EurAsian Journal of BioMedicine, Vol.1, No.5, Jun. 2008 11

Surgical rehabilitation of patients with open fractures of long bones Yersin ZHUNUSSOV Department of Polytrauma, Scientific Research Institute of traumatology and orthopedics of Republic of Kazakhstan, Astana .

ABSTRACT In given article results of 251 patients with open fractures of long bones of limbs, choice of tactics of treatment which was carried out on the classification advanced by authors, are resulted. Thus it is marked that offered classification precisely reflects dynamics of current of open fractures of long bones, thereby it helps to choose optimum tactics of treatment, to this testifies the remote results of 230 patients, where the excellent outcome is received at 38 patients (16, 5 %), good - at 95 (41, 3 %), satisfactory - at 75 (32, (32, 6 %) and unsatisfactory outcomes are marked at 22 patients (9, 5 %).

Key words: open fractures, classification, diagnostics and complex treatment.

*Correspondence: Yersin ZHUNUSSOV, Department of Polytrauma, Scientific Research Institute of traumatology and orthopedics of Republic of Kazakhstan, Astana, 010000, Astana, Zheltoksan str. 48/1 - 15. E-mail: [email protected]

INTRODUCTION. NTRODUCTION Treatment of open fractures of long bones of limbs long since concerns the extremely actual and it is difficult solvable problem in operative traumatology and orthopedics. According to the literature [1,2,3] complications of treatment of open traumas in many respects are connected to development of pyoinflammatory process, which detaining reparative regenerations of tissues results to such complications as pyesis (from 12 up to 42,0 %), osteomyelitis (from 18 up to 68 %), failure of union and pseudoarthrosis (from 11 up to 48 %), physical inability (from 8,0 up to 23 %) and lethality (from 1,5 up to 3,5 %).

In connection with above-stated, development and optimization of tactics of treatment of open fractures of long bones is a priority direction of modern traumatology [4, 5, 6, etc.]. The purpose of the present research was improvement of results of treatment of patients with open fractures of long bones of limbs. MATERIALS AND METHODS The given research work is based on the results of treatment of 251 patients with open fractures of long bones of limbs. Depending on limitation period of trauma reception, patients have been divided into 2

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Surgical rehabilitation after open fracture / Zhunssov E.

clinical groups, the first group includes 139 patients with fresh open fractures without complication by purulent infection, and the second group includes 112 patients with open fractures of long bones complicated with purulent infection. Males were 156 and females - 95. By the form of traumatism prevailed traffic - at 83, industrial - at 72, street - at 41, household - at 25, agricultural - at 18 and railway trauma - at 12 patients. Among patients prevailed persons of young and healthy age (69, 0 %), than elderly and senile (31, 0 %).

At entering into the hospital, the diagnostic algorithm including urgent X-ray, ultrasonic sonography, immunogram, the biochemical analysis of blood, angiography, osteodensitometry, fistulography, a computer tomography, electroneuromyography and bacteriological monitoring has been led to all patients. In both groups of patients the types of open fractures of long bones and tactics of treatment were defined according to our classification [7]. The structure of classification of open fractures of long bones of limbs is submitted in table №1.

Table №1 Classification of open fractures of long bones Scientific Research Institute TO (2005) The external dermal wound

size

of

I up to 2,0 cm

II from 2 up to 9 cm

III from 10 and more

IV heavy

Damage of skin and S0-deficiency is not present subject soft tissues (S) S1- from 2 up to 6 cm + muscular tissue within the limits of 1-st groups of muscles S2-deficiency from 6 up to 10 cm + muscular tissue within the limits of 2 groups of muscles S3-deficiency more than 10 cm + muscular tissue more than 2 groups of muscles Damage of bone tissue G0-defect is not present (G) G1-defect from 2 up to 6 cm G2-defect from 6 up to 10 cm G3-defect more than 10 cm Damage of the main M0-damage of vessels and nerves is not present vessels and nerves (M) M1-damage of vessel (clottage, ischemia, intima rupture) M2-damage of nervous trunk (concussion, bruise, prelum or full rupture) M3-damage of the main vessel + nerve Type of open fractures ISGM II-SGM III-SGM IVSGM Kind of fracture

Cross-section, slanting, spiral, splintered, double

Localization of fractures

Top, average, bottom third diaphysis of humeral, ulnar, radial, femoral, tibia and fibula (without displacement and with displacement)

Complications

Skin necrosis dry damp

Deep pyesis subfascial intermuscular

Osteomyelitis trailer medullar canal

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Table №2 Localization and types of open fractures in I-st group of patients. Segments Shin Hip Shoulder Forearm In total

