LOW INVASIVE OSTEOSYNTHESIS FOR INJURIES TO THE MUSCULOSKELETAL SYSTEM IN POLYTRAUMA Dyusupov A.A., Bukatov A.K., Bazarbekov E.N., Serikbaev A.S., Manarbekov E.M., Dyusupova B.B.
Semey State Medical University,
Emergency Medical Care Hospital, Semey, Republic of Kazakhstan
The proportion of patients with polytrauma is 28 % from the general amount of trauma patients. Polytrauma is characterized by high (up to 40 %) mortality. Among the causes of mortality, it takes the third place after tumors and cardiovascular diseases, and the first place in persons younger than 40. The special significance of the problem is associated with high disability (more than 40 %) and long time of work incapability of patients with polytrauma due to severity of trauma and multiple surgical interventions of various severity and complexity [1].
The analysis of foreign and domestic achievements in medicine, traumatology and surgery, and the trends in science and technologies indicate the importance of wide use of low invasive methods instead of well-known common stable-functional techniques of osteosynthesis with use of plates, rods and screws for decreasing negative consequences in management of polytrauma [1, 2]. At that, the search of more spare techniques of surgical management with possibility of use in early period of traumatic disease without worsening the patient’s condition is necessary. Early fixation has not only local, but general importance, making the significant contribution into positive outcome of polytrauma management. Transosseous osteosynthesis (TO) meets these requirements to the greater degree [3, 4].
The advantage of low invasive osteosynthesis in polytrauma is non-invasiveness of surgical methods with possibility of realization in early posttraumatic period with disordered tissue perfusion in the fracture region, and realization of stable fixation of fragments after reposition before union; and the main thing is exclusion of the second hit, which provokes the breakdown of weak immunologic cascade of the body after successful primary treatment of severe trauma with correction of shock states of various severity [1, 4, 5].
Objective of study – improvement of the results of treatment of limb bone fractures in patients with polytrauma.
Tasks of study: to investigate the rate of complications of the common techniques of transosseous osteosynthesis in the stable-functional methods of osteosynthesis with plates and nails; to develop the new closed and evidence-based low-invasive techniques of fixation of fragments and methods of TO and implementation into clinical practice of healthcare, to conduct the comparative analysis of the results.
MATERIALS AND METHODS
The study was conducted in concordance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects 2013 and the approval from the ethical committee of Semey State Medical University (the protocol No.4, October 14, 2015).
In the traumatology and orthopedics clinic in the emergency care department of Semey State Medical University, some low traumatic techniques (devices, navigators) and some transosseous fixation methods for treatment of single and multiple fractures of locomotor system segments in the upper and lower extremities have been developed in the period from 1998 till the present time and are successfully used in the clinical practice for patients with polytrauma.
Particularly, a device has been developed for precise transosseous introduction of the pins during skeletal traction in transosseous fixation with external fixation devices (EFD) [7]. The device allows fast and easy estimation of patency of the pin tract through bone tissue with consideration of topical location of vessels and nerves in this region. It reduces the time of conduction of the pins, excludes a damage of big vessels and nerves, and, the main thing, increases the accuracy of conduction of the pins through the thickness of segments of locomotor system in the given direction.
A method for transosseous osteosynthesis of a fracture of surgical neck of humerus has been developed [8]. The method is technically simple and reduces the amount of the pins two times, with penetration of lower number of humerus muscles, reduction of amount of complications in pin tracts, and preservation of functional activity of the humerus in the humeral and ulnar joints. So, the time of treatment reduces, the weight of the construct decreases two times as compared to Ilizarov’s device or other EFDs.
The device for reposition of fragments of the leg has been developed [9]. The offered device corrects the displacement of fragments along the length, along the width and at the angle in the presurgical period, i.e. simplifies the conditions of installation of transosseous fixation devices, reduces the time and traumatic effect of the surgical approach
Moreover, in preliminary reduction of bone fragments, the covering tissues of the segment are reduced in relation to fragments, and in through-thickness penetration of fragments, the pin tracts are located almost at the same level around tensioned pins with smooth surrounding on all sides, preventing the pressure on soft tissues of the covering tissues around the pins. Therefore, we observe only rare postsurgical negative consequences of transosseous fixation such as pin, bedsores and inflammatory inflammation of the wound in contrast to use of the crossing pins in the known EFDs.
A method for treatment of diaphysis of the long bones has been developed [10]. Under general anesthesia, ZUG device is used for conduction of the pins (3-8) through the fragments (1, 2) with supporting platforms (9) in parallel to each other, with alternation of mutually antithetical direction, with 2 or 3 through central (1) and peripheral (2) fragments with consideration of typical displacement of bone diaphysis (Fig. 1). The pins (3-8) are strained in the semi-rings of Ilizarov’s device. Reposition of fragments is performed (1, 2), and they are fixed until union appears. Position of fragments is controlled in X-ray examination.
