Інформація призначена тільки для фахівців сфери охорони здоров'я, осіб,
які мають вищу або середню спеціальну медичну освіту.


Підтвердіть, що Ви є фахівцем у сфері охорони здоров'я.

"Тrauma" Том 15, №5, 2014

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Important aspects in the treatment of impaired fracture consolidation of the tibia

Authors: N.L. Ankin, A.V. Kalashnikov, V.L. Shmagoj

Categories: Traumatology and orthopedics

Sections: Clinical researches

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Introduction

Violation of reparative osteogenesis is a complex pathology that occurs due to malfunction of the physiological process of consolidation in the place of damaged bone and soft tissues structures which treatment should be carried out on the basis of physiological reasons that led to the violation, namely as a set of sequential steps to stabilize the debris, renovation blood supply at the site of injury, replacement of damaged soft tissues and bone structures, and normalization of the local humoral and cellular metabolism.

The greatest number of violations fusion accounts for fractures of the tibia, according to various estimates, from 25 to 40 %. Over the past decade in 52-78 % of patients with diaphyseal fractures of tibia fixation is performed, the results of which are found unsatisfactory in 2,7-13,8 % of cases.

Analysis of poor treatment outcomes as a consequence of disturbances of bone fractures leg and analysis of sources of scientific information indicates limited experience using diagnostic and therapeutic algorithm, the absence of clear indications to certain types of osteosynthesis according to the degree of vascular disorders and disturbances of the state of bone tissue. We have developed a diagnostic and therapeutic algorithm for selecting survey methods and scope of operational tactics depending on the severity of the injury, stability of debris, inflammatory processes, such as violations of regeneration, such as a false joint, the degree of blood flow disorders of bone fragments and an abnormal blood flow to the lower extremities, disturbances of cellular homeostasis, given comorbidity and genetic susceptibility and interactions between them.

Materials and methods

During 2011-2013 at the Kyiv Regional Clinical Hospital treated 92 patients with non-infectious disorders shin bone fractures, including 62 men (67 %), 30 women (33 %), age group 22-73 years. All patients had diaphyseal fractures of the bones by AO classification: 42A2 - 6, 42A3 - 11 42V1 - 12, 42V2 - 20, 42V3 - 21, 42S2 - 13, 42S3 - 9, respectively.

Compared the results of treatment of these patients with a group of patients that were treated with the same diagnosis in the previous period of 2008-2010, the study included 89 patients, including 66 men (74 %), 23 women (26%) aged 26 to 77, respectively AO classification: 42A2 - 8 42A3 - 13, 42V1 - 15, 42V2 - 16, 42V3 - 19, 42S2 - 11, 42S3 - 7.

Conducted comprehensive general clinical and biochemical examination, radiography, computed tomography, ultrasonography, dopplerography, angiography, studied the stability of bone fragments, circulatory disorders, functional and dynamic disturbances, measured the frequency and nature of complications outcomes.

During the survey in addition to operating in certain cases in order to clarify the debris mobility between X-rays used for further questions about the location and viability of fragments using computed tomography. Deficiency of blood and vitality of soft tissue and bone fragments were determined by dopplerography, angiography, MRI when necessary. When operating to the survey also showed comorbidities that could impair reparative response bones and tissues in the fracture, such as disturbances of homeostasis and structural-functional state of bone tissue with additional biochemical and immunological studies. In some cases, to identify violations of structural and functional state of bone densitometric study was performed additionally. In the presence of peripheral neurological disorders, conducted neyromiohrafiy, neyrometriy, thermometry.

In the pre and postoperative period, patients receiving infusion therapy and physiotherapy treatment aimed primarily at reducing postoperative edema and normalization of rheological parameters of blood, improved medication and physical methods, microcirculation in the damaged limb, conservatively and operatively treated local circulatory disturbances, normalized structural functional state of the skeletal system.

