FEATURES OF TREATMENT OF A PATIENT WITH THE CONSEQUENCES OF A COMBINED INJURY IN THE TYPE OF NON-HEALING FRACTURE OF DISTAL FEMUR Khominets V.V., Gubochkin N.G., Metlenko P.A., Shakun D.A., Ivanov V.S., Kazemirskiy A.V., Lukicheva N.P.
Kirov Military Medical Academy,
Russian Vreden Scientific Research Institute of Traumatology and Orthopedics, Saint Petersburg, Russia
Treatment of multi-fragmentary fractures of the lower one-third of the femoral bone in severe concomitant injury in persons at the age of retirement in combination with concurrent diseases remains the complex problem of modern traumatology and orthopedics [1-4]. Features of blood circulation, the pattern of the injury and presence of osteoporosis in such patients worsens the processes of osteoreparation [2, 5]. One can observe the significant prolongation of time of fracture union. False joints occur in some cases. So, according to some authors, the percentage of non-union and false joints of shaft fractures of the femoral bone can achieve 4.1-12.5 % [2, 5, 6, 7]. This severe complication causes physiological and morphological changes with abnormal symptom complex, which includes circulatory insufficiency, scar changes of the skin, nerve stem and muscular changes, vegetative disorders, bone mineralization disorders, contractures, ankylosis, vicious positions of joints [8]. Currently, there are three main factors, which negatively influence on reparative regeneration of bone tissue in fractures:
1. Mechanic factor, which determines the direct relationship between the a fracture mechanism and energy of trauma. Mainly, these are severe single or associated injuries with multiple fractures of extremities, opened (gun-shot) fractures with extensive wounds and injuries to muscles, vascular and nervous formations, and primary loss of bone tissue in a fracture [9, 10].
2. Biological factor, which is determined by individual characteristics of patients − presence of concurrent chronic diseases and their manifestations: diabetes mellitus, hyperparathyroid disorder, anemia, vascular atherosclerosis, varicose disorder, osteoporosis, obesity, gastrointestinal diseases. Also the biological factors include long term uptake of pharmaceutical agents (steroids), chronic intoxication due to unhealthy habits (alcohol, smoking), work in conditions of high levels of harmful substances and others [11].
3. Therapeutic factor, which is associated with quality of treatment. First of all, it is violation of technique and technology of osteosynthesis, incorrect treatment of wounds, and inadequate treatment or its absence.
At the present time, non-unions are classified according to morphological changes in ends of bone fracture due to quality of bone tissue; according to bone mass loss, position of fragments and their mobility; according to point estimation of non-union and relationship between clinical picture and management strategies [12].
Diagnostics of non-unions is based on the clinical picture and additional methods of examination such as X-ray imaging, computer tomography, magnetic resonance imaging, MRI with dynamic contrast, positron emission tomography with fluor dioxide glucose (FDG/PET).
Objective of our report − to demonstrate the modern possibilities of surgical treatment of a patient with the consequences of a combined trauma in the form of an atrophic non-union of the distal third of the femur against a background of systemic osteoporosis and an allergic reaction.
We would like to share our experience in treatment of a female patient with avascular non-union of the femur with use of individual multi-stage surgical treatment.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and the Rules for clinical practice in the Russian Federation (the Order of Health Ministry of Russia, June 19, 2003, No. 266). The patient gave her informed consent for participation in the study and for publication.
The patient, age of 52, received a concomitant injury to the head, chest and extremities in a road traffic accident. Opened TBI. Brain contusion of middle severity, a fracture of nasal bones, a rupture of nasal septum. A laceration of the lower lip. A fracture of sternum body and ribs 1-6 to the right. Subcutaneous emphysema. Opened fracture of the base of the first metacarpal bone and the head of the second metacarpal bone of the left hand with displacement of fragments. A closed fragmented transcondylar fracture of the right femoral bone. A fracture of the left fibular bone in the lower one-third with displacement of fragments. Opened fracture-dislocation of metatarsal bones of the right foot in tarsometatarsal joint. Opened subtalar fracture-dislocation of the left foot. Traumatic shock of degree 2.
3 days later, after realization of urgent surgical and intensive care procedures, the patient was transferred from the central regional hospital to the trauma center of level 1. There she received the following surgical interventions: closed reposition, plate osteosynthesis of the fibular bone with LISS and LCP. The wounds healed with primary tension. The patient was discharged from the hospital after one and a half month.
Subsequently, complex inhospital rehabilitation treatment was conducted several times. The treatment was oriented to the false joint of the lower one-third of the right femur, right-sided gonarthrosis of degree 3, valgus positioning of the right leg, combined contracture of the right knee. The achieved flexion in the knee joint was 120°, extension − 175°.
7 years after trauma (25.01.2011), the patient was admitted to the clinic of military traumatology and orthopedics. She had non-union of the distal femur in view of atrophic false joint of the lower one-third of the right femur fixed with two plates (Fig. 1), posttraumatic arthrosis deformans, combined contracture of the right knee joint, shortening of the right lower extremity by 2 cm, local (systemic) osteoporosis, polyvalent allergy.
