PROBLEMS OF ARRANGEMENT OF MEDICAL CARE FOR PATIENTS WITH POLYTRAUMA AND OPENED FRACTURES OF LONG BONES OF LOWER EXTREMITIES Blazhenko A.N., Dubrov V.E., Kurinny S.N., Mukhanov M.L., Gomonov S.A., Shkoda A.S.
Kuban State Medical University,
Research Institute – Ochapovsky Krasnodar City Hospital No.1, Krasnodar, Russia,
Fundamental Medicine Faculty of Lomonosov Moscow State University,
Vorokhobov City Clinical Hospital No.67, Moscow, Russia
Severe opened fractures of lower extremity bones of Gustilo-Anderson types II, IIIA, B and C [17] are caused by high energy trauma [13] and in most cases are accompanied by severe multiple and/or associated injuries in several anatomical fields with development of mutual burdening syndrome [14] and systemic inflammatory response syndrome (SIRS), sometimes resulting in multiple organ dysfunction syndrome (MODS) [26] and causing problems for arrangement of medical care for such patients. All this determined the necessity for development of the special strategy for treatment of such injuries.
In the beginning of the 20th century, the following treatment strategy for treatment of such patients appeared (and is used now). It is directed to decreasing mortality and the rate of infectious complications:
- For critical or unstable condition, the treatment of all injuries is conducted with consideration of Damage Control Surgery (DCS) [26]. Only after correction of life-threatening consequences of injury, the treatment of severe opened fractures is initiated with wound toilet with antiseptic solutions, surgical stabilization of a fracture with external fixator (EF) and application of aseptic dressing [11, 12, 13, 25].
- After achievement of relative stabilization of condition or if condition was stable or relatively stable initially, full primary surgical preparation (PSP) of the opened fracture wound is obligatory performed, and in the following days – staged recurrent surgical preparations (SP) which complete the first stage of treatment – limb salvage, if possible [13].
- The task of the second stage is recovery of soft tissues in the fracture site, and prevention of infectious complications [13].
- The third stage includes final reposition and fixation of fractures for stimulation of union and restoration of extremity functioning [13].
According to some domestic and foreign authors, the development and implementation of DCS and staged management for opened fractures reduced the mortality rate in patients with polytrauma, including with opened fractures. However at the present time, the rate of infectious complications in high energy opened fractures of extremities (Gustilo-Andersen II, IIIA, B, C types [25]) do not show a trend to decrease and consists up to 23-25 % [5, 13, 23], and treatment is completed with disability in 4.5-17.6 % of cases [1, 22].
According to some authors [6, 7, 13], most infectious complications are determined by tactical and organizational errors in PSP and/or recurrent SP of wounds of severe opened fractures.
Unfortunately, available literature does not include any analysis of errors relating to these surgical interventions, evidence-based treatment protocols depending on a type of opened fracture, estimation of patient’s condition, equipping of primary admission hospital, professional experience. All these determine the actuality of this study.
Objective – analysis of mistakes made in the planning and execution of surgical treatment of wounds of opened fractures in patients with polytrauma.
MATERIALS AND METHODS
The present multicenter study is based on the analysis of the treatment results of 454 patients (age of 18-60) with polytrauma (NISS > 17) and opened fractures of lower extremity long bones who were treated in the clinical bases of orthopedics, traumatology and military field surgery department of Kuban State Medical University, Research Institute – Ochapovsky Krasnodar City Hospital No.1, general and specialized surgery chair of Fundamental Medicine Faculty of Lomonosov Moscow State University and Moscow Vorokhobov City Clinical Hospital No.67 in 2012-2016.
The inclusion criteria were:
- correspondence between identified injuries to soft tissue and bones and Gustilo-Anderson types I, II, IIIA, B and C [25];
- severity of injuries with NISS > 17 [16];
- absence of concurrent pathology (diabetes, arterial or venous insufficiency and others), which could influence on processes of opened fracture wounds recovery.
The group 1 included 334 (73.6 %) patients who were admitted to the facilities corresponding to level II trauma centers according to equipment and staff training [7, 19], and who were transferred to level 1 trauma center within 12-92 hours after injury and after correction of life-threatening consequences of trauma: 182 (60.1 %) patients for arrangement of specialized and/or high tech care, 121 (39.9 %) – with phenomenon of mutual burdening and signs of MODS.
