FEATURES OF CONSECUTIVE OSTEOSYNTHESIS IN TREATMENT OF PATIENTS WITH GUNSHOT FRACTURES OF LONG BONES OF THE EXTREMITIES

Khominets V.V., Shchukin A.V., Mikhaylov S.V., Foos I.V.

Kirov Military Medical Academy, Saint-Petersburg, Russia

 FEATURES OF CONSECUTIVE OSTEOSYNTHESIS IN TREATMENT OF PATIENTS WITH GUNSHOT FRACTURES OF LONG BONES OF THE EXTREMITIES

Generalization of the experience of the world wars and local combat conflicts shows the evidences that the rate of gunshot wounds of the extremities is 54-70 %, with continuous prevailing; the proportion of patients with gunshot fractures of bones is 35-40 % [1]. According to B. Owens, gunshot fractures of extremity bones are encountered more often (about 50 %) among military sanitary losses [2]. The improvement in various explosive materials and weapon is a continuous process increasing the volume and severity of destruction of soft tissues and bones, and increasing rate of multiple and associated injuries [3-6]. The special attention is given to medical care for patients with gunshot fractures of extremity bones in civilians, considering the increasing rates of terroristic attacks [7-10].
Considering only one of directions of this important topic, i.e. the techniques for immobilizing fragments during union of gunshot fragments, one should note a clear trend to wider use of some or other techniques of internal fixation at different stages of specialized treatment of gunshot fractures. New findings of abnormal pathology, abnormal physiology and bone tissue regeneration in conditions of recovery of gunshot bone and muscular wounds, and development of reconstructive plastic surgery, pharmacology, angiosurgery, anesthesiology and critical care medicine allowed wider and relatively safe use of internal fixation in management of patients with gunshot fractures of the extremities [11-22].
Wide clinical implementation of modern technologies of minimal invasive intramedullary fixation with locking, angle stability plates and anatomic design threw light on the problem of fixation of bone fragments in gunshot fractures. The domestic [23, 24] and foreign [25, 26] literature shows only rare reports on transition from external fixation to internal osteosynthesis. It testifies the hopelessness of this direction and dictates the necessity for proper search of possibilities for wider use of various types of subsequent fixation.
The study was carried out in the clinic of military traumatology and orthopedics of Kirov Military Medical Academy. Its objective was improving outcomes of surgical management of patients with gunshot fractures of the extremity bones by means of development and implementation of gradual osteosynthesis.

