated with higher rate of gunshot fractures as compared with complications after other fractures [11, 14]. For example, the gunshot injuries were accompanied by shortening and deformations of the extremities in 21.2 % of the patients, bone defects and false joints – in 15.4-20.3 % of the patients [5, 16].

Inevitable consequences and complications of severe gunshot wound impede the realization of delayed reconstructive operations, decrease the total efficiency of treatment, particularly, the possibility of restoration of the function of an injured extremity [1, 7, 15, 16]. So, the development of fixed contractures of the extremities was noted in 72.6 % of the clinical cases in the military men with gunshot injuries who participated in the counterterrorist operation in North Caucasus [7].

The surgery of injuries is associated with unsolved issue of possibilities and indications for use of surgical techniques of surgical techniques of early osteosynthesis in conditions of a gunshot wound [1, 8, 9, 16]. Particularly, the detailed analysis requires the strategic issues of primary surgical preparation of gunshot injuries to the extremities, the concept and the tactical techniques of internal fixation. The above-mentioned arguments testify the importance of the problem of optimization of treatment for patients with gunshot fractures of the long bones and necessity for use of all possibilities of the modern medicine.

The objective of the study – to substantiate the possibilities of increasing efficiency of complex treatment of patients with gunshot shaft fractures of long bones of the extremities by means of implementation of the modern low invasive technologies of internal osteosynthesis and technologies of pharmacotherapy with modern immune active drugs into clinical practice of civil healthcare.

The clinical analysis also included the solution of the problems of estimation of the short term and long term results of treatment of the patients with low- and high energy gunshot shaft fractures of the long bones depending on a chosen technique of treatment, the used methods of fixation and the conservative methods.

MATERIALS AND METHODS

The prospective comparative clinical study was based on the results of the examination and treatment of the patients with gunshot injuries of the extremities who were operated and treated with the participation of the authors in the Al-Mutawakel hospital (Sana, Yemen). The victims suffered from gunshot injuries as result of the tribal warfare and military activity from the government troops against the terrorists (76 %); 9.5 % of the cases were associated with accidental conflicts and 9.1 % with home conflicts, 7.4 % – with firing during celebrations. The materials of the clinical part of the study included 104 patients with gunshot fractures of the extremities. The men presented the absolute majority of the patients (80.7 %). The age of the patients varied from 15 to 80. The mean age was 38.5 ± 5.7.

The examined group of the patients was distributed (random sampling technique) into the comparison subgroup (52 patients) and the main subgroup (52 patients) (the table 1). The patterns of the gunshot fractures (shaft fractures of the long bones of the extremities) and the patients’ condition in the compared subgroups were similar (i.e., the compared groups were representable).

The patients of the comparison subgroup were treated with the conventional technique that supposed radical primary surgical preparation of a gunshot wound with removal of all free bone fragments and stabilizing the fracture with use of the various external fixing devices – Ilizarov device or external rod devices (AO constructs) before the moment of fracture union. In 2004-2006 such surgical techniques were common (before wide implementation of low invasive fixation with angle stability screws). In the present study such technique was used for surgical care for the patients who had no access to LCP or refused from the second stage of fixation. The main subgroup included the patients who received the treatment with the improved technique of complex treatment of gunshot fractures of the long bones of the extremities.

The improved technique of treatment of uncomplicated gunshot fractures of long bones of the extremities was used for the patients (the main clinical subgroup) and included: 1) the saving and sparing primary surgical preparation of the gunshot wound with preservation of all bone fragments; 2) removal of big foreign bodies, 3) fasciotomy (in presence of indications); 4) primary functional stable osteosynthesis with modern implants (low energy gunshot fractures); 5) use of the external fixing devices (the maximal period for primary fixation of fragments – 5-6 days) and subsequent fixation with the  modern implants (high energy gunshot fractures).

Additionally, for non-specific immune prevention of infectious complications we used the inductive immune-oriented therapy with cycloferon (NTFF POLYSAN Ltd., Saint Petersburg, Russia) as the international aid for Al-Mutawakel hospital. Non-specific immune prevention with cycloferon was conducted after primary surgical preparation and realization of osteosynthesis for the patients of the main clinical subgroups. Cycloferon was introduced intramuscularly. The scheme of course administration of the drug: 1 injection of cycloferon with the dose of 250 mg (2 ml of the injection solution) immediately after primary surgical preparation and fixation, the subsequent injections – on the  days 3 and 5 after the moment of gunshot injury. The additional immune replacement  therapy with human recombinant IL-2 (0.5 mg/500,000 units/400 ml of isotonic solution of NaCl with  addition of 10 ml of 10 % albumin, one time, intravenously, with very slow rate of administration) was used for high energy gunshot fractures and absence of immune-correcting effect of cycloferon. The patients of both clinical subgroups received: 1) antibiotic prevention with wide spectrum drugs (cephalosporins of 3rd generation: Rocephin F/ceftriaxone, intramuscularly, 1 g, 3 times per day for 5 days), 2) therapy with narcotic and non-narcotic analgetics, 3) infusion therapy with blood protein preparations and vitamin-mineral complexes.

