EXTERNAL OSTEOSYNTHESIS FOR FRACTURES OF LOWER LIMB LONG BONES

Bagirov A.B., Tsiskarashvili A.V., Laymuna Kh.A., Shesternya N.A., Ivannikov S.V., Zharova T.A., Suvarly P.N.

Priorov National Medical Research Center of Traumatology and Orthopedics,
 Sechenov First Moscow State Medical University, Moscow, Russia

EXTERNAL OSTEOSYNTHESIS FOR FRACTURES OF LOWER LIMB LONG BONES

The modern stage of science and technology shows the improvement in methods and offers some high technologies for solving various problems and tasks [1]. In traumatology and orthopedics, the drive to using more advanced and efficient methods, schemes and technologies is fully justified [2].
The quality of life has been improving gradually, the data field has been extending, and the patients’ appetency to get modern, adequate and qualitative medical care appears [3].
The treatment of complicated fractures of pelvic and leg bones presents a serious problem in traumatology and orthopedics [4, 5]. These injuries lead to long term working incapacity and present one of the main causes of disability [6, 7].
The main difficulties in treatment of bone fractures are associated with the fact that the processes of union and recovery of function in an injured extremity segment are often complicated by contractures and deformations, osteomyelitis and extremity shortening [8].
The treatment of factures includes two main directions: internal and external osteosynthesis [9, 10]. Each of them has some positive and negative moments. Internal osteosynthesis is convenient for the patient, but uncontrollable in the postsurgical period [6]. External osteosynthesis is controllable, but uncomfortable for the patient [11-13].
Objective – to substantiate the new modified assembles of the external fixation apparatus, which combine stability and comfort for the patient.

MATERIALS AND METHODS

The main terms were used for understanding the technology of transosseous osteosynthesis: a bone, a pin or a rod, support and configuration [14, 15].
The term bone uses the following parameters: a) characteristics of a bone in place of pins or rods (cortical layer thickness and osteoporosis degree); b) sizes of bone fragments and their amount; c) lever properties of fragments [16-18].
As the element, the pins demonstrate the following characteristics: a) diameter and amount; b) strength properties during tension in the ring system; c) the variant for processing the sharp end (with the special grinding tool or the common grinding tool); d) surface type (with supporting platform or without it); e) variants of insertion (insertion through the bone or console installation) [7, 19-22].
The term rod characterizes: a) diameter, length and number; b) size of thread segment in the bone, and size of smooth part; c) a variant of processing the sharp end; d) a variant of processing the blunt end; e) depth of blades of thread, the square of its contact with bone tissue; f) direction of insertion [23].
The term support includes the characteristics: a) geometrical appearance (the ring, the semi-ring, the sector); b) the holder or the beam [24].
The term configuration combines the actions of specialists in assembling the external fixation device (with the hinge or without it), the number and variety of threading rods connecting the supports.
Depending on the segment location, characteristics and size of the bone and its fragments (the term bone), the required number and the diameter of pins and rods (the terms pin or rod) is selected; the diameter of semi-rings and sectors, the length of beams and holders (the term holder) are selected. In other words, development of the external construct for osteosynthesis corresponds the term configuration of the external fixation device.
We think that the systematized approach to the external fixation method can promote the decrease in amount of errors at each stage of transosseous osteosynthesis.
The offered concept of external fixation devices is as described below. The devices are used in the manner when they perform their functions: stabilization of fragments in the targeted position; minimal injury to muscular mass. They have to be simple to operate. They should not hinder the radial diagnosis and they should not create any discomfort situations for the patient. Certainly, it is necessary to strive to conduct osteosynthesis in the manner that all tension forces in the device would perform the useful function and would exclude harmful tension forces.
We believe that consideration of these characteristics will favor the decrease in number of errors during each stage of transosseous osteosynthesis.
Clinically, as the support, we used the sectors, the beams, and the rods in contrast to the common configurations. The rods are introduced into the bone with use of the console.
For preventing the muscular mass damage, we introduce the pin of 3 mm diameter into the distal femoral metaphysis and into the proximal tibial epimetaphys in the frontal plane.
Certainly, the choice of configuration depends on location and biomechanical properties of the fracture site. The important stage of surgery is preliminary reposition of fragments on the orthopedic table.
The parameters of displacement of bone fragments during load were compared in the experimental study with virtual 3D-models of Ilizarov device and our configuration with use of Solid Works software and applied software. The influence of load on the elements of configuration of the device was identified, and the degree of displacement of fragments was estimated.
The statistical preparation of the results was conducted with Excel and StatSoft Statistica 6.0. For quantitative signs, the results were presented as mean arithmetic (M) and standard deviations (σ), for qualitative ones – as absolute values with percentage (%).
The critical level of significance (σ) for testing the statistical hypotheses was 0.05. Student’s test (t) for independent samples was used for comparison of intergroup differences in case of confirmation of normal distribution of the values. Differences were statistically significant with p < 0.05.
The study corresponds to Helsinki declare – Ethical Principles for Medical Research with Human Subjects, and the Rules for clinical practice in the Russian Federation confirmed by Russian Health Ministry, June 19, 2003, No.266. All persons gave their written consent for participation in the study.