Figure 1
A way of treatment of diaphysis of long bones.
Conduction of the pins with the offered technique excludes the dislocation of bone fragments in the pins. Conduction of the pin with positioning of its supporting platform on the cortical layer of the bone on the side of typical displacement of fragments in traction of the pin along the axis from its acute end allows eliminating the displacement of fragments up to the basic level under the control of clinical and X-ray study. Correction of displacement of fragments in other plane perpendicular to the initial one is achieved with movement of the pin in parallel direction to the axis in both sides depending on a type of displacement of fragments. Therefore, a possibility for elimination of displacement of fragments in all directions necessary for good reposition is achieved, considering the low amount of the pins which is 50 % lower than the well-known technique for fixation and reposition of fragments in EFD.
A technique for transosseous osteosynthesis of a fracture of the patella has been developed [11]. After manual clinical reposition of fragments (1, 2) of the patella along the fracture line (3), the fragments are closely placed onto the site of intercondylar fossa of the femoral bone (4), and the reduction site is preliminary fixed with two pins (5, 6) in the frontal plane perpendicular to the fracture line (3) of the fragments (1, 2), with subsequent introduction of two pins (8, 9) with the supporting platform (10) in the mutually reverse direction along the horizontal plane perpendicular to the axes of the first pins (5, 6). The pins (8, 9) supporting the fragments (1, 2) are fixed with the semi-rings (11, 12) in the strained position in the mode of compression of fragments (1, 2) (Fig. 2). The offered way is low invasive and excludes the secondary displacement of fragments during transosseous fixation, improving the result of treatment.
Figure 2
An approach for transosseous osteosynthesis of patella fracture.
A device for transarticular introduction of the pins through the foot to the tibial bone has been developed. It can be used for precise introduction of the pins for fixation of the foot to the tibial bone after correction of subluxation of or dislocation of the foot in complex fractures of the ankle joints and the borders of the tibial bone [12]. The device consists of the proximal and distal rods (1, 2), which are connected in perpendicular manner with a possibility for movement and fixation in relation to each other. The chosen position is fixed with the locking screw (3). The proximal end of the rod (1) is rigidly connected with the bed (4) for placement of the lower one-third of the leg (5). The bed (4) includes the elements of fixation (6) to the leg (5). The distal rod (2) includes the guide (7) of the pin (8) with a possibility for placement in coaxial relationship with the axis (9) of the bed (4) of the lower one-third of the leg (5). The chosen position of the guide (7) is fixed to the rod (2) with the locking screw (10). The rod has a mark (11), which aligns with the axis (9) of the bed (4), and mm scale (12) (Fig. 3). The stationary coaxial position of the axes of the bed of the leg and the guide allows precise transarticular introduction of the pins through the foot (the calcaneal and ankle bones) and the ankle joint for fixation of the foot to the tibial bone after correction of the foot subluxation and reposition of fragments of the ankle joint and the borders of the tibial bone.
Figure 3
A device for
transarticular conduction of pins through the foot to the tibial bone.
A device for traction and fixation of the pins to the external supports of the transosseous fixation device [13] has been developed. It allows positioning the pin in coaxial relationship with the axis of the pin tract of the covering tissues and a bone in multiple tension of the pin for reposition of and fixation of fragments. It decreases the rate of development of bedsores in the walls of the wound channel of the pins and removes the pain feelings in the postsurgical period.
The results of the clinical materials are based on the analysis of the data of the examination and treatment of 475 patients with polytrauma who received the treatment in the intensive care, anesthesiology and traumatology-orthopedics units in the rehabilitation department of Semey Emergency Medical Care Hospital in 1998-2017. The patients were distributed into two groups: the study group (SG) – 254 patients who received the treatment with our methods, and the comparison group (CG) – 221 patients who received the various common techniques of osteosynthesis (Ilizarov’s device, external and intramedullary techniques).
The general clinical, X-ray, computer (tomography), biomechanical, ultrasonic, hemodynamic, laboratory and statistical methods with parametric techniques (Student’s test) were used. If t-test was not effective because of absence of normal distribution of the ordered sample, the bootstrap technique was used. The comparison of the relative values was realized with Pearson’s test and two-tailed exact Fisher’s test (t). P value < 0.05 was a bordering criterion of statistical significance.
The table shows the distribution of the patients with injuries to the long bones according to injury location.