The group 2 included 120 (26.4 %) patients who were admitted to facilities corresponding to level 1 trauma center according to equipment and staff training [7, 19] immediately from the accident site; 23 patients were admitted in unstable or/and critical state, 97 (80.8 %) – in relatively stable state.
According to severity of opened fractures of lower extremity long bones, the patients were distributed into the subgroups with consideration of Gustilo-Anderson classification:
- type I Gustilo-Anderson – 188 (44.4 %) patients: the group 1 (n = 139), the group 2 (n = 49);
- type II Gustilo-Anderson – 102 (22.5 %) patients: the group 1 (n = 88), the group 2 (n = 14);
- type IIIA Gustilo-Anderson – 98 (21.6 %) patients: the group 1 (n = 57), the group 2 (n = 41);
- type IIIB – 53 (11.7 %) patients: the group 1 (n = 40), the group 2 (n = 13);
- type IIIC– 13 (2.9 %) patients: the group 1 (n = 10), the group 2 (n = 3); this subgroup included more patients with ruptures of magistral arteries, in all cases were noted thrombosis at the level of fracture of femoral and/or tibial condyles.
The mortality in the study group was 7.7 % (n = 35).
The table 1 shows the distribution of various types of fractures according to their location. The analysis of the data concluded that opened tibial diaphyseal fractures prevailed among other opened fractures; opened femoral fractures are characterized by injuries of Gustilo-Anderson II-IIIA. Most opened fracture wounds with covering tissue defects (Gustilo-Anderson IIIB) were found in tibial fractures at different levels.
Table 1
Location and types of opened fractures in patients of study groups
|
Types of opened fractures according to Gustilo-Anderson |
Location of opened fractures |
|||||||||
|
Femoral diaphysis, n = 62, abs. |
Distal femoral metaepiphysis, n = 36, abs. |
Proximal tibial metaepiphysis, n = 48, abs. |
Tibial diaphysis, n = 275, abs. |
Distal tibial metaepiphysis, n = 33, abs. |
||||||
|
Group 1 |
Group 2 |
Group 1 |
Group 2 |
Group 1 |
Group 2 |
Group 1 |
Group 2 |
Group 1 |
Group 2 |
|
|
I, n = 188 |
22 |
6 |
7 |
4 |
7 |
5 |
97 |
32 |
5 |
3 |
|
II, n = 102 |
16 |
5 |
7 |
5 |
7 |
3 |
36 |
11 |
7 |
5 |
|
IIIÀ, n = 98 |
9 |
4 |
8 |
3 |
9 |
4 |
41 |
10 |
7 |
3 |
|
IIIÂ, n = 53 |
0 |
0 |
0 |
0 |
1 |
1 |
36 |
12 |
2 |
1 |
|
IIIÑ, n = 13 |
0 |
0 |
2 |
0 |
8 |
3 |
0 |
0 |
0 |
0 |
|
Total, n = 454 |
47 |
15 |
24 |
12 |
32 |
16 |
210 |
65 |
21 |
12 |
The patients of both groups did not demonstrate any statistical differences in age (p > 0.73), gender (p > 0.94) and severity of injuries (p > 0.58). Distributions of numerical values were different from normal law. Therefore, Mann-Whitney non-parametric test (U-test) was used for confirming their correspondence [4].
Characteristics of PSP variants for opened fracture wounds
Besides prevention of infectious complications and creation of conditions for optimal union, all surgical treatment of opened fractures in patients with polytrauma was directed to decreasing the probability of mutual burdening phenomenon and not worsening the patient’s condition. For this purpose, the staged management for opened fractures [6, 13] and DCS [26] were used.
PSP of opened fracture was not conducted for Gustilo-Anderson type I fractures in patients with polytrauma: skin toilet was performed with antiseptic solutions, aseptic dressing was applied to the wound, antibiotic prevention of infectious complications was conducted, and external fixator was used for fixation of fragments in acute period of polytrauma.
We identified three variants of PSP after examination of the cases of the patients of the study group with Gustilo-Anderson types II, IIIA, IIIB and IIIC opened fractures.
