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THE ANALYSIS OF EFFECTIVENESS OF OSTEOSYNTHESIS METHODS IN PATIENTS WITH INJURIES TO FOREARM BONES
Panov A.A., Kopysova V.A., Burnuchyan M.A., Khalaman A.G., Shashkov V.V.
Novokuznetsk State Institute of Postgraduate
Medicine, All-Russian Scientific Practical Center of
Shape Memory Implants, OOO Grand Medica, Novokuznetsk City Clinical Hospital No.5, Novokuznetsk, Russia
Medical
Center of Healthcare CJSC Aramyants, Yerevan, Armenia
Fractures of diaphyseal segment of forearm bones consist 11.2-15.7 %
among all skeletal injuries. In 50.6-77.5 % of cases, they are accompanied by
displacement of bone fragments with requirement for reposition and
osteosynthesis [1-3]. Reposition and preservation of stable position of bone
fragments are hindered by some anatomical and functional features of the
forearm: relationship of the paired bones which are connected with interosseal
membrane, proximal and distal radioulnar joints, the curve of the radial bone,
rotational movements of the forearm bones [4-6].
The use of the external fixation devices provides satisfactory
stabilization of bone fragments. However correction of all types of
displacement is often achieved with opened reposition. Placement of pins and
nails (to the lesser degree) promotes the reactive inflammation of soft
tissues, and it requires additional treatment or preliminary removal of pins
(nails). Good results are achieved in 81.0-88 % patients [7]. However
osteosynthesis with external fixation devices is the most optimal option for
patients with fractures of bones of the forearm at two or more levels,
fracture-dislocations and fragmented injuries.
The high amount of complications (up to 44 %) of intramedullary fixation
with rectangular cross section rods (pins) and insufficient compression of bone
fragments cause the high probability of rotation displacement and preliminary
migration of the nail from the intramedullary channel. Therefore, external
osteosynthesis is mainly used for fixation of the forearm bones [2, 4, 6, 8,
9]. After fixation with LC-DCP and LCP, good and excellent results are achieved
in 98.2-96.1 %. It is acknowledged that external fixation (also with low
invasive techniques) is not enough appropriate for complex fractures (type C2,
C3) in patients with osteoporosis. Moreover, the price of dynamic (locking)
plates with limited contact is quite high, and it prevents its wide-spread use
[2, 10-12].
According to some authors, intramedullary fixation with locking nails in
proximal and distal bone fragments is low traumatic, provides restoration of
the length of the axis of injured bones, preservation of the radial bone
curvature, removes the rotational stability of bone fragments and migration of
nails. It is proved that anoxia reduces by 33.9 % 3 days after surgery, and
after external osteosynthesis with LC-DCP – by 12.3 %. The time of union of bone
fragments is 8-20 weeks, with good results in 96.4 % [5, 11, 13].
Medical technology of intramedullary fixation with memory-effect
compression braces in treatment of patients with fractures shows the prospectivity
of this technique. However the possibilities of the method for patients with
fracture-dislocations, fragmented and bifocal fractures have been studied
insufficiently [1].
Objective – to
perform a comparative analysis of the results of extramedullary, intramedullary
and transosseous osteosynthesis, and combination with adjunctive fixation of
bone fragments with shape memory clamps in patients with single fractures and
fractures in both forearm bones, as well as in patients with fracture-dislocations
and multiple fractures.
MATERIALS AND METHODS
The randomization method was used for selection of 153 medical records
of the patients with single, combined diaphyseal fractures,
fracture-dislocations and multiple fractures of the forearm bones in 2000-2017.
The study group included the patients, the age < 18 and > 65. The trauma
period was more than 2 days. The patients had the opened fractures with bone
tissue defect > 50 mm. ICD-10 was used for estimation of location of
patterns of the injuries.
According to the fixation techniques, the control group and the main
group were separated. DCP, LC-DCP and LCP, Kirschner wire and Ilizarov devices
were used for 78 (51 %) patients (the table 1). 75 (49 %) patients of the main
group received the combined osteosynthesis (with additional fixation with shape
memory clamps (the table 2).