MATERIALS AND METHODS

The study included three phases. The first phase included the examination of the input flow and the volume of care at the previous phases of medical evacuation. In the second phase, the outcomes of treatment were estimated, and the surgical tactics of gradual osteosynthesis was substantiated and implemented. The third phase included the comparative analysis of the internal fixation techniques and the anatomic and functional results of the treatment.
The study was based on the analysis of the treatment outcomes of 148 patients with gunshot fractures of the extremity bones. The patients were treated in the clinic of military traumatology and orthopedics, Kirov Military Medical Academy, in 1999-2015. All patients were distributed into two groups (the main group and the controls) in dependence on use of the gradual osteosynthesis technique. The main group included 86 (58.1 %) patients with gunshot fractures of the extremities who received early (before formation of scar tissue between the fragments, i.e. within 3 weeks after trauma) gradual minimally invasive osteosynthesis. The control group included 62 (41.9 %) patients who received late (3-6 weeks) delayed gradual osteosynthesis with opened reposition and internal fixation. Each group included two subgroups of patients with gunshot fractures of long bones of the upper and lower extremities.
All patients were men, mean age of 35.4 ± 12.2. The severity of all wounds in all patients was characterized as high: Military Field Surgery Score-Injury (Gunshot Wound) = 1.0–12.0 points; the patients’ state according to Military Field Surgery Score-Condition at Admission was of middle severity (13-20 points) or severe (21-31 points). Single injuries were in 36 (41.9 %) patients in the main group and in 33 (53.2 %) patients in the control group. Multiple wounds were observed rarer: 32 (37.2 %) patients who received gradual osteosynthesis, and 23 (37.1 %) patients with delayed surgery. Associated injuries were in 18 (20.9 %) patients in the main group and in 6 (9.7 %) in the control group. Both groups had the patients with shrapnel wounds – 52 (60.4 %) and 43 (69.4 %) patients correspondingly. The amount of bullet wounds was lower – 33 (38.4 %) in the main group and 18 (29 %) in the control group. Mine blast wounds were only in the single cases – 1 (1.2 %) patient in the main group and in 1 (1.6 %) in the control group. The wounds were complicated by shock in 59 (68.8 %) patients who received early minimally invasive gradual osteosynthesis and in 41 (66.1 %) patients with delayed osteosynthesis. Most extremities fractures were splintered – 75 (87.2 %) and 58 (93.5 %).
Before admission to the clinic, all patients received the specialized medical care. Single-plane rod devices were more often used for fixing the fragments of the extremities. Such fixation of bone fragments was conducted for 49 (57 %) patients in the main group and for 27 (43.5 %) in the control group. Ilizarov devices were used in the main and control groups in rarer cases: 29 (33.7 %) and 26 (41.9 %) correspondingly. Plaster immobilizing was performed for 8 (9.3 %) patients in the main group and for 8 (12.9 %) patients in the control group at the previous stages of medical evacuation.
Therefore, the compared samples of the patients were similar according to an injuring missile, the patterns and severity of a wound, the fixation techniques at the previous stages of medical evacuation that allowed correct comparison of the treatment outcomes.
At the same time, the patients were admitted to the clinic at different time points after the accident. These differences determined the choice of management for the patients of the compared groups. So, this period was 3-17 (7.2 ± 3.1) days in the main group. Minimally invasive gradual osteosynthesis was carried out in the early terms – after 8-21 (18.5 ± 3.1) days. The patients of the control group were admitted within 15-69 (41.8 ± 13.9) days, and internal fixation of gunshot fractures with opened reposition – after 25-81 (47.8 ± 13.5) days after trauma.
There was an analysis of efficiency of the gradual fixation techniques in the groups of the patients with gunshot fractures of the extremities with consideration of such parameters as mean intrasurgical blood loss, anatomical and functional results of the treatment and the incidence of infectious complications after osteosynthesis.
The analysis of the treatment outcomes was conducted within 10-16 months after the surgery. The clinical and radiologic estimation of fracture union was conducted, and the functional capabilities and the life quality of the patients were assessed. VAS was used for estimation of postsurgical pain syndrome. The functional outcome of the treatment was estimated with DASH. Neer-Grantham-Shelton scale (our modification) was used for estimating functional outcomes of the treatment of the lower extremities fractures, where the section “motions in the joint” was characterized in concordance with the table 4, the Order of the government of the Russian Federation, July 4, 2013, No. 565 “About confirmation of the regulation on military medical expertise”.
Student’s test, non-parametrical Wald-Wolflowitz and Mann-Whitney tests were used for estimating the significance of the difference in the mean values and the incidence of signs in the different groups of the patients. The relationship between the signs was estimated with non-parametrical Pearson correlation coefficient and Pearson c2-test.
The methods of the study were not in conflict with the laws and the regularities relating to compliance of the principles of biomedical ethics and were reviewed during the session of the independent ethical committee of Kirov Military Medical Academy.  