Table
Distribution of patients with injuries to long bones according to trauma location
|
Injury location |
Groups |
|||
|
Study group (SG) |
Comparison group (CG) |
|||
|
abs. |
% |
abs. |
% |
|
|
Humerus surgical neck |
33 |
13.0 |
19 |
6 |
|
Humerus |
49 |
19.3 |
30 |
3.6 |
|
Leg |
98 |
38.6 |
105 |
47.5 |
|
Hip |
17 |
6.7 |
12 |
5.4 |
|
Ankles |
32 |
12.6 |
38 |
17.2 |
|
Patella |
25 |
9.8 |
17 |
7.7 |
|
TOTAL |
254 |
100 |
221 |
100 |
The patients of the study group were mainly operated within the first five days after injury. Some patients received the osteosynthesis on the first or second day. The comparison group received the osteosynthesis on the days 7-9 after injury, depending on injury severity, and on the days 12-14 for opened injuries, since these patients required for more proper preparation for surgical treatment.
The efficiency of the developed techniques and devices for treatment of fractures of the above-mentioned segments of the extremities was compared to the common techniques on the basis of the following criteria: terms of treatment (inpatient and outpatient); time course of recovery of muscular strength; period of working incapability; results of treatment, and complications.
RESULTS AND DISCUSSION
The mean duration of inhospital treatment of patients with fractures of the lower one-third of the femoral bone was 17.5 ± 4.62 days (p < 0.05), and 27.3 ± 5.94 days in the comparison group.
The time of outpatient treatment of the patients with fractures of the distal one-third of the hip was 119.5 ± 16.3 days in the comparison group, and 108.9 ± 11.13 days (p < 0.05) in the study group. The duration of treatment decreased by 3-4 weeks in the study group: 126.4 ± 15.75 days in the study group as compared to 146.8 ± 22.24 days in the comparison group.
The results of treatment in the group show the efficiency of the developed techniques for treatment of the lower one-third of the femoral bone. So, the study group showed 2.1-fold increase in excellent outcomes of treatment (17.6 %) as compared to the comparison group (8.3 %). The good results were in 53 % of the cases in the study group and in 41.7 % in the comparison group (1.3-fold increase). The satisfactory results (23.5 %) were 1.4 times lower than in the comparison group (33.3 %). The amount of unsatisfactory results decreased 2.8 times in the study group (5.9 %) as compared to 16.7 % in the comparison group. The decrease in the rate of satisfactory and unsatisfactory outcomes, with simultaneous increase in excellent and good results was possible owing to decrease in the rate of complications in the groups.
The mean duration of inhospital treatment of the patients with leg fractures was 9.9 ± 1.2 days in the study group (p < 0.01) and 18.8 ± 1.5 days in the comparison group.
The duration of outpatient treatment was 87.9 ± 4.8 days (1.4-fold decrease) in the study group as compared to 122.8 ± 3.3 (p < 0.01) days in the comparison group. Therefore, the total period of treatment of these patients decreased significantly – 97.8 ± 6.0 days (almost 1.5 month) in the study group against 141.6 ± 4.8 in the comparison group (p < 0.01).
The study group showed 1.4 time less satisfactory outcomes as compared to the comparison group (23.1 and 31.3 % correspondingly). The amount of negative outcomes decreased 2.6 times in the study group – 3.6 % as compared to 9.4 % in the comparison group. Such high difference in the outcomes of treatment was caused by the rate of complications in the groups.
Inflammation of soft tissues as the most common complication in the study group was in 7.1 % of the cases with development of pin tract osteomyelitis in 1.3 % of the patients. The comparison group had 11.3 and 1.9 % correspondingly.
The mean duration of hospital treatment of the patients with humerus fracture was 11.3 ± 1.6 days in the study group and 25.9 ± 2.2 days in the comparison group. The time of outpatient treatment was 1.2 time lower in the study group than in the comparison group, where the patients received the common osteosynthesis – 85.4 ± 5.4 days as compared to 103.1 ± 9.4 (p < 0.05) correspondingly.
The strength of biceps muscle and triceps of the arm restored faster in the patients who had received the common techniques. This difference was especially evident in the examination of the biceps muscle (10-30 %). One should note that the study group showed almost 1 month faster recovery of strength of biceps and triceps of the arm.
The duration of hospital treatment of the patients with patella fracture was 6.3 ± 0.7 days in the study group, and 10.8 ± 1.3 days in the comparison group, and the period outpatient treatment was 10.3 ± 1.4 and 20.5 ± 1.2 weeks correspondingly (p < 0.01). The long term complications in the comparison group were migration and breakdown of the metal construct (21.4 %), secondary displacement of fragments (16.7 % against 5.1 % in the study group), formation of a false joint (4.8 %), which were not observed in the study group.