Table 1. Osteosynthesis techniques in 78 (51.0 %) control patients in the subgroup without complications (61 (78.2 %)) and in the subgroup with complications (17 (21.8 %)) of injuries to forearm bones
|
Subgroups of injuries, their location, characteristics and ICD-10 |
Osteosynthesis technique |
||||
|
Extramedullary |
Intramedullary |
Intramedullary + extramedullary |
Transosseous |
Total |
|
|
Uncomplicated fractures |
|||||
|
Radial bone fracture S52.3 |
16 |
5 |
- |
- |
21 |
|
Ulnar bone fracture S 52.2 |
8 |
5 |
- |
- |
13 |
|
Fracture of both forearm bones S 52.4 |
10 |
6 |
9 |
2 |
27 |
|
Total |
34 |
16 |
9 |
2 |
61 |
|
Complicated fractures |
|||||
|
Radial bone fracture, dislocation of radioulnar joint (Galeazzi) S 52.3, S 53.3 |
5 |
2 |
- |
- |
7 |
|
Ulnar bone fracture, dislocation of radial head (Monteggia) S 52.2, S 53.0 |
1 |
2 |
- |
- |
3 |
|
Ulnar process fracture, dislocation of ulnar bone diaphysis (Malgaigne) S 53.1, S 52.0, S 52.2 |
- |
1 |
- |
- |
1 |
|
Multiple fracture of forearm bones S 52.7 |
1 |
- |
- |
5 |
6 |
|
Fragmentary bilocal fracture of ulnar bone with bone tissue defect S 52.7 |
- |
- |
- |
- |
- |
|
Total |
7 |
5 |
- |
5 |
17 |
Table 2
Osteosynthesis techniques in 75 (49.0 %) patients of the main group in the subgroup without complications (45 (60.0 %)) and in the subgroup with complications (30 (40.0 %)) of injuries to forearm bones
|
Subgroups of injuries, their location, characteristics and ICD-10 |
Osteosynthesis technique |
|||||
|
Intramedullary + braces |
Extramedullary + intramedullary + braces |
Transosseous + braces |
Fixation with bone graft |
Fixation with porous implant |
Total |
|
|
Uncomplicated fractures |
||||||
|
Radial bone fracture S52.3 |
15 |
- |
- |
- |
- |
15 |
|
Ulnar bone fracture S 52.2 |
13 |
- |
- |
- |
- |
13 |
|
Fracture of both forearm bones S 52.4v |
14 |
3 |
- |
- |
- |
17 |
|
Total |
42 |
3 |
- |
- |
- |
45 |
|
Complicated fractures |
||||||
|
Radial bone fracture, dislocation of radioulnar joint (Galeazzi) S 52.3, S 53.3 |
8 |
- |
- |
- |
- |
8 |
|
Ulnar bone fracture, dislocation of radial head (Monteggia) S 52.2, S 53.0 |
2 |
- |
2 |
- |
- |
4 |
|
Ulnar process fracture, dislocation of ulnar bone diaphysis (Malgaigne) S 53.1, S 52.0, S 52.2 |
- |
2 |
- |
- |
- |
2 |
|
Multiple fracture of forearm bones S 52.7 |
7 |
- |
- |
- |
4 |
11 |
|
Fragmentary bilocal fracture of ulnar bone with bone tissue defect S 52.7 |
- |
- |
- |
2 |
3 |
5 |
|
Total |
17 |
2 |
2 |
2 |
3 |
30 |
Depending of characteristics of injuries, the control and main groups
were divided into the subgroups. The subgroup of the patients with
uncomplicated fractures included the single fractures of the radial bone
diaphysis (S 52.3), fractures of ulnar bone (S 52.2) and both bones of the
forearm (S 52.4). The subgroup of complicated fractures included the patients
with fracture-dislocations (S 52.3, S 53.3, S 52.2, S 53.1, S52.0, S52.2), multiple
fractures (bifocal, fragmented with intercalated fragments and bone tissue
defects S 52.7) (the tables 1, 2).
The methods of diagnostic examination and treatment corresponds to the
standards of the program of government guarantee for free medical care (the
Order by Government of RF, October 22, 2016, No.2229-r), and the Rules for
Clinical Practice in the Russian
Federation (the Order by Russian Health Ministry, April 1, 2016, No.200n).
There are the registration certificate and declaration of correspondence for
the osteosynthesis fixators.