RESULTS AND DISCUSSION

All patients received gradual osteosynthesis. The aim of internal fixation of the bones was early rehabilitation, improving life quality and, as result, achievement of the best anatomic and functional outcomes of the treatment. The criteria for switching from external fixation to internal osteosynthesis were elimination of signs of traumatic disease in the patients with severe injuries and shock, hemodynamics correction, blood loss replacement, early active treatment and uncomplicated recovery of soft tissue wounds, absent signs of soft tissue inflammation around pins and rods of the external fixing devices.
The surgical technique of early and delayed gradual osteosynthesis in treatment of patients with single and multiple gunshot fractures of the extremities was developed with consideration of estimating severity of general condition, severity of wounds, features of soft tissue damages and presence of complications and time of delivery to the stage of specialized treatment. We adhered to the following points during treatment.
First of all, the patients without clinical manifestations of traumatic disease and with uncomplicated course of the wound process and absent signs of tissue inflammation around pins and rods of the external devices received the early closure of the wounds (if possible) and gradual minimally invasive fixation 10-14 days after the wound.
Secondly, for patients with wounds accompanied by shock, the time of transition to internal fixation depended on a prognostic variant of traumatic disease which was determined in concordance with condition of main vital systems in dependence on the values of Military Field Surgery Score-Selective Estimation of State. In early compensation confirmed by the score values < 70 points, gradual osteosynthesis was carried out in the early period after trauma, immediately after wound closure (healing). For the patients in the period of relative stabilization of vital functions and development of life threatening complications (Military Field Surgery Score-Selective Estimation of State ≥ 70), internal minimally invasive fixation was carried out after intensive care and subcompensation (usually 14-21 days after trauma).
Thirdly, management of patients who were delivered to the specialized care stage with delay (3-6 weeks and more after trauma), especially with long term untreated displacement of bone fragments in the external fixing devices and purulent complications of bone and muscle wounds, suggested the realization of a proper study, including a microbiological one, with subsequent correction of homeostasis, sanitation of purulent foci, and targeted antibacterial therapy. Late gradual osteosynthesis was carried out only after uncomplicated wound healing at the background of satisfactory general condition of the patients and normalizing homeostasis values.
Fourthly, for early reconstructive plastic replacement of investing tissue defects in treatment of patients with gunshot fractures of the extremities, the modified closure technique for the most common small and middle gunshot skin round-shaped defects with triangle flaps [27]. Moreover, according to the indications, we used reconstructive plastic surgery with use of skin fascial and muscular flaps, including free flaps with microsurgical technique.
Fifthly, removal of purulent complications was of complex pattern. The patients with extensive wounds, especially with inflammatory complications, and significant displacement of bone fragments in single-plane action devices received the remounting for the external construction with transition to Ilizarov device for restoration of the axis and the length of the segment and removal of rotation displacement. Infected wound sanitation was made with antibacterial spacers and the system for treating wounds with controlled negative pressure (Suprasorb CNP P1) with the variable mode (60-80 mm Hg, with 2-5 min. intervals). The dressings were changed 1 time per 3-5 days. The total time of vacuum draining was 7-10 days. Moreover, the masquelet technique, local decompression, ultrasonic cavitation and hyperbaric oxygenation were used during the complex treatment of patients with gunshot fractures of the extremities. After appearance of mature granulations, the wounds were closed with split-skin grafts or local tissue complexes. Microsurgical transplantation of the tissue complex was used in 19 cases (12.8 %).
If a purulent content in the intramedullary cavity was suspected, the first phase included the drilling and irrigation of the intramedullary canal with the antiseptic (pressure of 0.5 atm.) of 6-10 l with Pulsavac Plus system. The secondary surgical preparation was carried out in presence of the indications. The next phase was intramedullary fixation with the antibacterial coating nail made of polimethyl methacrylate bone cement with addition of 3 g of gentamicin and 1 g of vancomycin. Postsurgical antibacterial therapy lasted for four weeks.
Sixthly, the treatment of primary and secondary bone defects included the original technique of their replacement, which was developed in the department of military traumatology and orthopedics (the patent on an invention No. 2211001, registration on August 27, 2003, the patent on an invention No. 2372875, registration on November 27, 2009).
Early minimally invasive gradual osteosynthesis was carried out for all patients in the main group within 13-21 days, with use of the various fixators (LCP, locked intramedullary nails) which were selected with consideration of patterns and location of a fracture. Reposition of bone fragments was achieved with the closed technique. The control patients received the late gradual osteosynthesis within 3-6 weeks after trauma; opened reposition and subsequent internal fixation of bone fragments were used. Minimally invasive osteosynthesis for those patients was not possible due to long term existence of bone fragments in the rod devices and due to formation of scar tissue in the interfragmentary zone with elements of soft callus preventing the closed reposition. During minimally invasive fixation, the mean intrasurgical blood loss was 0.76 ± 0.17 l, for opened reposition and internal fixation – 1.07 ± 0.22 l (29 % higher). Blood transfusion was required for 4.6 % of the patient and for 6.5 % of the control patients during surgery for fractures of the extremities.
The treatment results in both groups were characterized by increasing average terms of union, which are common for closed fractures, but also were characterized with low incidence of false joints and unions with segment deformations. The incidence of slow union of fragments was 6.1 % lower in the main group, union of deformed bone fragments – 7.3 % lower. The incidence of false joints was 1.8 % lower in the main group in comparison with the control group. The generalized data of the incidence of bone fragments union are presented in the figure 1.