ISGM 9 8 4 3 24

Types of fractures IISGM IIISGM 18 14 16 9 13 8 7 9 54 40

In offered classification, unlike existing, types of open fractures and presence of deficiency of soft tissues, defects of bone and damage of the main vessels and nerves were determined during or after performance of operation «primary surgical processing of wounds » According to our classification localization and types of open fractures in I-st group of patients is submitted in table №2. From table №2 it is visible, that open fractures most frequently (66, 1 %) were located in bones of the lower limbs and less often (33, 9 %) in the upper limbs. Open fractures of II-III-IV type represented significant difficulties in treatment, and the success thus depended on presence or absence of deficiency of soft tissue, defect of bone and the main vessels and nerves. Unlike I-st group, in the II-nd group of patients besides heavy types, open fractures were accompanied by pyoinflammatory processes of various character. Localization, types and kinds of infectious complications in the II-nd group of patients is submitted in table №3. According to the summary data, resulted in table №3, in the second group of patients open

Abs., number IVSGM 12 6 2 1 21

53 39 27 20 139

Frequency in % 38,1 28,0 19,4 14,5 100

fractures of the lower limbs than the upper limbs prevailed. As open fractures of the lower limbs are always connected to the development of purulent infection, moreover patients of this group have been transferred from other medical establishments. The structure and frequency of pyoinflammatory complications is submitted in table №4. Infectious complications directly depended on the type and the localization, open fractures of long bones, as seen from table №4 at fractures of bones of shin, hips of II-III-IV type is much higher specific weight of osteomyelitis and sepsis, than at fractures of humeral bone and bones of forearm, it is connected to anatomico -physiological features of these segments. Presence of deficiency of soft tissues and defect of bone tissue SGM1,2,3 of degree served in all cases as the reasons of complication. Besides, from discharged documents it was possible to find out that in most cases at primary calls, to these patients because of weight of the common condition primary surgical processing of wounds has not been led. At entering to us in the hospital, to all patients for achievement of favorable outcome of treatment in complex therapy was done

Table №3 Localization and types of open fractures in II-nd group of patients. Segments Shin Hip Shoulder Forearm In total

ISGM 1 1

Types of fractures IISGM IIISGM 16 20 11 18 6 9 6 14 39 61

IVSGM 6 4 1 11

Abs., number 42 34 15 21 112

Frequency in % 37,7 30,3 13,3 18,7 100

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Surgical rehabilitation after open fracture / Zhunssov E.

Table №4 Structure and frequency of infectious complications in II-nd group of patients. Complications Superficial necrosis Deep pyesis Osteomyelitis Sepsis In total

Shin 12 11 15 4 42

Segments and types of fractures Hip Shoulder Forearm 12 7 7 14 4 10 5 4 3 3 1 33 15 21

primary and if necessary secondary surgical processing of open fracture with obligatory draining of anatomic structures of the damaged segment (medullar canal, paraosseous, intermuscular and hypodermic cellular tissue) by the flow and outflow system, endoarterially were injected antibacterial preparations in view of sensitivity of microflora, normalization of blood circulation and metabolism of the damaged tissues was created by the device for creation of the abacterial environment, suppression of infection and rising of protective forces of organism was made by endolimphatic injection of the preparation roncoleukinum (human interleukin - 2), were transfused preparations of blood and the medical products, improving microcirculation of damaged limb (vasoprostan - prostoglandin Е) and desintoxicational preparations. Well-known, that the pledge of success at treatment of open fractures of long bones depends on kind and way of fixing bone fragments, which unfortunately, is not always possible for realizing at the moment of entering of the patient in hospital. First of all

Abs., number 38 39 27 8 112

Frequency in % 34 35 24 7 100

it is connected by that open fractures are always accompanied by such terrible complications as traumatic shock, damages of internal bodies, a craniocerebral trauma, etc. RESULTS AND DISCUSSION At entering into the hospital conservative methods of fixing, than operative methods were frequently applied to our patients. However treatment is completed by conservative methods only at 21 (7,5 %) patients, and in the others 230 (92,5 %) cases in process of improvement of condition of the patient and favorable current of healing of soft tissues in the zone of fractures, ways of the operative method of treatment have been used. Depending on kind and term of use of operative methods of fixing is submitted in table №5. Use of transosseous osteosynthesis in 62, 6 % cases is connected by that in our material specific weight of patients with open fractures of bones of a shin and a forearm for which extensive damages of soft tissues with bared

Table №5 Kinds and terms of the osteosynthesis of open fractures of long bones of limbs Kinds of osteosynthesis

Terms of osteosynthesis

transosseous osteosynthesis locking intramedullary osteosynthesis the combined osteosynthesis In total

Primary Deferred Primary Deferred Primary Deferred

Examined groups of patients I-group II-group 37 12 44 51 2 27 6 8 2 7 34 125 105

Abs., number

Frequency in %

49 95 2 33 10 41 230

21,3 41,3 1,0 14,3 4,3 17,8 100

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Table №6 Structure and frequency of pyoinflammatory processes among patients with unsatisfactory results Complications Phlegmon Osteomyelitis Sepsis Nonunion, false joints and defects of a bone In total