All patients received the opened reposition of bone fragments with
subsequent osteosynthesis of injured bones with a chosen technique. The
patients with fracture-dislocations received the reduction of a dislocation,
and pin diafixation of distal segments of the radial and ulnar bones in
Galeazzi fracture-dislocations. 3 patients with a multi-fragmented fracture of
the upper one-third of the diaphysis of the ulnar bone received the porous
cylindrical implant including the distal and proximal semicylindrical ledges
with the internal end-to-end channel (the registration certificate
No.2009/04558, point 2 of the application). The ulnar bone was fixed with the
intramedullary nail, the implant – with ring-shaped devices and the shape
memory form (the registration certificate No.2009/04558, the point 13 of the
application).
2 The first stage was transosseous osteosynthesis for 2 patients with
fragmented fracture of the lower one-third of the ulnar bone diaphysis and for 4
patients with multiple fractures including the intraarticular compression
fracture of the distal segment of the radial bone. After 1-2 weeks, the
reconstructive osteosynthesis was initiated with use of the S-shaped bracket
with the intramedullary stem and with the fibular autograft for the patients
with a comminuted fracture of the ulnar bone. The porous flat implants were
used for replacement of a bone defect of the radial bone (the registration
certificate No.2009/04558, the point 13 of the application, the declaration of
compliance ROSS.RU.AYa79.D11341). The fixation was conducted with use of the
intramedullary nails and S-shaped braces with termomechanic effect.
The patients with uncomplicated fractures received two weeks of external
immobilization after external and intramedullary osteosynthesis in combination
with the shape memory clamps. The patients with complicated fractures received
3.5-4 weeks of immobilization. The immobilization lasted up to fracture union
in the control group.
The comparative analysis of efficiency of osteosynthesis techniques in
the control and main groups, and in the subgroups with uncomplicated and
complicated fractures considered the absence of inflammatory responses,
migration (fracture) of constructs, quality of intrasurgical reposition and
preservation of anatomical and topographical parameters of the forearm in the
rehabilitation period up to union of fragments, terms and a type of union
(according to criteria by Anderson) and a degree of recovery of volume of
movements in the injured extremity (with use of Grace and Eversmann’s system
[14]).
Statistica 6.0 was used for preparation of the data. χ2-test
was used for estimation of significance of mean values and frequency of signs
in the groups and the subgroups of the patients. Yates correction for
continuity was used in presence of low frequency. For frequencies < 5, the method
of Fisher’s four-fold tables was used. The critical level of significance for
testing the null hypothesis was 0.05.
RESULTS AND DISCUSSION
The duration of operations in the main and the control groups was
similar and depended on complexity of a fracture and osteosynthesis technique.
Unsatisfactory results of intramedullary fixation were conditioned by
migration of a nail, diastasis between the fragments and absence of union in 3
(18.8 %) of 16 patients of the control group (two patients with fractures of
both bones, 1 patient with a fracture of the ulnar bone). The recurrent
surgical intervention with the intramedullary nail for compression of bone
fragments was performed with S-shaped form with shape memory effect.
Due to a fracture of the plate and secondary displacement of bone
fragments in a patient with a fracture of the ulnar bone, the osteosynthesis
was performed with use of the intramedullary nail in combination with S-shaped
clamp (the table 3).