Figure 1. The rate of full union and disorders of fracture union in the patients in the main and control groups (%)

In the main group, the mean duration of hospital treatment was 2.5 times lower (by 44.8 days) than in the control group – 25.7 ± 12.5 and 70.5 ± 23.7 days correspondingly.
The treatment results were estimated with the special questionnaires (the table 1-2). DASH was used for estimating the functional capabilities of the upper extremity. The amount of fine and good results was 31.3 % higher as compared to the treatment results in the main group. According to the scale by Neer-Grantham-Shelton, the good treatment outcomes of gunshot fractures of the lower extremities were observed 21.7 % more often than in the control group.

Table 1. Results of treatment of patients with gunshot fractures of upper extremity in the main and control groups according to DASH

Result

Main group

Control group

Abs. number

%

Abs. number

%

Fine

11

37.9

5

21.7

Good

13

44.9

7

30.5

Satisfactory

4

13,8

9

39.1

Unsatisfactory

1

3.4

2

8.7

Total

29

100

23

100

Table 2. Results of treatment of patients with gunshot fractures of lower extremity according to the data of the modified score by Neer-Grantham-Shelton

Result

Main group

Control group

Abs. number

%

Abs. number

%

Good

46

80.7

23

59

Satisfactory

10

17.5

11

28.2

Unsatisfactory

1

1.8

5

12.8

Total

57

100

39

100

Therefore, theaccepted management of gunshot fractures of the extremities gave the excellent functional results in 105 patients (70.9 %).
Infectious complications were in 5.8 % of the cases in the main group. Most complications were superficial purulence of postsurgical wounds (3.5 %) without influence on the treatment outcomes. Deep purulence and chronic osteomyelitis developed in 1.2 % of the patients. The control patients demonstrated the infectious complications in 9.7 % of the cases that was 3.9 % higher than in the main group; moreover, superficial purulence was identified in 4.8 %, deep purulence – in 1.6 %. Chronic osteomyelitis was identified in 3.2 % of the cases in this group. The figure 2 shows the information on the infectious complications in the compared groups.

Figure 2. The rate of postsurgical infectious complications in the patients in the main and control groups (%)


The following clinical cases are given for demonstrating the surgical management and the treatment outcomes of gunshot fractures of the extremities.

The patient L., age of 37, suffered from a non-penetrating wound of the left hip, a gunshot fragmented fracture of the femoral bone with displaced fragments and shock of degree 1. Primary surgical preparation of wounds, femoral bone fixation with the rod device and anti-shock therapy were carried out at the previous stages of medical evacuation in the day of trauma. After general state compensation 7 days after trauma, the patient was delivered to the clinic. The examination showed the instability of the device, and serous discharge in the wounds after surgical preparation (Fig. 3).

Figure 3. The patient L., age of 37: a – appearance of the left hip; b and c – frontal and lateral X-ray images of the left femur. The femoral bone is fixed with the rod device (unsatisfactory position of the fragments)

    

Considering the splintered and fragmented pattern of the fracture of the left femoral bone diaphysis and non-stable fixation of femoral bone fragments with the single-plane device, the rod device was demounted, and Ilizarov device fixation with restoration of the segment length and removal of angle and rotation displacement of fragments were performed. Intramedullary locked nail fixation was performed after stabilizing general state of the patient (Military Field Surgery Score-Selective Estimation of State = 55) and his activization and soft tissues recovery (Fig. 4). Intrasurgical blood loss was 150 ml.

Figure 4. The patient L., age of 37: a and b – frontal and lateralX-ray images of the left hip after replacement of the external fixing device; c and d – frontal and lateral X-ray images of the left hip after internal fixation with intramedullary nail with locking

      

After 3 months, the control examination in the clinic showed the recovery of joint motion range in the left lower extremity. Bone tissue remodeling and complete union of the femoral bone were noted in 8 months (Fig. 5). The treatment outcome was excellent according to Neer-Grantham-Shelton score (85 points).

