TREATMENT OF TRAUMATIC DEFECT OF THE TIBIA DIAPHYSIS WITH METHOD OF COMBINED SEQUENTIAL BILOСAL AND LOCKING OSTEOSYNTHESIS Bondarenko A.V., Plotnikov I.A., Guseynov R.G.
Altay State Medical University,
Regional Clinical Hospital of Emergency Medical Care, Barnaul, Russia
Leg fractures take the leading place among causes of disability caused by consequences of injuries to extremities [1-3]. Infected diaphysis defects after severe opened fractures present the most significant difficulties for treatment [4-6]. In the middle of 20th century, Ilizarov G.A., outstanding Russian traumatologist-orthopedist, offered a technique for bilocal combined compression distraction osteosynthesis for replacement of diaphysis defects. It consisted in formation of the distraction regenerate during transfer of an osteotomy fragment through the defect zone [7-9]. The problem of the technique consisted in the fact that bone union was often absent in site of conjunction of fragments after completion of defect filling, requiring for additional surgical interventions [10-12]. It was associated with some causes: thinning of one or both bone fragments over the long distance, different thickness of their ends, insufficient congruence at the junction etc. [13, 14]. However, some studies showed that the main cause of non-union was natural weakening or compete termination of the reparative response at the conjunction [15].
It is known that a fracture initiates release of biologically active agents in the fracture site which activate the reparative response, which triggers and provides the course of the process of union [15-17]. While union continues, the intensity of the reparative response decreases until it disappears. This is what happens by the moment of conjunction of fragments, resulting in absence of union at the site of conjunction and need for opened surgical interventions at site of contact of fragments for initiation of disappearing reparative response [15].
Opened surgical intervention at site of conjunction is accompanied by additional injury to soft tissues, devitalization of ends of fragments with disorder of periosteal perfusion, probability of infectious complications etc.
In such conditions, stimulation of osteogenesis at the site of conjunction after completion of distraction can be perspectively realized with combined use of osteosynthesis techniques with replacement of external fixation to internal one, with use of locking intramedullary nailing (LIN) [18]. The use of LIN for achievement of appropriate union at site of conjunction of fragments has some advantages as compared to transosseous and plate fixation.
Firstly, the nail is introduced in closed position. The point of introduction of the nail is positioned over the long distance from site of conjunction of fragments. Soft tissues and periosteum are not injured at site of conjunction [18].
Secondly, intramedullary construct prevents the closure of intramedullary canals of fragments that promotes growth of vessels through the conjunction site, and combining of vascular basins which is required for appropriate union [19].
Thirdly, the nail, which is blocked in the canal, prevents the bone regenerate from deformation during axial loads in conditions of dynamic blocking. It s also the strong stimulus, which stimulates the reparative response at site of conjunction of fragments [20-21].
Moreover, the reduction of period of fixation with external apparatus decreases the risk of local complications − transfixation contractures of adjacent joints, local osteoporosis, inflammation in site of installment of transosseous elements, venous hypodynamic disorders, and also promotes the improvement in life quality in period of treatment and reduces treatment time.
Considering the above mentioned facts, there was a decision to replace fixation with external apparatus to internal intramedullary nailing after defect filling during realization of bilocal compression distraction osteosynthesis. It will allow appropriate union of fragment at site of conjunction, will decrease the time of external fixation, will prevent the development of local complications and will improve life quality.
Objective – to conduct a comparative analysis of the use of combined sequential bilocal osteosynthesis and the traditional technique of transosseous compression-distraction osteosynthesis in the treatment of post-traumatic tibial diaphysis defects.
MATERIALS AND METHODS
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and with the Rules for Clinical Practice in the Russian Federation (the Order by Russian Health Ministry, June 19, 2003, No. 266), and with patients' consent for participation in the study, with approval from the local ethical committee. Patients were included with use of blind method for the single territory and for the same time interval.
For the period from 2009 to 2018, 23 patients with polytrauma (ISS = 26-40) [22] were treated in the concomitant injury department in Regional Clinical Hospital of Emergency Medical Care. One of the components of polytrauma was opened fragmented irregular fracture of tibial diaphysis with bone tissue defect. There were 18 men and 5 women, age of 18-54. Leg injuries were unilateral and were combined with traumatic brain injury (TBI) in 18 patients, internal organ injuries − in 5, extremities fractures in other locations − in 18, pelvic injuries − in 4, spine injuries − in 1.
During the study, two groups were formed by means of random distribution − the main group and the controls. The main group included 14 patients treated with the original technique of treatment [23] with combined sequential use of one of fragments of transosseous fixation (after lengthening osteotomy) for Ilizarov device and unreamed tibial nail (UTN). The size of the tibial defect was 2-7 cm in the main group (3.9 ± 0.9 cm on average).