Variant 1 – full traditional PSP for opened fracture. It was realized for 195 (58.4 %) patients in the group 1 and included all classical stages regardless of estimation of condition severity [9, 10]: wound dissection, resection of non-vital tissues (necrectomy), removal of foreign bodies, wound toilet with antiseptic solutions. If thrombosis signs in magistral veins were found, a wound was packed with drapes with antiseptic solutions or levomekol ointment; vascular surgeons were attracted from the regional multi-profile hospital and cooperated in autovenous arterial plasty followed by wound draining with different techniques (active, intake-outtake), wound suturing or wound closure with apposition sutures. Surgical stabilization of a fracture was conducted with various external fixators (frame monolateral, pin and/or pin-frame). Moreover, 52 (26.6 %) patients received PSP with technical errors, which are common for other regions of Russia [6], and were found before and during recurrent surgical preparation such as:
- inappropriate revision of the wound with remaining foreign bodies, non-vital soft tissues, small bone fragments without blood perfusion sources;
- instable fixation of a fracture with skeletal traction (ST) system, inappropriate external fixation with frame of plaster bandage;
- wound suturing with relief skin incision for soft tissue edema;
- absence of drains or passive draining for opened fracture wound.
Variant 2 – PSP for realization of damage control concept – was used for the group 2 for 23 (32.4 %) unstable or/and critical patients with polytrauma. It was realized as followed: immediately after DCS surgeries of the first surgical stage [7, 9, 14, 26, 27], wound toilet with antiseptic solutions was conducted, the wound was packed with surgical drapes with antiseptic solutions or levomekol, an aseptic dressing was applied, and the external frame fixator was used.
After achievement of relative stabilization of condition within 4-12 hours after trauma, wound PSP was carried out with wound dissection, removal of foreign bodies, necrectomy, hemostasis, wound toilet with antiseptic solutions. For intraarticular fractures, we tried to restore the congruity of articular surface. For this purpose, we conducted reposition of articular surface and fixed the fragments with K-wire (5-6 %, n = 4). If thrombosis signs in magistral veins were found, we carried out autovenous plasty (1.4 %, n = 1). VAC-dressing was applied for treatment of wounds in conditions of negative pressure – 125 mm Hg [2, 15].
Variant 3 – PSP – was used in the group 2 for 48 (67.6 %) patients in relatively stable (subcompensated) or stable (compensated) condition. It included wound dissection, removal of foreign bodies, realization of necrectomy, hemostasis, wound toilet with antiseptic solutions, fracture stabilization with external frame fixator for intraarticular fractures, recovery of articular surface and temporary fixation of fragments with K-wire (12.6 %, n = 9). Autovenous plasty was conducted if thrombosis signs in magistral veins were found (4.2 %, n = 2). After that, the wound was packed with drapes with antiseptic solutions and/or levomekol ointment for achievement of warranted hemostasis. After 6-24 hours, VAC-dressing for wound treatment with negative pressure was applied – 125 mm Hg [2, 15].
Features of recurrent surgical preparations (SP) of opened fracture wound (n = 639) in dependence on location and type of opened fracture were the following:
1. After transfer of patients from hospitals of primary admission within 2-4 hours, recurrent surgical preparation was conducted. Its aim was removal of the above-mentioned possible technical defects in PSP and application of VAC-dressing for negative pressure wound therapy – 125 mm Hg.
2. For cases with opened fractures of femoral and tibial bones of type II (n = 118), we did not have situations with impossibility of covering the bone and magistral veins with tissues, but we needed for 3.5 ± 2.1 recurrent SP for resection of new muscular tissue necrosis, dermotension (application of contractive sutures) in recurrent SP for decreasing the wound size along with correction of traumatic edema of soft tissues of the extremity with application of VAC-dressing.
The first stage of surgical treatment was considered as completed if bacteriological analysis of wound discharge was negative, signs of muscular tissue necrosis were absent and borders of skin wound were connected that determined the possibility for final internal osteosynthesis.
3. 98 (21.6 %) patients with type IIIA opened fractures of femoral and tibial diaphysis and also with intraarticular opened fractures showed the destruction of bone and covering tissues without defects.
A strive to save the vitality of covering tissues of the extremity determined the necessity for use of vacuum assisting with dermotension (application of contractive sutures) at the stages of recurrent SP along with decreasing posttraumatic edema of soft tissues. Therefore, 69 (70.5 %) patients of this subgroup showed the recovery of wounds and they could receive osteosynthesis immediately after that.