RESULTS AND DISCUSSION

Longitudinal compression between the fragments was performed for transverse fractures after precise reposition in the clinic. We think that counter-lateral compression is necessary for marginal and spiral fractures. For achieving this effect, one of the coauthors developed the device for transfocal osteosynthesis (the author's certificate 1219068, January 22, 1985) and the technique for treatment of spiral fractures (the author's certificate 1762905, May 22, 1992). The figures 1-2 show the schemes of the device for counter-lateral compression and the variants of location of pins with supporting platforms for provision of counter-lateral compression. The figures 3-7 demonstrate the efficiency of low invasive technology of configuration of the device for transosseous osteosynthesis.

Figure 1. The schemes of the device for counter-lateral compression

    

 

Figure 2. The variants of location of pins with supporting platforms for provision of counter-lateral compression

  

 

Figure 3. A spiral fracture on the border of the middle and distal one-third of the tibial bone. Time of fixation with our device is 48 days. Complete union is noted.

     


Figure 4. An oblique fracture in region of distal femoral epimetaphys. Time of fixation with our device is 74 days. 3 years later, control X-ray images shows complete union of the fracture, almost without signs of the previous fracture.

       

Figure 5

Multifragmented fracture of left femoral bone diaphysis. Osteosynthesis with the device with rods and pins. Condition after dismounting the device. Complete fracture union has been observed. Time of fixation with the device is 102 days.

     


Figure 6. A closed oblique fracture of tibial bone diaphysis. The external fixation device with rods and pins. X-ray images after device dismounting – complete union. Time of fixation with the device is 60 days.

     


Figure 7. A fragmented fracture of femoral bone diaphysis on the border of the upper and middle one-thirds. The rod-pin configuration of the device is presented. Time of fixation with the device is 82 days. X-ray images after device dismounting – complete union.

     


Using these principles, 148 patients with fractures of the extremity long bones were treated. The mean duration of fixation for femoral fractures was 100 days in 21 cases, for leg fractures – 93 days in 127 cases. It shows the efficiency of the used techniques of external osteosynthesis (the table).

Table. Distribution of patients according to age and time of transosseous fixation in fractures of femur and leg bones

< 20

21-30

31-40

41-50

51-60

> 60

Total

Femur

5 (69.6)

9 (111.1)

4 (79.25)

1 (153)

2 (156.5)

1 (91)

21 (100.5)

Leg

6 (77.7)

27 (85.2)

30 (102.4)

32 (88.3)

17 (91.5)

15 (107,2)

127 (93.1)

Total

11 (74)

35 (91.1)

34 (99.7)

33 (90.2)

19 (98.3)

16 (106.2)

148 (94.2)

Pin tract inflammation is the most common complication. The clinical manifestations are flushed skin, pain feelings and wound discharge. The treatment of these complications was mainly conducted with the conservative methods (antiseptic solutions for local administration, antibiotics), and the pins were replaced in only 8 patients, the rods – in 4 patients.
Replacement of the pins or the rods was conducted for 12 patients with disordered stability of fixation.
Pain syndrome was often identified in some patients. It was especially intense during the first days after surgery and was caused by long term walking. Pain syndrome was corrected with decreasing physical activity and prescription of analgetics.
Insignificant transitory edema was noted in almost 80 patients in early period after surgical intervention. Slow union in the fracture site of the tibial bone was noted in 18 patients, in the fracture site of the femoral bone – in 5. These patients required for stimulation of regeneration and adaptation of fragments with continuing fixation with compression mode. The patients did not demonstrate any neurovascular disorders during insertion of the pins or the rods. The best tolerability of the external fixation device promoted the decrease in the patients’ negative attitude to this technique. 

CONCLUSION

The use of the developed configuration of the external fixation device allows achieving the union of the long bones fractures of the lower extremities within the optimal time intervals and providing more comfort life of the patient.

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of clear or potential conflicts of interests relating to publishing this article.

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