CONVERSION OSTEOSYNTHESIS IN TREATMENT OF PATIENTS WITH LONG BONE FRACTURES

CONVERSION OSTEOSYNTHESIS IN TREATMENT OF PATIENTS WITH LONG BONE FRACTURES

Zagorodniy N.V., Solod E.I., Alsmadi Ya.M., Lazarev A.F., Abdulkhabirov M.A., Ananyin D.A., Petrovskiy R.A., Dmitrov I.A.

 Traumatology and orthopedics department, Peoples' Friendship University of Russia,  Eramishchantsev City Clinical Hospital, Moscow, Russia 

 Treatment of fractures of extremity long bones is especially important in modern traumatology owing to high percentage of patients with polytrauma, disability and lethal outcomes [1-5]. According to the literature data, hip fractures consist about 2-2.7 % of all fractures and are often accompanied by traumatic shock [2, 4]. The mortality reaches 17.3 % [1]. Fractures of leg bones consist 11-13 % in the group of fractures of long bones, fractures of humerus diaphysis – 4 %, forearm fractures – 11.3 % of all number of fractures [1, 6].
The use of plaster splints or skeletal traction system for treatment of patients with long bone fractures extends the period of treatment. Moreover, contractures and false joints appear often [6, 7].
Currently, many patients use the conversion osteosynthesis with damage control for treatment of long bone fractures with polytrauma. The first stage includes the extrafocal fixation with pin, rod or rod-pin systems of external fixation [2, 4, 8-12]. After improvement in general condition, the second stage includes the intramedullary fixation with locked or non-locked nails, and external fixation with plates of different design and various functions [8, 9, 13-18].
M. Bhandari et al. believe that patients with multi-fragmental fractures of long bones, especially with multiple fractures, require for fixation of the injured segment with external fixation as anti-shock therapy [4, 17, 19-21].
However, there are different opinions on terms and techniques of conversion osteosynthesis [2, 4].
Pape H, Nicholas B. et al. indicate that patients with stable or border-line condition can receive the primary internal fixation of fractures [22, 23].
Seleznev S. et al. think that early osteosynthesis of long bones with polytrauma is fixation within the first three days from the moment of the injury, but osteosynthesis within 4-10 days is characterized by very high risk of infectious complications [2, 24].
Paderni et al. believe that internal osteosynthesis can be conducted after 2-3 months from the moment of application of the external fixator, resulting in a decrease of the risk severe complications: adult respiratory distress syndrome, multiple organ dysfunction, pneumonia and sepsis [4].
Gianluca Testa et al. consider that the final treatment for patients with long bone fractures and polytrauma with use of the external fixator presents the ideal method. It gives satisfactory results with acceptable incidence of complications and decreasing requirement for other opened and invasive surgical interventions [25].
Samusenko D. et al. show that Ilizarov’s device can be used as the final treatment for patients with long bone fractures with polytrauma since it allows transportation over long distances, and patients can perform active movements with simultaneous training of movements in adjacent joints. Moreover, they did not find any infectious complications after introduction of pints of rods [26].
Khominets V. and Pairon P. consider that adequate selection of technique and terms of treatment of patients with long bone fractures is important for fracture union and for positive functional outcomes [2, 4].
Therefore, the objective of the study was evaluation of the results of conversion osteosynthesis in different clinical situations and to improve the treatment outcomes. 