The efficiency of the used methods of the treatment in the clinical subgroups was estimated on the basis of the comparison of the achieved results according to the following criteria: 1) duration of surgical aid and the parameters of the degree of an injury; 2) the clinical and radiological values of restoration of integrity of an extremity (absence of a significant defect of the bones and displacement of bone fragments, presence and quality of osteotylus etc.); 3) duration of hospital treatment; 4) the  values of recovery of the motor and support functions of an injured extremity after the complex of reconstructive and rehabilitation measures and the degree of its functioning. The monitoring of the results of the treatment was conducted in the control examinations of the patients with use of the instrumental and laboratory methods, the special functional tests and questionnaire.

The criteria of the classification for opened fractures by R.B. Gustillo and J.T. Anderson (1984) were used for estimating the severity of the gunshot injuries. This classification is usually used for estimation of single mechanic injury [17]. During planning the surgical interventions and the surgery, the maximal attention was given to preservation of perfusion in bone fragments, but not to achievement of ideal reposition and fixation of small bone fragments. The above-mentioned arguments were used during primary surgical preparation for the patients with gunshot fractures.

During the dynamic observation we also controlled: 1) the condition of a gunshot wound; 2) the presence of signs of infectious complications and possible chronization of the infectious process (the presence of fistulas or the signs of osteomyelitis and purulence in the regions of introduction of pins or rods of the external fixing devices); 3) the values of the general blood analysis at different time points of the observation; 4) the immunological values of the cellular link of immunity. The range of the additional clinical and laboratory and instrumental methods (CT, MRI, ultrasound investigation) was used according to the indications (in the cases of multiple fragmentary gunshot fractures and in presence of injuries to the magistral vessels).

The clinical analysis of the blood was conducted according to the results of the hematological examination of venous blood from the ulnar veins on the 3rd day after surgery. Also the immunological analysis of the peripheral blood cells with determination of the phenotypic status of lymphocytes in the time course of the posttraumatic period was conducted. For the immunological analysis the blood was placed into the vacuum tubes with EDTA reagent. The main goal of the hematological and immunological examinations of the peripheral blood cells was investigation of the condition of the red and white lineages of the blood cells with estimation of the signs of presence of anemia, mesenchymal-inflammatory syndrome and identification of the signs of immune depression with the leukogram and the phenotypic status of mononuclear cells.

The hematological examination included: quantitative estimation of the count of blood cells, estimation of their morphological patterns, estimation of mean parametric sizes of the cells with construction of distribution histograms at the moment of admission and during the posttraumatic course. The examination of the blood samples in the control group and in the victims was conducted with the hematological analyzer and was supplemented with blood testing with manual techniques and blood sedimentation rate and (if necessary) the leukogram. The hematological examinations were conducted with the automatic hematological analyzer Celly 70 (BioCode, France). The subpopulation structure of the mononuclear cells of the peripheral blood was realized with laser flow cytofluorometry [18, 19] with FACSCanto II (Becton Dickinson, USA), which registers up to 3 luminescence probes concurrently. The proportion (percentage from total leukocyte count) and the absolute amount of the mononuclear cells with the following phenotypic markers were estimated: CD3⁺ (T-lymphocytes),     CD3⁺4⁺ (T-helpers), CD3⁺8⁺ (T-killers), CD3^-CD16⁺56⁺ (natural killers/NK-cells), CD25⁺ (subpopulation of lymphocytes expressing the receptor for IL-2), CD95⁺ (subpopulation of lymphocytes expressing the receptor, which mediates apoptosis), HLA-DR+ mononuclear cells. The examinations with use of the laboratory equipment and the appropriate reagents were conducted in compliance with the protocols recommended by the manufacturing companies.

The control group included 20 citizens of Yemen Republic, men and women, the mean age of 35.3 ± 8.8 years without gunshot injuries, without chronic diseases, who required for outpatient care with preventive medical examination. This group of the patients received the hematological and immunological examinations and their results were considered as the conventional standards in this region.

The statistical analysis of the data of the clinical studies was conducted with Excel 2000, Statistic 5.773, analysis of variance, calculation of mean values (M) and arithmetical deviations (± m). Student’s test (t) was used for estimation of reliability (significance) of differences of two mean values. The differences with p ≤ 0.05 were considered as statistically significant.

RESULTS AND DISCUSSION

The simple estimation of the injuries in the included patients testified the presence of significant difference in fractures of the extremities: the patients had either low- (66 patients) or high-energy (38 patients) gunshot shaft fractures that was possibly associated with gun-shot distance and the type of a bullet. The distinctive features of low energy shaft fractures were as follows: the volume of soft tissue injury is insignificant, the length of bone tissue defect < 2 cm, low amount of bone fragments and their relatively big sizes, absence of injury to vascular and neural anatomic structures and microstructure of soft tissues (according to the classification by R.B. Gustillo and J.T. Anderson (1984) such gunshot injuries are classified as fractures of types I and II). The specific signs of high energy shaft gunshot injuries of the long bones are as indicated: the volume of soft tissues is significant, the length of the bone tissue defect > 2 cm, high amount of small bone fragments without connection with the anatomic structures of the extremity, presence of injuries to vessels and nerve endings, high contamination of subjacent soft tissues (according to the classification by R.B. Gustillo and J.T. Anderson (1984) such gunshot injuries are classified as fractures of types IIIA, IIIB and IIIC).

