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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.
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].
Table 1. Location and types of opened fractures in patients of study groups
|
Location of opened fractures Types of opened fractures according to Gustilo-Anderson |
Femoral diaphysis, |
Distal femoral
metaepiphysis, |
Proximal tibial
metaepiphysis, |
Tibial diaphysis, |
Distal tibial
metaepiphysis, |
|||||
|
Group 1 |
Group 2 |
Group 1 |
Group 2 |
Group 1 |
Group 2 |
Group 1 |
Group 2 |
Group 1 |
Group 2 |
|
|
I, |
22 |
6 |
7 |
4 |
7 |
5 |
97 |
32 |
5 |
3 |
|
II, |
16 |
5 |
7 |
5 |
7 |
3 |
36 |
11 |
7 |
5 |
|
IIIА,
|
9 |
4 |
8 |
3 |
9 |
4 |
41 |
10 |
7 |
3 |
|
IIIВ, |
0 |
0 |
0 |
0 |
1 |
1 |
36 |
12 |
2 |
1 |
|
IIIС,
|
0 |
0 |
2 |
0 |
8 |
3 |
0 |
0 |
0 |
0 |
|
Total,
|
47 |
15 |
24 |
12 |
32 |
16 |
210 |
65 |
21 |
12 |
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, |
3 / 2.4 % |
2 / 1.4 % |
I , |
1 / 2.0 % |
1 / 2.0 % |
p > 0.5 |
|
II, n = 88 |
9 / 10.2 % |
8 / 9.1 % |
II, |
1 / 7.1 % |
1 / 7.1 % |
p < 0.01* |
|
IIIА, |
41 / 71.9 % |
11 / 19.3 % |
IIIА, |
6 / 14.6 % |
2 / 4.8 % |
|
|
IIIВ, |
29 / 72.5 % |
8 / 20.0 % |
IIIВ, |
6 / 46.2 % |
2 / 15.4 % |
|
|
IIIС, |
8 / 80.0 % |
2 / 20.0 % |
IIIС, |
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.
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