MATERIALS AND METHODS

This study was based on the prospective and retrospective analysis of clinical materials of conversion osteosynthesis in 105 patients with fractures of extremity long bones. The patients were admitted within one hour after trauma within the period from January 2017 till January 2019. There were 56 (53 %) women and 49 (46 %) men at the age of 18-67. The study excluded the patients who died before conversion osteosynthesis and within 4 weeks after it as result of complications not relating to osteosynthesis since it was necessary to estimate the long term results of recovery of fractures and soft tissues.
All patients were distributed into two groups. The first group included 41 patients with long bone fractures (hip, leg, shoulder, forearm) with polytrauma. The second group included 64 patients with closed single non-stable fragmented and multi-fragmented fractures of long bones (hip, leg, shoulder, forearm) with evident posttraumatic edema and closed injuries to soft tissues with high risk of soft tissue complications. For estimation of fractures of long bones and soft tissues, we used the AO International classification of fractures and soft tissue injuries.
After admission, all patients were examined for integrity of skin surface, intensity of edema and hematoma, presence or absence of injuries to magistral vessels and nerves. Also frontal and lateral X-ray imaging with capture of adjacent joints was conducted. For diagnosis of the associated injury, the computer imaging of the head and the pelvis was carried out, for intraarticular fractures – CT of a fracture for presurgical planning.
The patients of the first group received the anti-shock therapy with urgent fixation of the injured segment with the external fixator using the principles of damage control. Such approach provided the possibility for efficient care and observation of patients to prevent traumatic shock, fat embolism, venous thrombosis in the injured segment, and secondary injury to magistral veins and nerves.
The first stage did not include the anatomical reposition since it was required to decrease the traumatic potential of soft tissues and to reduce the time of surgery. The traumatologists gave specific attention to delicate handling with soft tissues, placement of transosseous elements with consideration of subsequent internal fixation and necessity for stable fixation of a fracture at the first stage. Intraarticular and periarticular fractures were treated with fixation of adjacent segments (joint-spanning external fixation technique) without fixation in the metaphyseal zone for intensification of fixation and for prevention of infectious complications.
After improvement in general condition, the second stage included the conversion to internal fixation with locked nails or plates, depending on patterns or location of fractures.
The minimal requirements for transition (conversion) from extrafocal fixation to internal osteosynthesis were hemoglobin > 90 g/l, hematocrit > 35, patients without ALV without dopamine (vasopressor), stabilization of arterial pressure > 90 mm Hg at least for one day, adequate diuresis within one day; stable values of blood saturation within one day, no acidosis, no signs of inflammation in wound of the extremity.
The patients of the second group included the primary fixation with rod devices in presence of evident edema and soft tissue injuries which did not allow primary internal fixation. The external fixators allowed stabilizing the fragments, decreasing the edema, accelerating the recovery of soft tissues, giving to patients the ability to walk and to make self-care up to the second stage of surgery.
The criteria for transition to internal fixation were regression of soft tissue edema, recovery of skin scratches, absence of infectious complications, satisfactory general condition according to blood analysis and additional examinations. The adherence to these conditions allowed the conversion to internal fixation with locked nails or plates depending on patterns or location of fractures.
In the postsurgical period, the patients of both groups were observed in outpatient conditions up to the fracture union within 1 year with visits within 6 weeks, 12 weeks, 6 months and 1 year.
The treatment results were estimated with the outcome estimation system (OES) by Luboschiz-Mattis-Schwarzberg. This score includes 9 points for the period from 6 months to 1 year after surgery. 3.5-4 points indicated the good outcome, 2.5-3.5 points – satisfactory one, 2.5 and less – poor outcome. The patients did not have any cases of soft tissue purulence in the analysis of results of conversion osteosynthesis.
The statistical analysis of the results was carried out with Excel. The methods of descriptive statistics were used.
The study corresponded to Helsinki Declare – Ethical Principles for Medical Research with Human Subjects, and to the Rules for Clinical Practice in the Russian Federation confirmed by the Order by Russian Health Ministry, 19 June 2003, No.266. All patients gave their written consent for participation. 

RESULTS

The generalized results of our observations are shown in the tables 1-2. Most patients (62 %) suffered from the high energy trauma: road traffic accidents, catainjury, falling from height of own altitude. It determined the multiple patterns of injuries and serious injuries to soft tissues.

Table 1

Fracture type

АО AO type

Number of cases

%

Mean time of conversion (days)

Type of internal fixation

Shaft fractures

Femoral bone 31A3, 32A-C

14

13 %

2

Intramedullary

Tibial bone, 42A-C

15

14 %

8

Intramedullary

Humerus, 12

5

5 %

12

Intramedullary

Metaphysial fractures

Distal part of femoral bone, 33A-C

3

3 %

3

External

Proximal leg, 41

8

8 %

6,50

External

Distal humerus, 13B-C

5

5 %

7

External

Malleolar fractures, 44A-C

33

31 %

7,15

External

Distal part of forearm, 2R3

16

15 %

4,75

External

Distal part of tibial bone, 43A-C

6

6 %

12

External

Total

105

100 %

Table 2. Distribution of patients into groups according to location of fractures, time of conversion and injury mechanism