Other patients with incomplete healing of skin wounds, but without bone exposure, were treated with extrafocal compression distraction osteosynthesis (EFCDO) with Ilizarov’s technique.
The treatment stage was considered as completed upon condition of absent necrosis of soft tissues and negative results of bacteriological analysis of wound secretion.
The amount of recurrent SP in this subgroup was 2.6 ± 1.4 on average, and duration of this treatment phase was 5.5 ± 1.5 days.
4. For opened tibial fractures of IIIB type (11.7 %, n = 53) at the stages of recurrent SP in presence of signs of disordered perfusion of the bone, 13 (24.5 %) cases (change in color in absence of periosteum) included its resection within the borders of vital tissues. After completion of this treatment stage and in impossibility of bone coverage with covering tissues, we carried out:
- layer-by-layer non-free skin plasty with advanced flaps – 9 (16.9 %);
- myoplasty for covering tissue defect with stems from gastrocnemius muscle – 11 (20.8 %) followed by muscle closure with split-thickness skin graft;
- transplantation of free thoracodorsal flap with use of microsurgical vascular technique – 2 (3.8 %);
- dermatotension resulted in closing the skin wound in only 3 (5.7 %) patients.
Simultaneously with defect closure, these patients received internal osteosynthesis with different techniques.
If the above-mentioned techniques could not remove a covering tissue defect, EFCDO with Ilizarov technique was used as final treatment in 28 (52.8 %) patients.
The number of recurrent SP was 3.1 ± 1.4 in this group, the duration of this treatment stage – 6.5 ± 1.1 days.
According to time of transfer to the regional multi-profile hospital, the patients of the study group 1 were divided as indicated below:
- within 24 hours after injury – 209 (62.6 %);
- within 24-48 hours – 67 (20.1 %);
- within 48-92 hours – 58 (17.3 %).
The comparative analysis of the rate of infectious complications in realization of various variants of PSP and different time intervals of transfer to the multi-profile hospital was conducted for estimation of the treatment results and selection of the optimal protocol for medical care.
It is necessary to note that we did not find any uniform special classification for estimation of infectious complications of opened fracture wounds in the medical literature.
Owing to the fact that the infectious complications were not determined by osteonecrosis (the signs of its development: changes in bone color and absence of periosteum – bone resection within the borders of healthy tissues was conducted), they were distributed into 2 groups:
- with deep infectious complications and involvement of subfascial tissues;
- with deep infectious complications and signs of process generalization (the obligatory condition was presence of SIRS and MODS).
Superficial inflammation (the infectious process involved only skin and subcutaneous adipose tissue) was not considered owing to the fact that almost all cases were corrected after planned recurrent SP, it did not influence on the results and did not require for changes in management.
The statistical preparation and analysis of the clinical results were realized with descriptive statistical methods. Non-parametrical χ2 test for random tables was used for comparison of hypotheses. P ≤ 0.05 was considered as significant [4]. SPSS 16.0 was used for statistical preparation.
All patients or their legitimate representatives gave their informed consent for participation according to the requirements of the Federal Law 152-FZ from 27 June 2006 (edited on 22 February 2017) “About personal data” that corresponded to Helsinki Declare – Ethical Principles for Medical Research with Human Subjects 1964 (revised in 2013), and to the Rules for Clinical Practice in the Russian Federation confirmed by RF Health Ministry on 19 June 2003 No.266. The presented data were anonymized.
RESULTS
The analysis of the incidence of complications in dependence on fracture severity and a hospital of primary admission and, as result, used management was conducted (the table 2).
Table 2.