Figure 1
X-rays of the right thigh in AP (a) and lateral (b) views upon admission to the clinic. Atrophic non-union of the femur in the lower third, fixed by two plates with angular stability of the screws and cerclage suture, hallux valgus deformity of210. Post-traumatic deforming arthrosis of the knee joint, osteoporosis
We planned the multi-stage surgical management, which was based on the fact of difficult primary estimation of formation of a bone defect in preparation of ends of the avascular false joint. Also there was a difficulty with primary selection of an implant for final fixation with consideration of future correction of deformation and changes in strength characteristics of the bone at the background of intense osteoporosis, multiple hole defects of femoral diaphysis and condyles, polyvalent allergy.
Therefore, the first stage included the removal of the metal construct, decortication of ends of the false joint and sclerotic regions in sites of removed screws before occurrence of pinpoint bleeding (Fig. 2).
Figure 2
Intraoperative X-ray imaging of the femur after removal of the metal structure in AP (a) and lateral (b) views. Multiple hole defects of the diaphysis and condyles with areas of osteosclerosis, moderate manifestations of osteoporosis, hallux valgus deformity at the level of the pseudoarthrosis 250 are determined. Post-traumatic deforming arthrosis of the knee joint
During surgery, after preparation of ends of the false joint up to vascularized regions, the bone defect increased by 2 cm, and valgus deformation increased by 4°. The strength of bone tissue was estimated as sharply low since it could be easily cut with the scalpel and penetrated with the injection needle. In the postsurgical period, the extremity was immobilized with the removable orthosis. The wounds healed with primary tension. The patient could walk with crutches with dosed load to the operated extremity. The shortening of the femoral bone was 4 cm.
After consultation by allergologist, allergy reaction to ultracain and baralgin in view of Quinke's edema was diagnosed. Treatment with dexamethasone was prescribed. Also osteoporosis was treated with Aclasta (0.05 mg/ml, 00 ml i.v., one time), Fosavance Forte (1 tablet, 1 time per week).
Three months later, the patient was admitted to perform the second stage of planned surgical management: knee joint arthrolysis, quadriceps myolysis and tenolysis, correction of valgus deformation by means of boundary internal osteotomy, osteosynthesis with retrograde femoral nail with drilling of bone marrow channel and locking, free bone autoplasty of the false joint with morselized grafts from resected parts of the femoral bone. In the end of surgery, the range of movements in the right knee joint was 110°, extension − 180° (Fig. 3).
Figure 3
X-ray imaging of the femur in AP (a) and lateral (b) views after osteosynthesis with a retrograde nail with distal blocking with a spiral blade and a screw, proximal with one screw. The valgus deviation of the condyles is 100. The gap of the non-union is not visible.
In the presurgical period, recurrent diagnosis was conducted with use of medical allergens. Allergic response to clexane, warfarin, vancomycin and bone cement was diagnosed. Anti-allergic therapy and treatment of osteoporosis with calcium tablets were carried out. Boundary adapting resection of medial parts of the femoral bone was conducted for correction of valgus deformation of the femur up to allowable values. Also the attention was given to decrease in square of holed bone defects by means of boundary formation of callus. Personally, an increase of strength of bone tissue was noted in view of difficulties in penetration of condyles with the injection needle. In the postsurgical period, the extremity was immobilized with the removable orthesis before removal of sutures. The wounds healed with primary tension. The patient could move with crutches with dosed load to the extremity during 1 and a half month, with subsequent gradual increase in load to full degree within 3 months. In that period, training of movements in the knee joint was initiated. The shortening of the femoral bone was 5 cm.
One and a half year after osteosynthesis, the patient was admitted to the clinic. During examination, she could walk with the cane, with limping right leg. The shortening of the right extremity was 5 cm. Valgus declination of the leg was 15°. Movements in the knee joint were limited: flexion − 100°, extension − 175°. The patient had some complaints for pain in the knee joint during load relating to walking more than one hour and in end position during movements. The proximal locking screw was removed to optimize reparative processes (Fig. 4).
Figure 4
X-ray imaging of the femur with a load in AP (a) and lateral (b) views 1.5 years after osteosynthesis with a retrograde nail with distal blocking, the proximal screw was removed. Hallux valgus deviation of the tibia 150. The gap of the non-union was not visible
After discharge, the load to the right lower extremity did not decrease. The patient received rehabilitation treatment. The pain in the region of the right knee joint brought discomfort to the patient. During the following year, she noted progression of shortening of the right lower extremity.