The results of treatment were assessed clinically and radiographically given fracture pattern, subjective feelings of the patient, the presence of biomechanical disorders, rehabilitation, and the presence of restrictions of movement in the joints and related neurotrophic disorders, deformities and shortening. Assessment of treatment outcomes was performed at the time of consolidation of fractures by a modified 100-point scale anatomical and functional results of the treatment of long bone fractures Neer-Grantham-Shelton, in three stages: excellent results 85-100 points, 70-84 points satisfying experience unsatisfactory result below 69 points.

Results

Average terms of previous treatment in patients with poor consolidation and non-union shin bones were 5,4 ± 4,2 months in group 1 and 4,7 ± 3,1 months in group 2, which also suggests a greater alertness to this pathology and more active medical tactic.

After analyzing the results of treatment of disorders of fusion in 2008-2010 revealed a lack of consistency in the operating room to the diagnosis and choice of methods and scope of surgical treatment. Having paid more attention to the findings in the survey vessel pathology leading to operational and post- operational period, developed a clear sequence of actions when planning the volume and choice of method re-osteosynthesis, using a biological approach to the choice of methods of surgical intervention.

During diagnostic testing for learning disorders hemodynamic doppler was used ( in 28 patients) and angiography (10 cases) for the assessment of peripheral blood flow were used to test the patency of vessels. When to operational examination revealed 3 major violations and great vessels in 2 cases required surgical treatment - angioplasty. In 26 patients had complications thrombosis and inflammatory vascular disease in the surgical treatment of tibia pseudoarthroses and violations of reparative osteogenesis, which in 8 cases required surgical treatment, in other cases conducted pharmacological correction. In 16 patients undergoing osteosynthesis submerged irregularities were detected deep venous hemodynamics in line with the lower limb, including thrombosis in 8 patients, recently conducted courses thrombolytic therapy, if necessary ( in 2 patients ) conducted in the department of surgical treatment of vascular diseases.

Deficiency bone volume, the latter filled with bone grafting, in most cases using the "gold standard", the spongy tissue of the iliac bone. We used different types of skin and soft tissues for plastic closure of soft tissue defects in the recovery area.

With re osteosyntesis methods to stabilisation the fragments was performed replacement metal retainers in 42 patients, replacement techniques fixation was performed in 38 cases. In order to normalize bone volume, stimulate local neoangiogenesis cell activity and complement fixation decortication ( 16 cases), removal of scars, tunelisation ( operation Back 12 cases), bone grafting spongy tissue of the iliac bone (in 19 patients ), local use fibrin gel ( 6 patients). Dynamization of intramedullar system by removing the distal or proximal screws performed in 12 cases.

As a result of treatment shows that the experimental group 2 the percentage of excellent results is higher (51 vs. 40 %), and the level of unsatisfactory results lower than in group 1 (7 and 14 %), confirming the effectiveness of the algorithm used in the diagnosis and action selection amount and type of surgical treatment of disorders of irrigation fractures of the tibia. Medium term treatment of patients with disorders of reparative osteogenesis decreased from 7,2 ± 1,4 months in group 1 to 5,9 ± 1,3 months in group 2 (without pre- treatment after initial injury), confirming the effectiveness of the algorithm actions of doctors during the examination and selection methods for surgical treatment of disorders of bone fractures of the tibia.

Conclusions:

1. Treatment of patients with disorders of reparative osteogenesis should be based on the optimization of biomechanical conditions for the functioning of the locomotor system, the treatment of disorders of gemodynamics and gomeostatic condition of the patient, the normalization of the local repair mechanisms, and treatment approach should be comprehensive.

2. The examination and preoperative planning must be considered in addition to stability, the number and position of the bone fragments, their viability, the blood supply of bone fragments and surrounding soft tissues, the activity of the local reparative processes, the choice of methods of osteosynthesis depends on these factors.

3. Prevention of reparative osteogenesis in patients with fractures of the shin bone is to facilitate the compensation of regional and local gemodynamic disorders, selecting the optimal method of fixing metal, ensuring efficient mode functional loading of the affected limb, pharmacological therapy directed local and general disturbances of homeostatic functions.



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