The general rate of complications in the main group was 20.5 %, in the comparison group – 71.4 % (3.5 times, χ2 = 21.05, p < 0.001).
The study group did not show any unsatisfactory outcomes such as joint contracture with limitation of mobility more than 50 % of the normal value. This group demonstrated only good (full recovery of mobility without pain) (82.1 %) and satisfactory (17.9 %) results. However there were not any significant differences in the rate of outcomes between the groups.
In the comparison group, the good results were in 64.3 % of the cases, satisfactory – in 28.7 %, unsatisfactory – in 3 patients with complications (7.1 %).
Secondary displacement of fragments was in 18 (47.3 %) cases in 38 patients with ankle joint fracture in the comparison group. Henceforth, these patients received the transarticular fixation of the foot to the tibial bone in 13 cases; 5 patients (27.8 %) received the screw fixation.
Among 32 patients of the study group, reposition of fragments of the ankle joints and their fixation for union of fragments with subsequent plaster immobilization was carried out for 23 patients (71.9 %), on the day 2 – 5 (15.6 %) and on the day 3 – 4 patients (12.5 %).
Low invasiveness of the offered techniques of transosseous fixation, as compared to the common techniques of compression distraction transosseous osteosynthesis, consists in two-fold (in theory) decrease in amount of pins for reposition of fixation of bone fragments of long bones, weight of the construct and complications in view of injury to big vessels and nerves. Moreover, instead of the rings holding the segments in circular manner, the semi-rings are used. The semi-rings are comfortable for functional development of motions in joints in the postsurgical period since the topical conduction of the pins in the same plane between the groups of antagonist-muscles prevents the fixation of muscle movement along the whole injured segment during contraction, and excludes an accidental injury to big joints and nerves.
One should note that fixation and reposition of bone fragments is performed with not common pins, but with pins with supporting platform which are conducted in parallel manner in the same plane with placement of the supports in mutually antithetic direction. If the pins are located on the side of displacement of bone fragments, it creates some conditions for correction of all types of displacement of bone fragments along the fracture line and fixation of fragments until they grow together, with exclusion of displacement of pins in the pin tract and fragments during process of treatment. Moreover, position of a pin is to be in coaxial relationship in the pin tracts of a bone and in the covering tissues on both sides allows smooth and hermetic coverage of the pin circle, with exclusion of bed sores of walls of the pin tract, pain from compression to soft tissues and, as result, inflammation of wounds, with significant improvement in treatment results that is difficult to achieve with crossing pins in other EFD.
CONCLUSION
1. The device for transosseous conduction of the pins allows introducing the pins through the segments of extremities in the proper direction, and decreases the risk of injuries to vessels, nerves, tendons and muscles of this region. It is proved by the absence of such complications in the study group.
2. Traumatic potential of the surgical technique is decreased by preliminary correction of displacement of fragments along the length, the width and at angle in the presurgical period of transosseous osteosynthesis, and continuous coaxial position of the axis of the pin and its tracts during multiple tension of a pin for reposition and fixation of fragments with use of the offered devices. It is especially important for patients with polytrauma within the first day after trauma for fracture fixation, decrease in pain in the pin tract and prevention of bedsores in the covering tissues that caused the 1.5-31.-fold decrease in pyoinflammatory complications in comparison with the common techniques of transosseous fixation.
3. As for treatment of fractures of the long bones along the surgical neck and humerus diaphysis, the lower one-third of the femoral bone, the leg, patella and ankles in patients with polytrauma with common techniques of osteosynthesis, almost 100 % of the patients of the comparison group had pain feelings around the pin tracts, 10-33.3 % – inflammation of soft tissues around the pins, 1.9-8.35 % – with development of osteomyelitis, 5.6-33.3 % – contracture in the adjacent joints, 2.5-10.5 % – secondary displacement of fragments, 3.3-5.3 % – change in type of osteosynthesis, 1.3-5.3 % – injuries to nerves and joints despite of proper preparation during 1-2 weeks in the posttraumatic period with consideration of condition in the presurgical period.
4. The developed complex of low-invasive surgical techniques of transosseous fixation in patients with fractures of long bones of the extremities, surgical neck of the humerus, ankles, patella allows the appropriate reposition and fixation within the first day of posttraumatic period in patients with polytrauma. Also it allows early atraumatic osteosynthesis and activation of patients, with minimal injury to muscles and the sources of blood supply of an injured segment. It reduced the period of disability by 1.0-1.3 months, increased the values of excellent and good outcomes by 1.2-2.1 times and, correspondingly, decreased the values of satisfactory and unsatisfactory results.