Group

 

Fracture type (AO)

Number of cases

% of the group

Percentage of high energy mechanism

%

Mean time of conversion

Group 1

31А3, 32

14

34 %

14

34 %

2

33

3

7 %

3

7 %

3

41

6

15 %

6

15 %

6,5

42

9

22 %

9

22 %

8

43

2

5 %

2

5 %

12

44

1

2 %

1

2 %

7

12

5

12 %

5

12 %

12

13

0

0 %

0

0 %

23

1

2 %

1

2 %

5

Total

41

100 %

41

100 %

Group 2

31А3, 32

0

0 %

0

0 %

33

0

0 %

0

0 %

41

2

3 %

2

3 %

6,5

42

6

9 %

3

5 %

8

43

4

6 %

4

6 %

12

44

32

50 %

7

11 %

7.2

12

0

0 %

0

0 %

13

5

8 %

3

5 %

7

23

15

23 %

5

8 %

4.75

Total

64

100 %

24

38 %

Total

105

100 %


Despite of condition of soft tissues, we should note that conversion for hip fractures (in compliance with damage control and polytrauma pathogenesis) was carried out within 48-72 hours after trauma even in subcompensated condition.
74 patients (70 %) were observed in the long term postsurgical period. There were 56 % (41) of good results, 1 % - a poor outcome, which was determined by multiple fractures and slow union.

DISCUSSION

Adequate selection of management, techniques of terms of treatment for patients with long bone fractures, especially with polytrauma, presents the important issue for positive outcome of treatment [2, 4].
According to the data by Khominets V. and Pairon P., the final osteosynthesis in the early period of polytrauma caused the lethal outcome, especially in significant thoracic, abdominal and traumatic brain injuries [2, 4]. The death happened in the first hours after surgery or on the days 5-7 as result of severe complications: adult respiratory distress syndrome, multiple organ failure, pneumonia, sepsis [2].
However according to Tishkov N.V., the long term treatment of patients with the external fixator up to the second stage of surgery or as the final treatment for patients with long bone fractures increases the risk of infectious and hypostatic complications with more discomfort in longer terms of treatment [27].
The late conversion (after two weeks) for patients with polytrauma coincides with the immune suppression phase (the days 10-20) and is contraindicated before restoration of immunologic status. The risk of infection increases in patients with single injury in absence of systemic effects of polytrauma, especially in single-stage replacement of the transosseous element to the intramedullary nail. For such cases, some researchers and practicians recommend to dismount the external fixator, to carry out the dynamic observation within a week and after recovery of wounds after use of the external fixator. However the realization of reposition in this period usually requires for opened surgery with wide approach and exposure of the fracture site. It increases the rate of non-union, terms of fracture union and promotes other complications.
At the first stage, the use of Ilizarov’s device as the final technique of osteosynthesis for patients with long bone fractures and polytrauma is associated with the complex preparatory stage, lengthening of surgery time and mounting of the construct. It negatively influences on the general condition of the patient. The use of Ilizarov’s device for patients with single fractures is the well-known technique with proven results. However at the modern stage of traumatology and orthopedics, the possibility of early rehabilitation, and comfort and absence of an external construct on the extremity are much more attractive for the patient who can choose the osteosynthesis technique according to doctor’s recommendation in conditions of peaceful time.
This study certainly has some limitations. This is the perspective analysis including only cases of conversion from the external fixator to internal fixation with exclusion of opened fractures as the class. One of the aspects of the study was estimation and search for regularities and general features in conversion osteosynthesis as the technique at whole, without transition. The absence of the comparison group with conservative treatment and primary fixation does not allow talk about absolute advantages of conversion osteosynthesis, but our study confirms the possibility of safe use of conversion in clinical practice.
For clarification of terms and details of conversion interventions, the future studies will compare the primary methods and will add the group of late conversion osteosynthesis. The most disputable issue is related to significance of a difference in rate of complications of early and late conversion osteosynthesis, as well as search for optimal time intervals.
We present two clinical cases.  