Examined groups I-group II-group 3 4 2 5 1 1 2 4 10

bones are characteristic during a segment is high and consequently extrafocal osteosynthesis of the given kind determines its rationality at such damages. Blocking intramedullary osteosynthesis is carried out to 35 patients (15, 3 %), basically with fractures of femoral or humeral bone and rarely at fractures of bones of a forearm and a shin. The indication for osteosynthesis, blocking cores served open fractures I-II such as SGM0, the favorable data of ultrasonography, immunogram and bacteriological monitoring. The combined osteosynthesis has been applied at 15 patients, the combination of transosseous and intraosseous osteosynthesis has been shown at double fractures or in the combination of diaphyseal fracture with about - intraarticular fractures. The remote results of treatment are investigated from 1 till 4 years at all patients. In the first group of 125 patients the excellent outcome is received at 21 patients (17, 0 %), good - at 60 (48, 0), satisfactory - at 34 (27, 0 %) and unsatisfactory - at 10 patients (8, 0 %). In the second group the remote results of treatment are investigated from 1 till 5 years at 105 patients. In spite of the fact, that in this group all patients had pyoinflammatory complications, the excellent outcome is ascertained at 17 (16, 1 %) patients, good - at 35 (33, 3 %), satisfactory - at 41 (39, 2 %) and unsatisfactory - at 12 (11, 4 %). For precise representation and for the avoidance of repeated mistakes at treatment of open fractures of long bones, were analyzed the reasons of unsatisfactory results, that in 92,0

12

Abs., number

Frequency in %

7 7 2 6

31,8 31,8 9,2 27,2

22

100

% it has been connected not only from type of the fracture, but also from quality of the led primary surgical processing, underestimation of processes (pathophysiological, immunological and metabolic) occurring in organism. Structure and frequency of complications is submitted in table №6. Besides the above-stated complications at these patients because of long immobilization and also absence of locomotorium function of limbs, adjacent joint stiffnesses have been tapped. It is necessary to note, that in the second group of patients relapse of osteomyelitis was observed at 5 patients, and in the others 2 cases it has developed in the first group. Microbiological monitoring at osteomyelitis has shown, that the basic activators were association of floras Staphylococcus aureus et Pseudomonas aerogenosis with low threshold of sensitivity to antibacterial remedies, and it has served as the reason of development of sepsis at 2 patients (9, 2 %). Unfortunately, it was possible to rescue from generalization of purulent complication only 1 patient, and in the second case the lightning form of sepsis and unsuccessfulness of treatment has led to the lethal outcome. Failure of unions, nearthrosises and not eliminated defects of bone were observed at those patients who have been directed to us from other regions of our country. In all cases, to these patients has been used transosseous osteosynthesis, inadequate care around of spokes was the reason of the pyesis of soft tissues, and it in turn has led to premature removal of the device of external fixing.

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Surgical rehabilitation after open fracture / Zhunssov E.

CONCLUSION Open fractures of long bones concern to highenergy traumas and are accompanied pathophysiological, immunological and metabolic infringements not only in the zone of fracture, but also as the whole in organism. The offered classification of open fractures of long bones of limbs to the full reflects dynamics of current of the posttraumatic period and allows to determine tactics of treatment correctly. Use of developed tactics of complex treatment of open fractures allows to increase specific weight of favorable outcomes and to lower amount of unsatisfactory results. Early restoration of function of limbs promotes normalization of nervimuscular function of a segment. REFERENCES 1. Bhandari M. et all. Treatment of open fractures of the shaft of the tibia: A SYSTEMATIC OVERVIEW AND METAANALYSIS// J Bone Joint Surg Br, Jan 2001; 83-B: 62 - 68. 2. Guseynov A.G. Method of closing of wounds at treatment of open and fire fractures of the lower limbs // Surgery. Magazine of a name of N.I.Pirogova: Scientific - practical magazine. M.: Media Sphere, 2005.-N6.-. 51-54

3. Jeffrey O. et all. Comparison of Soap and Antibiotic Solutions for Irrigation of LowerLimb Open Fracture Wounds. A Prospective, Randomized Study // J. Bone Joint Surg. Am., Jul 2005; 87 : 1415 - 1422. 4. Sokolov A.В. and co-authors. Replacement of external fixing on intramedullary blocking pin at open fractures of long bones at patients with polytrauma // the Bulletin of traumatology and orthopedy of a name of N.N.Priorova: quarterly scientific - practical magazine / the Central scientific research institute of traumatology and orthopedy of a name of N.N.Priorova. M.: Medicine, 2007.-N1.-. 3-7. 5. Naique S. B. et all. Management of severe open tibial fractures: THE NEED FOR COMBINED ORTHOPAEDIC AND PLASTIC SURGICAL TREATMENT IN SPECIALIST CENTRES // J Bone Joint Surg Br, Mar 2006; 88-B: 351 - 357. 6. Lawrence X. et all. Analysis of SurgeonControlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures // J. Bone Joint Surg. Am., May 2007; 89 : 923 - 928. 7. Zhunussov Y.T. and co-authors. Classification of open fractures of long bones (the review of the literature) // the Genius of orthopedy: Scientific-theoretical and practical magazine. Kurgan: Regenerative traumatology and orthopedy, 2005.-N3.-. 106-113.