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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 |
Comparison group |
Total |
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.
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