Clinical case No.1

The patient B., female, age of 61, (case history 10620/18, 27 February 2018) received the injury in the street. She was admitted to Eramishchantsev City Clinical Hospital. The diagnosis was: “A closed multi-fragmental fracture of left leg and fibular bone in the lower one-third with displacement” (Fig. 1).

Figure 1. Closed multi-fragmented fracture of left leg and fibular bone in the lower one-third with displaced fragments

After admission, due to intense edema of the leg, and the risk of epidermal blisters, the osteosynthesis with the external fixator was performed (leg-foot configuration). Intrasurgically, during one stage, the satisfactory position of fragments was achieved (Fig. 2, 3). The duration of application of the external fixator was 27 minutes.

Figure 2. Fixation of leg fracture with external fixing device



Figure 3. Appearance of external fixing device

The duration of the first stage was 5 days. On the fifth day after regression of edema, the second stage of osteosynthesis was performed: dismounting of the external fixator, and intramedullary fixation with the plate and screws (Fig. 4).

Figure 4. Plate and crew fixation. Frontal and lateral views

The postsurgical period was without complications. After two days from the surgery moment, the patient could actively move with the crutches. The wounds healed with primary tension.

Clinical case No.2

The patient V., female, age of 63, (case history 1382/19, 10 January 2019) was admitted to Eramishchantsev City Clinical Hospital one and half hour after falling from the fifth floor. The diagnosis was: “Polytrauma, a closed fragmented fracture of the left femoral bone in the middle-lower one-third with displacement of fragments. A closed unstable fracture of the pelvis of type B: laceration of pubic symphysis, a bilateral fracture of the sacrum (Denis 2). A closed fracture of both calcaneal bones with displacement of fragments. A closed fracture of transverse processes L1, L2 on both sides, L5 to the left. Lung contusion. Traumatic shock of degrees 2-3, ISS = 41” (Fig. 5).

Figure 5. Closed fragmented fracture of left femur in the middle-lower one-third with displaced fragments (a). Closed fracture of both calcaneal bones with displaced fragments (b). Closed unstable pelvic fracture of type B: laceration of pubic symphysis, bilateral fracture of sacrum, closed fracture of transverse processes L1, L2 on both sides, and L5 to the left

     

The patient was admitted in unstable condition. At the background of anti-shock therapy, the hip and the pelvis were fixed in the external fixator (pelvis-hip-leg configuration) with application of C-frame onto posterior parts of the pelvic ring. During surgery, during one stage, the satisfactory position of fragments was achieved (Fig. 6). The duration of application of the external fixator was 30 minutes, C-frame – 15 minutes. The patient was in the intensive care unit for 5 days. She was transferred to the traumatology unit on the sixth day.

Figure 6. Fixation of anterior parts of pelvic ring (a) and hip (b) with external rod device (pelvis-hip-leg configuration), application of C-frame on posterior parts of pelvic ring (c)

    

On the sixth day, the second stage of subsequent osteosynthesis was carried out: dismounting of the external fixator (hip-leg) and C-frame, osteosynthesis of lateral masses of the sacrum with cannulated screws on both sides; closed retrograde locking intramedullary fixation of the femoral bone (Fig. 7).

Figure 7. Dismounting of C-frame and fixation of lateral masses of sacrum with cannulated screws on both sides (a). Dismounting of hip-leg external fixing device, closed retrograde locking intramedullary fixation of femoral bone with the nail (b)

   

On the tenth day, the third stage of subsequent osteosynthesis was performed, as well as dismounting of the external fixator, fixation of pubic symphysis with plates and screws, osteosynthesis of calcaneal bones with cannulated screws (Fig. 8).

Figure 8. Dismounting of external fixing device. Fixation of pubic symphysis with plate and screws (a). Fixation of calcaneal bones with cannulated screws (b)

   

The postsurgical period was good. The patient could make movements in her bed. On the 14th day, she moved with the crutches. The wounds healed with primary tension.