The comparison (control) group included 9 patients treated with standard bilocal transosseous compression distraction osteosynthesis by Ilizarov. The size of the tibial defect was 2-7 cm in the control group (3.6 ± 1.6 cm on average). There were not statistically significant differences in the main parameters (gender, age, polytrauma severity, defect size and others) in the groups.
After correction of life-threatening conditions, all patients received surgical preparation of wounds in the site of opened fractures of the leg, with removal of non-vital tissues and devitalized bone fragments, with fixation of main fragments in Ilizarov apparatus. In 10 patients, intermediate free diaphyseal fragments were lost at the accident site, in 13 − the bone defect appeared as result of ischemic necrosis in anterior internal surface of the leg on weeks 2-3 of treatment after recurrent surgical preparation within the limits of healthy tissues.
After healing of the wound in the site of a bone defect, the patients received the lengthening osteotomy for one of tibial fragments (longer) with transfer of the intermediate fragment through the defect zone. Distraction (transfer of the free fragment into defect zone) was initiated from 7th day after osteotomy: 1 mm per day, 4 sessions, up to achievement of end stop with contralateral fragment. Single use of osteotomy was sufficient for 20 patients with defect size < 5 cm. 3 patients with defect up to 7 cm received 2 lengthening osteotomy procedures.
After achievement of contact between fragments, Ilizarov apparatus was dismounted within 4-30 days in the main group, and it was replaced to UTN. Osteal endosteal decortication of fragments with reaming was performed for 4 patients to simplify introduction of the nail. External immobilization was not used after NIL.
Apparatus fixation was continued up to complete union and rebuilding of the regenerate in the site of conjunction of fragments in the control group. It required for surgical intervention at the conjunction in 4 cases: 2 patients received osteal periosteal decortication of fragments, 2 patients − economic resection of their ends with adaptation.
During treatment process, the constructs of the pilot factory Ilizarov Research Center - Reconstructive Traumatology and Orthopedics, as well as Osteomed (Moscow) and SYNTHES (Switzerland) were used.
If contraindications were absent, the axial load (up to 10 kg) was initiated next day after surgery. Patients moved with crutches with the above mentioned load over the whole period of recovery of soft tissue wound, and transfer of the bone fragment. After completion of distraction, the transition to full weigh load was gradual within 1.5-2 months.
The amount of local complications after completion of distraction (conjunction of fragments) before transition to complete weigh load was estimated, as well as time intervals of external fixation, time intervals of transition to complete load after completion of external fixation, general and long term results of treatment.
χ2-test, Yates correction and Bonferroni method for multiple comparisons were used for estimation of statistical significance of differences. For testing the null hypotheses, the critical level of significance was less than 0.05 [24].
RESULTS AND DISCUSSION
34 local complications were identified: 6 complications in the main group, 28 − in the controls. The differences were statistically significant (p < 0.05). The table shows the characteristics of the local complications.
Table
Characteristics and incidence of local complications in groups of patients after completion of distraction with Ilizarov device
|
Complication type |
Main group (n = 14) |
Comparison group (n = 9) |
Total (n = 23) |
p |
|
Soft tissue inflammation in site of pins |
2 |
8 |
10 |
< 0.001 |
|
Ischemic necrosis of wound skin in surgical site at junction |
- |
2 |
2 |
- |
|
Metal construct fracture (screws, pins) |
1 |
4 |
5 |
< 0.05 |
|
Regenerate deformation |
- |
2 |
2 |
- |
|
Stiffness in ankle joint |
1 |
5 |
6 |
< 0.02 |
|
Post-thrombotic syndrome |
2 |
4 |
6 |
> 0.1 |
|
Total |
6 |
28 |
34 |
< 0.05 |
As the table shows, inflammation in region of pins was the most common. It was associated with higher duration of external fixation. This complication was more often in the comparison group; the differences were statistically significant (p < 0.001). Ankle joint stiffness was more often in the comparison group; the differences were statistically significant (p < 0.02). Fractures of metal constructs were more often in the comparison group; the differences were statistically significant (p < 0.05). The incidence of post-thrombotic syndrome was higher in the comparison group, although there were not any statistically significant differences between the groups (p > 0.1). There were not any deformations of the regenerate and local complications at the site of conjunction in the main group.
The time intervals of external fixation after completion of distraction varied from 4 to 30 days in the patients of the main group (17.7 ± 7.6 days on average). In the control group, the time intervals of external fixation varied from 87 to 148 days (110 ± 3.7 days on average). The differences in main and comparison groups were statistically significant (p < 0.05).
The time intervals of transition to full weigh load after completion of external fixation were 49.8 ± 13.5 days in the main group, and 57.4 ± 11.8 days in the controls. There were not any statistically significant differences (p > 0.1).