Table 3. Results of osteosynthesis in control patients
|
Osteosynthesis technique |
Results |
Total |
||||||
|
Good |
Satisfactory |
Unsatisfactory |
||||||
|
abs. |
% |
abs. |
% |
abs. |
% |
abs. |
% |
|
|
Uncomplicated fractures |
||||||||
|
Extramedullary |
29 |
85,3 |
4,0 |
11,8 |
1,0 |
2,9 |
34 |
100,0 |
|
Intramedullary |
8 |
50,0 |
5,0 |
31,3 |
3,0 |
18,8 |
16 |
100,0 |
|
Intramedullary + extramedullary |
8 |
88,9 |
1,0 |
11,1 |
- |
- |
9 |
100,0 |
|
Transosseous |
2 |
100,0 |
- |
- |
- |
- |
2 |
100,0 |
|
Total |
47 |
77,0 |
10,0 |
16,4 |
4,0 |
6,6 |
61 |
100,0 |
|
Complicated fractures |
||||||||
|
Extramedullary |
3 |
42,9 |
2,0 |
28,6 |
2,0 |
28,6 |
7 |
100,0 |
|
Intramedullary |
1 |
20,0 |
- |
- |
4,0 |
80,0 |
5 |
100,0 |
|
Transosseous |
4 |
80,0 |
- |
- |
1,0 |
20,0 |
5 |
100,0 |
|
Total |
8 |
47,1 |
2,0 |
11,8 |
7,0 |
41,2 |
17 |
100,0 |
After 2.5-3 months, the union of bone fragments was achieved, after 3.5-4
months – full recovery of function of the injured extremity in 44 (77 %) of 61
patients with uncomplicated fractures of the forearm, including 29 (85.3 %) of
34 patients after external osteosynthesis, in 8 (50 %) of 16 patients after
intramedullary fixation (the table 3). 10 (16.4 %) of 61 patients received the
union of bone fragments in 25-26 weeks after osteosynthesis, with two cases
(the patients with a fracture of both bones of the forearm) of persistent (10
months) limitation of the radioulnar deviation (3-5°) and pronation-supination
(5-7°) as compared to a healthy extremity. The results of treatment were satisfactory (the table 3).
The comparative analysis in the control group with uncomplicated
fractures of intramedullary and external osteosynthesis with the plates showed
the statistically significant differences, with χ2 = 5.329, p = 0.021.
In the main group, 42 (93.3 %) of 45 patients with uncomplicated
fractures of the forearm bones showed the union of bone fragments with correct
anatomical position in 8-10 weeks after osteosynthesis of single fractures, and
recovery of full range of motions – after 12-13 weeks. The patients with a
fracture of both bones of the forearm showed the union after 15-16 weeks (the
table 4). 3 (6.7 %) patients with fragmented fractures of both bones showed
satisfactory results of treatment, with correct anatomical union in 27-28 weeks
after fixation (the table 4).
Table 4. Results of osteosynthesis in patients of main group
|
Osteosynthesis technique |
Results |
Total |
||||||
|
Good |
Satisfactory |
Unsatisfactory |
||||||
|
abs. |
% |
abs. |
% |
abs. |
% |
abs. |
% |
|
|
Uncomplicated fractures |
||||||||
|
Intramedullary + braces |
40 |
95,2 |
2 |
4,8 |
- |
- |
42 |
100,0 |
|
Extramedullary + intramedullary + braces |
2 |
66,7 |
1 |
33,3 |
- |
- |
3 |
100,0 |
|
Total |
42 |
93,3 |
3 |
6,7 |
- |
- |
45 |
100,0 |
|
Complicated fractures |
||||||||
|
Transosseous + braces |
2 |
100,0 |
- |
- |
- |
- |
2 |
100,0 |
|
Osteosynthesis + graft + braces |
2 |
100,0 |
- |
- |
- |
- |
2 |
100,0 |
|
Osteosynthesis + implant + braces |
5 |
71,4 |
2 |
- |
- |
- |
7 |
100,0 |
|
Intramedullary + braces |
16 |
94,1 |
1 |
- |
- |
- |
17 |
100,0 |
|
Extramedullary + intramedullary + braces |
1 |
50,0 |
1 |
- |
- |
- |
2 |
100,0 |
|
Total |
26 |
86,7 |
4 |
13,3 |
- |
- |
30 |
100,0 |
The comparative analysis of the results of external fixation in the
control group with uncomplicated fractures and intramedullary fixation combined
with termomechanical memory clamps in the main group did not show any
statistical significant differences (χ2 = 1.192, p = 0.275).
The number of unsatisfactory results reached 41.2 % in the control group
in the patients with fracture-dislocations, multiple fractures of the forearm
bones (the table 3). The union of bone fragments before 6 months from the
moment of osteosynthesis and recovery of motions in the joints were achieved in
only 8 (47.1 %) of 17 patients (Fig. 1). The comparative analysis of efficiency
of treatment in the control patients with complicated and uncomplicated
fractures showed the statistically significant differences, with χ2 =
4.399, p = 0.036.