CONCLUSION

As the result of the analysis, we have made the following conclusions.
1. Fixation of long bone fractures with rod devices of external fixation provides the stabilization of fragments and prevention of shock, other posttraumatic complications and secondary vascular and nervous injuries at the first stage.
2. Conversion (transition) of extrafocal fixation to internal fixation for patients with polytrauma is preferable within 3-11 days. It is strictly limited by general condition of the patient and by a degree of immune suppression.
3. Conversion (transition) of extrafocal external fixation to internal osteosynthesis for patients with closed fractures and with significant soft tissue injuries is possible only from the days 5-8 after injury, with minimal thereat of inflammatory complications in the postsurgical period.
4. Urgent fixation of unstable fractures with use of rod devices causes faster correction of soft tissue edema, preventing the development of hypostatic complications and creates the favorable conditions for care and dynamic follow-up of soft tissues.

Information on financing and conflict of interest

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

REFERENCES:

1.       Yamkovoy AD. Osteosynthesis of fractures of long bones with nails. Abstracts of candidate of medical science. 14.01.15. M., 2017; 3-4. Russian (Ямковой А.Д. Остеосинтез переломов длинных костей конечностей гвоздями с пластической: автореф. дис. ... канд. мед.ких наук: 14.01.15. М., 2017. С. 3-4)
2.       Khominets VV, Belenkiy IG, Kutyanov DI, Pechkurov AL. Management of treatment of fractures of long bones of extremities in patients with polytrauma. MEDLINE.RU. Russian Biomedical Journal. (Electronic journal). 2011; 12(2): 631-645. Access mode: http://medline.ru/public/art/tom12/art53.html. Russian (Хоминец В.В., Беленький И.Г., Кутянов Д.И., Печкуров А.Л. Тактика лечения переломов длинных костей конечностей у пострадавших с политравмами //MEDLINE.RU. Российский биомедицинский журнал. (Электронный журнал). 2011. Т. 12, № 2. С. 631-645. Режим доступа: http://medline.ru/public/art/tom12/art53.html)
3.       Yamkovoy AD, Zorya VI. The use of intramedullary system fixation for treatment of shaft fractures of long bones 2014. Priorov Herald of Traumatology and Orthopedics. 2014; (3): 34-39. Russian (Ямковой А.Д., Зоря В.И., Применение интрамедуллярного остеосинтеза системой фиксации при лечении диафизарных переломов длинных костей 2014 //Вестник травматологии и ортопедии им. Н.Н. Приорова. 2014. № 3. С 34-39)
4.       Pairon P, Ossendorf C, Kuhn S, Hofmann A, Rommens PM. Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits. European Journal of Trauma and Emergency Surgery. 2015; 41(1): 25-38
5.       Kavalerskiy GM, Garkavi AV. Classifications of multiple injuries. Features of clinical course and diagnosis. Medicine of Critical Situations. Disaster Surgery. M.: Medical Information Agency, 2015; 165-367. Russian (Кавалерский Г.М., Гаркави А.В. Классификация политравм. Особенности клинического течения и диагностики //Медицина чрезвычайных ситуаций. Хирургия катастроф. М.: Медицинское информационное агентство, 2015. С. 165-376)
6.       Korzh NA, Dedukh NV. Reparative regeneration of bone: the modern view of the problem. Stages of regeneration. Orthopedics, Traumatology and Prosthetics. 2006; (1): 77-84. Russian (Корж Н.А., Дедух Н.В. Репаративная регенерация кости: современный взгляд на проблему. Стадии регенерации //Ортопедия, травматология и протезирование. 2006. № 1. С. 77-84)
7.       Backus JD, Furman BD, Swimmer T, Kent CL, McNulty AL, Defrate L, et al. Cartilage viability and catabolism in the intact porcine knee following transarticular impact loading with and without articular fracture. J. Orthop. Res. 2011; 29(4): 501-510
8.       Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, et al. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control. Injury. 2013; 44(2): 221-225
9.       Patka P. Damage control and intramedullary nailing for long bone fractures in polytrauma patients. Injury. 2017; 48(Suppl 1): S7-S9