Figure 5. The patient L., age of 37: a –functional capabilities in 3 months after surgery; b and c – frontal and lateral X-ray images of the left femur in 8 months

    

The patient T., age of 30, received a non-penetrating gunshot wound of the right hip resulting in a splintered fracture of the femoral bone diaphysis and a primary defect of bone tissue over 3 cm. Primary surgical management of the wound and femoral bone fixation with the rod device were carried out at the previous stage of medical evacuation on the accident day. The wounds healed without complications. One month later, the patient was delivered to the clinic of military traumatology and orthopedics of Kirov Military Medical Academy. The external view of the damaged segment and the X-ray images of the right hip are presented in the figure 6.

Figure 6. The patient T., age of 30: a – appearance of the right hip; b and c – frontal and lateral X-ray images at the moment of admission

    

After the in-depth examination, considering the satisfactory condition of the patient, soft tissues healing and absent inflammatory events around the rods, but the unsatisfactory position of the fragments, the decision was made to conduct the gradual osteosynthesis with open reposition from small approach for correction of fragments in the lateral plane and intramedullary locked nail fixation and intramedullary canal drilling. Intrasurgical blood loss was about 600 ml.
During the postsurgical period, the rehabilitation treatment was carried out. It was oriented to recovering the right lower extremity function. The dosed load to the right leg was allowed after decrease in pain syndrome on 3rd day after the surgery. Two months later, the patient was examined in the clinic. The extensive contracture of the right knee joint with moderate disorder of function was identified (Fig. 7). The good functional outcome was noted. There were not any infectious complications after the surgery. The control X-ray images (7 months after the surgery) showed the union of the complex comminuted gunshot fracture of the femoral bone with 2.5 cm shortening of the segment. The treatment outcome was satisfactory according to the score by Neer-Grantham-Shelton (68 points).

Figure 7. The patient T, age of 30: a and b – frontal and lateral X-ray images of the right hip in 7 months after nail osteosynthesis; the fracture union is noted

  

In 8 months after osteosynthesis, the 2.5 cm lengthening of the femoral bone by means of formation of the bone regenerate on the intramedullary nail (the patent on an invention No. 2372875) was performed. For this purpose, osteotomy was performed and the distraction pin-rod device was used for the subtrochanteric region. After 10 days, distraction was initiated with its rate of 1 mm per day (Fig. 8).

Figure 8. The patient T., age of 30: a and b – frontal and lateral X-ray images after osteotomy in subtrochanteric region; the distraction device is applied and distraction is initiated

  

After achieving the appropriate length of the femoral bone, the distal locking of the intramedullary nail and demounting the external fixing device were carried out (Fig. 9).

Figure 9. The patient T., age of 30: a – functional capabilities of the patient after femoral bone lengthening; b and c – X-ray images of the right femur after lengthening by 2.5 cm; the bone regenerate is visualized in the region of osteotomy

    

CONCLUSION

1. Gradual minimally invasive osteosynthesis allows reliable (p < 0.05) decreasing intrasurgical blood loss (by 29 %), reducing the mean time of hospital treatment (by 44.8 days), decreasing the rate of disordered union of extremity fractures (by 15.2 %), decreasing the rate of infectious complications (by 4.8 %) and increasing the rate of good and excellent treatment outcomes (by 24.9 %) as compared to gradual opened reposition and internal fixation of gunshot fractures of the extremities.
2. The developed and clinically tested surgical management, on the basis of the complex approach to estimation of general and local disorders in gunshot fracture of the long bone, and use of gradual internal fixation, allows receiving good anatomic and functional outcomes in 70.9 % of cases.
One should note that our results do not contradict to the experience described in the foreign literature. So, administration of intramedullary fixation for 160 patients with gunshot fractures of femoral and tibial bones in the Sana Military Hospital (People's Democratic Republic of Yemen) showed that functional recovery was faster with use of the two-staged technique [25]. The presented materials include 28 patients with gunshot fractures of the leg and the femur in the Federal Medical Center in Ovo (Nigeria). The author indicates the absence of deep purulence and good anatomic and functional outcomes of internal fixation [28]. The interesting results are presented by the treatment of 81 patients with gunshot fractures of the femoral bone in Detroit Hospital (USA) with use of intramedullary fixation. No infectious complications were diagnosed [26].

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