The results of the hematological and immunological examinations were more significant in the patients with high energy fractures. Already on the 3rd day after gunshot wound this category of the patients demonstrated insignificant leukocytosis, trend to decreasing the proportion of lymphocytes among all leukocytes (relative lymphopenia) and the signs of immune depression (absolute lymphopenia according to the subpopulations of T-lymphocytes and T-lymphocytes helpers, the increasing proportion of CD3+CD25+ and CD3+CD95+ lymphocytes) (the table 2).

Estimation of the results of treatment of low- and high-energy gunshot injuries was conducted with the common (standard) and our improved surgical techniques, and it identified some significant differences in efficiency of treatment in relation to all tested values (the table 3). 

The received results show that adherence to the improved surgical techniques for gunshot fractures resulted in more than 3-fold decrease in the volume of necessary surgical approach during the operation. During surgical intervention the volume of blood loss showed two-fold decrease. The received objective data allows estimating the improved techniques of surgical treatment as surgical technologies characterized by low invasiveness. Low invasiveness significantly reduced the duration of hospital stay. The last circumstance is the main criterion for higher efficiency of the techniques of the earliest osteosynthesis with LCP and BIOS techniques.

The additional criterion of efficiency of complex treatment was the rate and features of complications in the postsurgical period which require additional treatment and/or recurrent surgical interventions. Therefore, the patterns and the rate of postsurgical complications were estimated, as well as general duration of the treatment. The table 4 shows the results of the analysis.     

It is evident that the structure and the rate of the postsurgical complications demonstrated some changes during adherence to the improved techniques of treatment of the patients with gunshot shaft injuries as compared with the conventional technique. As compared with the clinical comparison subgroup, the patients of the main clinical group showed the sharp decrease in the rate of complications requiring the recurrent admission and surgical intervention (4 and more times). The main promising results were prevention of such complications such as appearance of contractures of the big joints (low energy fractures – absence of complications vs. 46.9 %, high energy fractures – 5.5 % vs. 61.7 %) and deceleration of fracture union (low energy fractures – absence of complications vs. 25 %, high energy fractures – absence of complications vs. 55.9 %). The significant reduction of the possibility of complications reduced the material costs for the patients (payment for recurrent consultations, costs for recurrent admission and surgical treatment). The material costs for the patients of the comparison subgroup significantly exceeded the values in the main clinical subgroups.

The possibility of active painful movements and early functional load to the operated extremity favored earlier initiation of rehabilitation in the patients who were treated with the improved techniques as compared with the patients of the comparison clinical subgroup (the table 5). The table 5 demonstrates the presence of quite significant differences between the tested parameters (time of fracture union, the criteria for recovery of functional capabilities of the extremities/time of initiation of load to the extremity) in the patients with gunshot fractures of different types treated with the different techniques.

Both inductive immunocorrection (inclusion of cycloferon into conservative treatment) and immune-oriented therapy (inclusion of cycloferon and yeasty rIL-2 into conservative treatment) were efficient according to the criterion of prevention of posttraumatic infectious complications in the patients with gunshot fractures (the table 4). The patients of the main clinical subgroups demonstrated the lower rates of wound purulence as compared with the patients of the comparison subgroups (4-fold decrease in the patients with low energy gunshot fractures; 2-fold decrease in the patients with high energy gunshot fractures). No cases of osteomyelitis in the region of a gunshot fracture were found in the patients of the main clinical subgroup with high energy fractures treated with the drugs for immune-oriented therapy, whereas osteomyelitis appeared in 5.8 % in the comparison subgroup. Use of the immune active drugs as the part of conservative therapy made the immune correcting effect according to the parameters of the immune status of the patients. Particularly, the progress of the above-mentioned signs of immune depression was prevented in the main clinical subgroup with high energy gunshot fractures. But the signs of immune depression intensified in the patients of the comparison subgroup with infectious complications who did not receive any immune active drugs as the part of conservative therapy.

During the rehabilitation period (6 months after surgical treatment) the questionnaire in the main subgroup and the comparison subgroup showed that the patients who were treated with the improved techniques demonstrated the higher percentage of self-care, home activity and physical efforts.

CONCLUSION

During realization of specialized medical care for civilian victims of war conflicts, the implemented technique for treating patients with gunshot shaft fractures of the long bones of the extremities including salving surgical preparation and early low invasive functional stable osteosynthesis with the modern implants in combination with the immune active drugs as the part of conservative therapy (cycloferon, yeasty rIL-2) was more efficient according to the following criteria: duration of stay in the hospital (reducing time), the rate of infectious complications (decreasing rate); the rate of complications leading to disability (decreasing rate), functional capabilities of an injured extremity (increasing capabilities), as well as more economical benefit as compared with the conventional treatment with the external fixing devices. The results of the study allow recommending the algorithm for realization of specialized medical care for patients with gunshot fractures of the long bones of the extremities (Fig.).