10.     Monni T, Birkholtz FF, de Lange P, Snyckers CH. Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series. Strategies Trauma Limb Reconstr. 2013; 8(1): 25-30
11.     Harbacheuski R, Fragomen A, Rozbruch S. Does lengthening and then plating (LAP) shorten duration of external fixation? Clin Orthop Relat Res. 2012; 470(6): 1771-1781
12.     Matsubara H, Shirai T, Watanabe K, Nomura I, Tsuchiya H. Clinical outcomes of conversion surgery from an external fixator to an iodine-supported titanium alloy plate. Journal of Microbial & Biochemical Technology. 2013; 6(1): 49-53
13.     van Dongen TT, Idenburg FJ, Tan EC, Rasmussen TE, Hamming JF, Leenen LP, et al. Combat related vascular injuries: dutch experiences from a role 2 MTF in Afghanistan. Injury. 2016; 47(1): 94-98
14.     Kataoka Y, Minehara H, Kashimi F, Hanajima T, Yamaya T, Nishimaki H, et al. Treatment combining emergency surgery and intraoperative interventional radiology for severe trauma. Injury. 2016; 47(1): 59-63
15.     Boutefnouchet T, Gregg R, Tidman J, Isaac J, Doughty H. Emergency red cells first: rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre. Injury. 2015; 46(9): 1772-1778
16.     Recknagel S, Bindl R, Wehner T, Göckelmann M, Wehrle E, Gebhard F, et al. Conversion from external fixator to intramedullary nail causes a second hit and impairs fracture healing in a severe trauma model. Journal of Orthopaedic Research. 2013; 31(3): 465-471
17.     Pairon P, Ossendorf C, Kuhn S, Hofmann A, Rommens PM. Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits. European Journal of Trauma and Emergency Surgery. 2015; 41(1): 25-38
18.     Matsumura T, Takahashi T, Miyamoto O, Saito T, Kimura A, Takeshita K. Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb. Journal of Orthopaedic Science. 2019; Feb 13. URL: https://www.sciencedirect.com/science/article/pii/S0949265819300429?via%3Dihub
19.     Xue XH, Yan SG, Cai XZ, Shi MM, Lin T. Intramedullary nailing versus plating for extra-articular distal tibial metaphyseal fracture: a systematic review and meta-analysis. Injury. 2013; 45(4): 667-676
20.     Bertrand ML, Andrés-Cano P, Pascual-López FJ. Periarticular fractures of the knee in polytrauma patients. Open orthopaedics journal. 2015; 9: 332-346
21.     Bhandari M, Zlowodzki M, Tornetta P3rd, Schmidt A, Templeman DC. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma. 2005; 19(2): 140-144
22.     Nicholas B, Toth L, van Wessem K, Evans J, Enninghorst N, Balogh ZJ. Borderline femur fracture patients: early total care or damage control orthopaedics? ANZ J Surg. 2011; 81(3): 148-153
23.     Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Annals of Surgery. 2007; 246(3): 491-499
24.     Traumatic disease and its complications. Edited by Seleznev SA. St. Petersburg: Polytekhnika, 2004. 414 p. Russian (Травматическая болезнь и ее осложнения /под общ. ред. С.А. Селезнева. СПб.: Политехника, 2004. 414 с.)
25.     Testa G, Aloj D, Ghirri A, Petruccelli E, Pavone V, Massé A, et al. Treatment of femoral shaft fractures with monoaxial external fixation in polytrauma patients. F1000Research. 2017; 6: 1333
26.     Samusenko DV, Karasev AG, Martel II, Shvedov VV, Boychuk SP. Ilizarov’s method in staged management of associated injury and multiple fractures. Polytrauma. 2014; (1): 44-49. Russian (Самусенко Д.В., Карасев А.Г., Мартель И.И., Шведов В.В., Бойчук С.П. Метод Илизарова в этапном столкновении с сочетанной травмой и множественными переломами //Политравма. 2014. № 1. С. 44-49)
27.     Tishkov NV, Danilov DG, Ochirov IA. Purulent complications in treatment of fractures of lower extremities with use of transosseous fixation techniques. Acta Biomedica Scientifica. 2007; 4(56); 175-176. Russian (Тишков Н.В., Данилов Д.Г., Очиров И.А. Гнойные осложнения при лечении переломов костей нижних конечностей методом чрескостного остеосинтеза //Acta Biomedica Scientifica. 2007. № S4(56). C. 175-176)

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