Figure
1. The picture of the X-ray images of the patient G.,
age of 33, with a fracture of the left ulnar bone and dislocation of the radial
head (Monteggia injury): a) before; b) 6 weeks after combined
osteosynthesis of the ulnar bone with titanium nail and the shape memory
contractive clamp
In the main group, 26 (86.7 %) of 30 patients with fracture-dislocations and multiple fractures of the forearm bones showed the union of bone fragments with preservation of relationships in the injured joints 5.5-6 months after osteosynthesis, the full recovery of motions – after 6-7 months (Fig. 2).
Figure
2. The picture of the X-ray images of the patient Ts.,
age of 52, with multiple fracture of the forearm bones (bifocal fracture of
ulnar bone, fragmented fracture of ulnar bone): a) 6 months after
extramedullary osteosynthesis; b) 2.5 weeks after removal of plates
The limitation of radioulnar deviation (up to 5°) in 2 patients with Galeazzi fracture-dislocation, flexion-extension, pronation-supination (up to 10°) in the patients with Monteggia and Malgaigne fracture-dislocation persisted to 8-8.5 months and fully recovered in 10 months (the table 3, Fig. 3).
Figure
3. The picture of the X-ray images of the patient
Shch., age of 45, with bifocal fracture of ulnar bone and fragmented
fracture of radial bone: a) before treatment; b) 3.5 months after osteosynthesis
The difference was statistically significant in comparison of the treatment results in the patients of the main and control groups with complicated fractures (χ2 = 6.649, p = 0.010).
DISCUSSION
Most profile scientific publications recommend the opened reposition for
multiple fractures, fracture-dislocations and fractures with rotational
displacement of bone fragments [10, 11]. Its efficiency and, as result, the
choice of fixing constructs highly depend on location and characteristics of an
injury [8, 9, 14]. The necessary condition of osteosynthesis is removal of all
types of displacement of bone fragments, minimization of surgical trauma, preservation
of motion activity in early terms after surgery [3, 12].
It is generally accepted that osteosynthesis with external fixing
devices (rods, rods and pins, Ilizarov G.A.) for patients with opened, multiple
fractures and fracture-dislocations is the most optimal. Considering the
clinical situational tasks, it was offered to use lots of combinations of
transosseous osteosynthesis [1, 7].
Despite of the disadvantages of intramedullary fixation with nails, the
intramedullary osteosynthesis was actually the single technique for simple
(uncomplicated) fractures of the forearm bones in the Russian Federation in 90s
of the previous century. With development of medical techniques and external
plates for stable fixation without subsequent external immobilization, the
techniques of external osteosynthesis have taken the leading place.
The efficiency of external fixation was higher in the comparative
analysis of the results of external and intramedullary fixation with nails of
square section in the patients with uncomplicated fractures of one or both
bones (χ2 = 5.329,
p = 0.021).
The analysis of the scientific literature has shown that unsatisfactory
results of external fixation as result of migration of screws, destabilization
of bone fragments and absence of union were 12.5 %, and that external fixation
poorly appropriate for patients with opened, multiple fractures and in patients
with osteoporosis [4].
The positive qualities of intramedullary fixation (low traumatic effect,
fixation of an injured bone along the whole length) were the foundations for
improvement in the constructs and medical technologies. The locked nails, as
well as nails for the radial bone with a curvature, have been offered for
prevention of rotational mobility and creation of compression between bone
fragments. The negative factor is absence of approximation of bone fragments
along the width in oblique and fragmented fractures [3, 5].
The use of the shape memory constructs (S-shaped clamps, ring-shaped
fixators) in combination with intramedullary fixation provides the adaptation
and compression of bone fragments, sufficient stabilization of injured bones,
with subsequent decrease in terms of external immobilization [1]. The
comparative analysis of efficiency of external fixation and intramedullary
fixation in combination with clamps with termomechanical memory showed the good
results in the patients with complicated fractures of one or both forearm bones
in 85.3 % and 95.2 % correspondingly (χ2 = 6.649, p = 0.010,
the difference is statistically significant).
CONCLUSION
External fixation and intramedullary osteosynthesis in combination with
termomechanical effect clamps are equally efficient for patients with
uncomplicated fractures (one or two bones).
Additional fixation of bone fragments with termomechanical effect clamps
improves the results of osteosynthesis in patients with fracture-dislocations
and multiple fractures of the forearm bones.
Information on financing and conflict of interests
The study was conducted without
sponsorship.
The authors declare the absence of
clear and potential conflicts of interests relating to publication of this
article.
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