The total period of treatment was 144.8 ± 19.5 days in the main group, and 195.5 ± 21.6 days in the controls. The differences between the groups were statistically significant (p < 0.05).
Lower duration of external fixation in the main group decreased the rate of local complications, reduced the general time intervals of treatment, and improved the life quality at the stage of alteration of the distraction regenerate.
9 patients of the main group and 6 patients of the control group were examined within the period from 1 year to 3 years after hospital discharge. All patients could move without additional supports. Low pain after physical load was noted in the ankle joint in 3 patients in the main group and in 2 patients in the controls. Slight flexion contractures of the ankle joint (limitation of dorsal flexion on the injured extremity as compared to the healthy one was 5-7 degrees) was noted in 1 patient in the main group and in 5 patients in the controls. Leg edema in the end of the day was noted by 5 patients in the main group and by 6 ones in the controls. X-ray signs of alteration of the distraction regenerate and union of fragments were found in all patients. 4 patients of the main group showed signs of leg shortening by 1-3 cm. Shortening was also noted in 5 patients in the control group. Metal constructs were removed in 5 patients of the main group within 1.5-3 years after surgery. In all cases, removal of UTN was not associated with medical indications, and was performed due to patients' requests.
Replacement of the external fixation apparatus to the locking intramedullary nail in the period of formation of the distraction regenerate and union of fragments at the site of conjunction allowed achieving the appropriate union of fragments at the conjunction, after exclusion of additional surgical interventions, providing the optimal conditions for life quality in the period of alteration of the distraction regenerate.
Here we present a clinical case of combined sequential bilocal and locking osteosynthesis in treatment of tibial diaphysis defects.
A patient, female, age of 23, was admitted to the clinic after road traffic accident. The diagnosis was: "Severe concomitant injury; closed TBI; brain concussion; contused wound of hairy skull; a closed fracture of arches of the second cervical vertebrae without displacement; an opened fragmented irregular fracture of the left tibial diaphysis in the lower one-third with displacement, with soft tissue defect on anterior internal surface of the leg and tibial diaphysis in the injury site; an opened double fracture of the left fibular bone; a closed fracture of the upper one-third of the right fibular bone; a contused wound of the left leg in the upper one-third; a closed subtalar dislocation of the right foot; thermal burn on anterior surface of chest to the right, degree 2, 4 % of square".
After admission, closed reduction of subtalar dislocation of the right foot, transarticular fixation with K-wire, primary surgical preparation of wounds and opened fractures of the left leg, and Ilizarov apparatus fixation were conducted. Traumatic brain injury, closed fracture of the right fibular bone, and thermal burn of the chest were treated with conservative methods.
On the second week after admission, the signs of posttraumatic ischemic necrosis of soft tissues of the left leg in the site of opened fracture were found. On 24th day after injury, secondary surgical preparation of the opened fracture, and necrectomy and resection of the central fragment of the tibia within the limits of healthy tissues were conducted. The size of the diaphyseal defect was 4 cm. The wound healed with primary tension without skin plasty. On 44th day after trauma, osteotomy of longer proximal fragment in the upper one-third of the diaphysis was conducted (Fig. 1).
Figure 1
The X-ray image of the left leg by the patient, female, age of 23. Bilocal osteosynthesis of the left tibia fracture with use of Ilizarov apparatus, osteotomy of central fragment.
In 7 days after osteotomy, the dosed lowering of the intermediate fragment (1 mm per days) was initiated and lasted for 38 days up to achievement of the peripheral fragment (Fig. 2). In 30 days after conjunction of fragments, Ilizarov device was dismounted, and LIN with UTN in position of dynamic blocking was performed (Fig. 3). One and a half month after LIN, the patient could move without additional supporting measures. The control X-ray image (8 months after trauma) showed the strong distraction regenerate in the defect zone with union of fragments at the site of conjunction in the contact site (Fig. 4). One year after trauma, the patient could move without additional supporting measures. There were not any fistulas and contractures of adjacent joints. Shortening of the left lower extremity was 1.5 cm (Fig. 5).
Figure 2
The X-ray image of the left leg during transfer of the intermediate defect into the defect site.
Figure 3
X-ray images of the left leg after dismounting of Ilizarov device and after intramedullary fixation of the left tibia with the dynamic locking nail.
Figure 4
The X-ray image of the left leg after 8 months from the injury.
Figure 5
Appearance of the lower extremities in one year after trauma.
CONCLUSION
In the period of alteration of the bone regenerate, the use of the locking nail (in bilocal osteosynthesis) significantly reduces the amount of local complications (p < 0.05), and gives 6.5-fold decrease in time of external fixation after completion of transfer of a fragment, resulting in significant improvement in life quality and 1.4-fold decrease in general time of treatment.
Information on financing and conflict of interest
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.