One year later, after dynamization of the metal construct, the patient was admitted to the clinic of traumatology and orthopedics. After admission, the patient could move with the cane with full load. Her right extremity was limping. Slight valgus declination of the right leg was noted. The shortening of the right lower extremity progressed to 7 cm. Palpation of the right patella was moderately painful in the site of femoral condyles. Patella ballotement symptom was weakly positive. Axial load was painless. There were not any signs of knee joint instability. The control X-ray imaging and computer tomography did not show remodeling of femoral bone tissue and signs of false joint union. Movements in the joint were limited: flexion − 100°, extension − 170°. Surgical management was planned. The first stage included removal of the intramedullary nail. Right-sided valgus gonarthrosis of the stage 4 was treated with complex endoprosthetics of the right knee joint with use of LCCKF with long intramedullary stems and femoral augments. In the postsurgical period, the extended plan of rehabilitation treatment was initiated. The patient was discharged for outpatient treatment. Comprehensive guidance was given, including for osteoporosis treatment. After complex restorative treatment, the range of movements almost achieved normal values, and the supporting ability of the right lower extremity was achieved (Fig. 5, 6).
Figure 5
X-ray imaging after endoprosthetics of the right knee joint in AP (a) and lateral (b) views
Figure 6
The appearance 3 weeks after surgery: a) standing without load, b) lying down
The control examinations were performed after 1, 2, 3 and 6 months from surgery, and each year subsequently (Fig. 7).
Figure 7
X-ray imaging of the right knee joint 3.5 months after surgery: a) in AP view, b) in lateral view
In the postsurgical period, the patient was examined within 7 years. Currently, the function of the right lower extremity recovered completely: strength of right leg muscles − 5 points) (six-point score "Muscular strength estimation", McPeak L., 1996, Weiss M., 1986). There were not any sensitivity disorders (Fig. 8).
Figure 8
Functional outcome (a, b, c) and X-ray imaging in AP (d) and lateral (e) views 5 years after the endoprosthetics
The previous level of life quality was achieved as result of complex multi-stage treatment. According to SF-36, GH (General Health) − 92.00, MH (Mental Health) − 100.00. The patient could walk without additional supporting. She used common shoes (the heel − 5 cm). The was no limping. Pain was absent.
CONCLUSION
Therefore, the individual approach to each patient with consideration of modern ideas about pathogenesis of development of non-union process allows selection of management strategy for such patients, with achievement of good functional results.
The important components of success in treatment of the patient with atrophic non-union at the background of osteoporosis and allergic response is the use of subsequent multi-stage surgical strategy and conservative treatment to create optimal conditions for further social rehabilitation.
DISCUSSION
The choice of this algorithm of actions can be explained by the following factors.
Firstly, the patient received the severe concomitant injury, resulting in realization of aggressive (according to our opinion) opened osteosynthesis of the multi-fragmentary fracture of the distal epiphyseal cartilage of the femoral bone with violation of osteosynthesis technique in view of detachment of periosteum, with surgeons' attempt to achieve absolute stability with high density of introduction of screws, the use of cerclage and two plates.
Secondly, the foci of osteolysis were clearly visualized during surgical intervention for removal of constructs. The strength of bone tissue over the distance of 7-20 cm more proximal than the knee joint cleft was estimated as sharply decreased. The trabecules could be easily cut with scalpel. They were easily penetrated with the injection needle. In this situation, the realization of recurrent osteosynthesis could be inefficient, and the surgery was delayed up to healing of wounds and bone tissue rebuilding at the background of prescribed treatment. The patient could move with dosed load to the leg.
Thirdly, in 3 months from that moment, osteosynthesis with retrograde nail was planned to provide union and to decrease intensity of osteoporosis. Without it, it would be impossible to achieve appropriate fixation of the future endoprosthesis. After surgery, the patient was discharged. The recommendations were given to progressively increase the load to the leg. After 6 months, dynamization of the nail was performed. Over time, CT showed an increase in volume of bone mass and its density after 2.5 years. The union of the atrophic false joint was achieved. The favorable conditions for installment of the femoral stem of the endoprosthesis were created − bone structure was dense around the nail, without signs of osteoporosis. The nail was along axis of the extremity.
The estimation of the patient's condition during outpatient treatment and in the period between operations is the important component of treatment. Treatment of osteoporosis and dosed load were the main factors of bone tissue rebuilding.
After realization of the above-mentioned series of preparative surgical interventions, the main problem was determined − to achieve the increase in life quality of the patient. Two main tasks were to be solved: to restore the length of the extremity and knee joint functioning.
By the moment of preparation to endoprosthetics, the patient was 60 years old. According to morphological measurements, the total length of the defect was about 7 cm. The patent refused from offered recovery of extremity length with Ilizarov's technique. It was solved to remove the prolonged stem of the femoral part of the endoprosthesis. It allowed lengthening the extremity by 2 cm. The remaining part of the defect was planned to replace by means of the insert for shoes or with special orthopedic footwear.
In the postsurgical period, multi-component rehabilitation treatment was planned and conducted.
CONCLUSION
We present this clinical case to demonstrate the possibilities of targeted multi-stage treatment of patients with complicated severe injury to the femur. It is necessary to accentuate the importance of planning of treatment and prediction of results at all stages − from primary intervention to final reconstructive and restorative surgery and extended rehabilitation.
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.