Comparison of incidence of infectious complications in dependence on a type of opened fracture according to Gustilo-Anderson
|
Group 1 (n = 334) |
Group 2 (n = 120) |
Validation criterion, χ2 test (random table), critical value χ2 = 23.104* |
||||
|
Fracture type and number of patients in subgroup |
Deep infectious complications, abs./% |
Deep infectious complications with signs of infection generalization, abs./% |
Fracture type and number of patients in subgroup |
Deep infectious complications, abs./% |
Deep infectious complications with signs of infection generalization, abs./% |
|
|
I, n = 139 |
3 / 2.4 % |
2 / 1.4 % |
I , n = 49 |
1 / 2.0 % |
1 / 2.0 % |
p > 0.5 |
|
II, n = 88 |
9 / 10.2 % |
8 / 9.1 % |
II, n = 14 |
1 / 7.1 % |
1 / 7.1 % |
p < 0.01* |
|
IIIÀ, n = 57 |
41 / 71.9 % |
11 / 19.3 % |
IIIÀ, n = 41 |
6 / 14.6 % |
2 / 4.8 % |
|
|
IIIÂ, n = 40 |
29 / 72.5 % |
8 / 20.0 % |
IIIÂ, n = 13 |
6 / 46.2 % |
2 / 15.4 % |
|
|
IIIÑ, n = 10 |
8 / 80.0 % |
2 / 20.0 % |
IIIÑ, n = 3 |
2 / 66.7 % |
1 / 33.3 % |
|
The data from the table 2 showed that the rate of infectious complications in the groups 1 and 2 in type I opened fracture was not statistically significant (not more than 4 %).
However the comparative analysis of the treatment results in use of three variants of PSP with subsequent recurrent SP, which are common for Gustilo-Anderson types II, IIIA, IIIB and IIIC, showed the statistically significant differences depending on a variant of primary surgical preparation. Moreover, the higher decrease in the rate of infectious complications was noted in patients with IIIA and IIIB opened fractures.
During realization of the variant 1 of PSP and recurrent SP in 195 patients of the group 1, the infectious complications were found in 116 (59.5 %) patients including 87 (44.6 %) with deep infectious complications and involvement of subfascial tissues, 29 (14.9 %) with deep infectious complications and signs of the process generalization.
During realization of the variants 2 and 3 of PSP and recurrent SP in 71 patients of the group 2, the infectious complications were noted in 15 (21.1 %) patients including 9 (12.8 %) with deep infectious complications and involvement of subfascial tissues, 6 (8.5 %) – with deep infectious complications and signs of the process generalization. We should note that the variant 2 of PSP was used only for unstable or critical patients; for other cases, the variant 3 was used.
The study group (n = 454) showed the rate of infectious complications of 59.5 % in the patients with high energy fractures in the group 1. It was reliably higher in comparison with the group 2 with the value of 21.1 %.
Another factor influencing on the rate of infectious complications, according to our opinion, is time of transfer of patients to the regional multi-profile hospital. A strong correlation was found between the rate of infectious complications and time of transfer (the table 3).
Table 3
Relationship between amount of infectious complications and time of transfer to level 1 trauma center
|
Time of transfer |
Number of patients with infectious complications |
|
Within first 24 hours |
28 (24.2 %) |
|
Within first 24-48 hours |
41 (35.3 %) |
|
Within first 48-96 hours |
47 (40.5 %) |
|
Spearman rank correlation, rs = 0.99 |
|
The data from the table 3 supposes that the lowest amount of surgical complications was noted in the patients admitted to the level 1 trauma center within 24 hours for realization of specialized and high tech medical care; it also allowed timely realization of recurrent SP and identifying and removing the PSP defects before appearance of infectious complications.
Therefore, for decreasing rate of infectious complications in high energy fractures, it is necessary to perform the variants 2 or 3 of PSP, and the transfer is to be performed within 24 hours in necessity for transportation for realization of specialized and high tech medical care to a medical facility corresponding to level 1 trauma center according to resources and staff experience [7, 20].
CONCLUSION
1. Management of patients with opened high energy fractures of the lower extremities (Gustilo-Anderson types II, IIIA, B and C) including the second variant of PSP with subsequent realization of planned recurrent SP for unstable and/or critical patients, with consideration of a type and location of a fracture, and for relatively stable (subcompensated) state – the third variant with subsequent realization of planned recurrent SP, with consideration a type and location of a fracture, allows decreasing the general incidence of infectious complications by 38.4 % as compared to the variants of management with traditional full PSP and subsequent surgical preparations of opened fracture wounds.
3. Transfer of patients with high energy opened fractures of extremities, necessity for specialized medical care, and/or polytrauma with uncertain or unfavorable prognosis for life, is realized within 24 hours after injury; 3 days of delay in recurrent SP promotes the increasing rate of infectious complications (by 19 %).
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.